20yrs ago, denies etoh\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Flowsheet Data as of 02:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 92 (85 - 92) bpm\n BP: 147/81(97) {141/74(95) - 154/84(97)} mmHg\n RR: 20 (19 - 24) insp/min\n SpO2: 98%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Total In:\n 1,429 mL\n PO:\n TF:\n IVF:\n 1,429 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,129 mL\n Respiratory\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n T 95.8 HR 85 BP 158/74 O2 100% RA\n GEN: cachectic elderly male, AOx2 (date- , )\n HEENT: EOMI, PERRL, sclera anicteric, dry MM, OP Clear\n NECK: JVP 10cm, no bruits, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, soft heart sounds\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses, rectal soft brown stool,\n guiac negative\n EXT: No C/C/E, no palpable cords\n NEURO: alert, oriented to person, place, not to time. CN II\n XII\n grossly intact. 5/5 strength in UE deltoid, bicep, tricep, wrist flex /\n ext, normal grip stregnth. stregnth in lower ext- quad, hamstring,\n dorsiflexion / plantarflexion. Normal sensation to light touch bilat\n symmetrical. cerebellar testing is normal. Reflexes normal\n throughout. Babinski equivocal.\n Labs / Radiology\n 154 K/uL\n 7.0 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 11 mg/dL\n 23 mEq/L\n 104 mEq/L\n 2.9 mEq/L\n 137 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n \n 2:33 A9/22/ 12:29 PM\n \n 10:20 P9/22/ 01:12 PM\n \n 1:20 P9/22/ 01:30 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.2\n Hct\n 20.6\n 30.4\n Plt\n 154\n Cr\n 0.6\n Glucose\n 123\n Other labs: Alk Phos / T Bili:/0.6, Differential-Neuts:90.3 %,\n Lymph:3.0 %, Mono:6.1 %, Eos:0.6 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L\n Fluid analysis / Other labs: u/a: >50wbc, + nitrite, sm Leuk esterase.\n coag + staph aureus, 10,000-100,000.\n Imaging: CXR: minimal volume overload. minimal pleural effusion on R\n side.\n Microbiology: 6:48 pm URINE Source: Catheter.\n URINE CULTURE (Preliminary):\n STAPH AUREUS COAG +.\n 10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.\n ECG: EKG: sinus. rate 85. LBBB, no ST T wave changes when compared to\n previous.\n Assessment and Plan\n assessment and plan:\n 85 yo man with multiple myeloma as well as a history neurogenic\n presyncope secondary to autonomic dysfunction presenting initially with\n weakness and UTI, now with aphasia in the setting of hypotension, both\n have resolved with fluid repletion.\n .\n #) Hypotension: low reserve for hypotensive insult given baseline\n orthostatic hypotension.\n -likely infection related given + u/a with urine culture growing staph\n aureus, f/u sensitivities but currently will cover with vancomycin.\n Contact precautions for MRSA but no previous resistent bacteria on\n previous culture data.\n -vanc 1g IV q12hrs, cefepime 1g q 12 hrs\n -resend CBC / diff\n -send lactate\n -keep SBP > 110, has rec'd 2 liter bolus IVF, continue at rate of\n 250cc/hr\n -f/u CXR\n -resend U/a, ucx\n -send blood cultures and f/u previously send blood cx\n -if diarrhea will send C diff\n -given staph aureus obtain echo to r/o valvular / regurgitant lesions\n -continue florinef at home dose and salt tabs\n -rule out MI with 2 sets of enzymes 12 hours apart\n .\n #) Mental Status Changes: apparently these were expressive aphasia. He\n has no known cerebrovascular disease in the past but given the nature\n of these episodes he likley has some cerebrovascular stenosis which\n cause some reversible hypoperfusion during episodes of hypotension.\n -continue to bolus IVF for hypotension and mental status changes\n -when stable will send for CT head without contrast, then carotid\n ultrasound and MRA / MRI of the head (no contrast)\n -aspirin 325mg po daily\n #) chronic lower back pain:\n - due to malignant compression fractures multiple\n myeloma.\n continue oxycodone prn.\n .\n #) multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression\n -s/p bone marrow biopsy to evaluate for amyloid, will need to f/u these\n results\n .\n #) prophylaxis:\n - ppi and subcut heparin\n .\n #) full code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2123-10-26 00:00:00.000","description":"Nursing Progress Note","row_id":635971,"text":"85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Altered mental status (not Delirium)\n Assessment:\n At start of shift pt A&O x 3. Appropriate with words and responses to\n questions. Followed all commands, PERRL.\n Action:\n Full neuro assessment performed. Head CT and MRI done yesterday on\n days. Reported results negative.\n Response:\n Around midnight MS started to change. Pt had expressive asphasia, was\n A&O x 2\n unaware of time as he thought it was ^th. No\n facial droop noted, followed commands and had equal strength in all\n four extremities. Team aware of MS change.\n Plan:\n Con\nt to monitor mental status and reorient pt as needed. Con\nt to\n monitor neuro status.\n Hypotension (not Shock)\n Assessment:\n SBP at start of shift up to 170\ns systolic. Team aware.\n Action:\n Started on 200mg PO Labetalol .\n Response:\n SBP down to 100\ns and pt\ns mental status started to deteriorate as he\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\n d/c\nd. BP has been normotensive throughout noc.\n Plan:\n Con\nt to monitor BP and treat as needed.\n"},{"category":"Nursing","chartdate":"2123-10-25 00:00:00.000","description":"Nursing Progress Note","row_id":635924,"text":"85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Urinary tract infection (UTI)\n Assessment:\n +staph in urine, wbc\ns 9.2, lactic acid 1.0\n Action:\n Contact precautions for possible MRSA, BC X2 sent, CXR; pt started on\n vanco/cefapime for ? urosepsis.\n Response:\n T 95-97; given Tylenol on 7F prior to coming to MICU.\n Plan:\n Continue antibiotics, follow cultures, wbc\n Hypotension (not Shock)\n Assessment:\n NBP 141-156/74-96 while in bed; HR 80-92, LBBB.\n Action:\n Pt received total of 2L of fluid since arrival to MICU. Receiving\n florinef.\n Response:\n BP stable.\n Plan:\n Monitor orthostatic BP, continue florinef, IV fluid boluses for\n hypotension.\n Altered mental status (not Delirium)\n Assessment:\n A&O X2, slow to respond but usually knows where he is and the date.\n Moves all extremities\n Action:\n Head CT and MRI done. Receiving ASA.\n Response:\n No acute bleed seen.\n Plan:\n Monitor neuro status, follow neuro recs, continue ASA\n .H/O electrolyte & fluid disorder, other\n Assessment:\n Na 137, K 2.9\n Action:\n Receiving sodium tabs and received 40meq KCL/1L at 250/hr.\n Response:\n Pending.\n Plan:\n Monitor lytes q 12hrs, replete per onc sliding scale.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2123-11-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 93410,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. Amyloid involvement\\nHeight: (in) 70\\nWeight (lb): 141\\nBSA (m2): 1.80 m2\\nBP (mm Hg): 130/80\\nHR (bpm): 85\\nStatus: Outpatient\\nDate/Time: at 15:58\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Mildly depressed LVEF. No\\nresting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\\nmotion consistent with conduction abnormality/ventricular pacing.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\\naorta. No 2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS. Trivial MR. LV inflow pattern c/w impaired\\nrelaxation.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\\nvalve supporting structures. No TS. Mild [1+] TR. Normal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is elongated. There is mild symmetric left ventricular\\nhypertrophy. The left ventricular cavity is small. Overall left ventricular\\nsystolic function is mildly depressed (LVEF= 40-50 %) at least in part due to\\ncontractile dyssynchrony. Right ventricular chamber size and free wall motion\\nare normal. The ascending aorta is mildly dilated. The aortic valve leaflets\\n(3) are mildly thickened but aortic stenosis is not present. Trace aortic\\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. The left\\nventricular inflow pattern suggests impaired relaxation. The tricuspid valve\\nleaflets are mildly thickened. The estimated pulmonary artery systolic\\npressure is normal. There is no pericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is reduced. The left ventricular\\nend diastolic cavity dimension remains quite low, suggesting significant\\ndiastolic filling impairment or volume depletion or both.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-24 00:00:00.000\",\n \"description\": \"MR L SPINE W/O CONTRAST\",\n \"row_id\": 1035271,\n \"text\": \" 8:50 AM\\n MR L SPINE W/O CONTRAST Clip # \\n Reason: Please evaluate for cord compression.\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with MM and autonomic neuropathy with persistent urinary\\n retension.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for cord compression.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n MR LUMBAR SPINE, \\n\\n HISTORY: Multiple myeloma and autonomic neuropathy with urinary retention.\\n\\n Sagittal imaging was performed with long TR, long TE fast spin echo, STIR, and\\n short TR, short TE spin echo technique. Axial long TR, long TE fast spin echo\\n imaging was performed. Comparison to a lumbar spine MR .\\n\\n FINDINGS: Again identified are extensive vertebral body signal intensity\\n abnormalities compatible with a diagnosis of multiple myeloma. Again seen is\\n loss of height of the T12 and L1 vertebral bodies. These findings appear\\n unchanged since the previous study. Again seen is a spherical region of\\n hypointensity on the short TR images in the L2 vertebral body. This is also\\n unchanged. There is no evidence of cauda equina compression. Alignment of\\n the spine appears normal. Axial images at T11-12, , , and \\n demonstrate mild degenerative disc disease with no evidence of canal or\\n foraminal encroachment.\\n\\n At L3-4, there is a protrusion of the intervertebral disc entering the right\\n side of the spinal canal. This causes posterior displacement of the right L4\\n nerve root. The neural foramina appear normal.\\n\\n At L4-5, there is asymmetric bulge of the intervertebral disc with no evidence\\n of nerve root compression. There is right-sided facet joint osteophyte\\n formation.\\n\\n At L5-S1, there is a minimal bulge of the intervertebral disc with no\\n encroachment on the thecal sac or neural foramina.\\n\\n Signal intensity abnormalities compatible with the history of myeloma are also\\n noted in the visualized portions of the sacrum and the iliac bones.\\n\\n CONCLUSION: Diffuse signal intensity abnormalities in the vertebral bodies\\n compatible with the history of multiple myeloma.\\n\\n No evidence of cauda equina compression.\\n\\n Right-sided disc protrusion at L3-4.\\n\\n (Over)\\n\\n 8:50 AM\\n MR L SPINE W/O CONTRAST Clip # \\n Reason: Please evaluate for cord compression.\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1035420,\n \"text\": \" 11:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please evaluate for infection or other abnormalities.\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with MM, autonomic dysfunction with acute onset of hypotension\\n and mental status change.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for infection or other abnormalities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Follow-up.\\n\\n As compared to the previous examination, there is no relevant change. No\\n newly occurred focal parenchymal opacity suggestive of pneumonia, no\\n overhydration.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1035064,\n \"text\": \" 4:27 PM\\n CHEST (PA & LAT) Clip # \\n Reason: infectious process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with weakness near syncopal episode\\n REASON FOR THIS EXAMINATION:\\n infectious process\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old male with weakness and syncopal episode, to rule out a\\n cardiopulmonary process.\\n\\n TECHNIQUE: AP and lateral radiographs of the chest were performed.\\n Comparison is made with CT chest of .\\n\\n FINDINGS:\\n\\n There are multiple surgical sutures at the right lung base from a prior\\n resection. There is stable cardiomegaly. There are no acute focal\\n consolidations. There is raised right hemidiaphragm consistent with lung\\n resection.\\n\\n Multiple gas-filled distended loops of colon are seen in the upper abdomen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 1035638,\n \"text\": \" 10:27 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: eval for stenosis\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with expressive aphasia in the setting of hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Expressive aphasia, evaluate for stenosis.\\n\\n FINDINGS: Areas of plaque formation are noted at the proximal right ICA, as\\n well as the proximal left ICA extending into the bulb. No hemodynamically\\n significant stenosis is identified. Velocities are as follows.\\n\\n For the right, proximal CCA 44 cm/sec, distal CCA 49 cm/sec, proximal ICA 34\\n cm/sec, distal ICA 42 cm/sec, additional distal ICA 35 cm/sec, ECA 48 cm/sec,\\n with antegrade flow in the vertebral artery. ICA/CCA ratio 0.83.\\n\\n For the left, proximal CCA 64 cm/sec, distal CCA 52 cm/sec, proximal ICA 47\\n cm/sec, mid ICA 45.2 cm/sec, distal ICA 41 cm/sec, ECA 69 cm/sec, with\\n antegrade flow in the vertebral artery. ICA/CCA ratio 0.74.\\n\\n IMPRESSION: No evidence of hemodynamically significant stenosis. Plaque\\n formation involving the origin of the internal carotid arteries bilaterally.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"MRA BRAIN W/O CONTRAST\",\n \"row_id\": 1035484,\n \"text\": \" 2:35 PM\\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \\n Reason: eval for acute stroke or for stenosis of intracranial vessel\\n Admitting Diagnosis: WEAKNESS\\n Contrast: MAGNEVIST Amt: 13\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with expressive aphasia in the setting of hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for acute stroke or for stenosis of intracranial vessels. PLEASE PERFORM\\n MRI AND MRA OF HEAD.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa MON 7:25 PM\\n There is no evidence of acute ischemic changes. Prominence of the ventricles\\n and sulci, likely age-related and developmental in nature. There is no shift\\n or normally placed midline structures. M2 segments bilaterally versus\\n artifact.\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI AND MRA OF THE BRAIN\\n\\n CLINICAL INDICATION: 85-year-old man with expressive aphasia in the setting\\n of hypotension, please evaluate for stroke or stenosis of the intracranial\\n vessels.\\n\\n COMPARISON: Prior MRI of the head and CT of the head dated .\\n\\n TECHNIQUE: MRI of the head. Pre-contrast axial and sagittal T1-weighted\\n images were obtained, axial FLAIR, axial T2, axial magnetic susceptibility,\\n diffusion-weighted sequences. After the administration of intravenous\\n gadolinium contrast material, the T1-weighted images were repeated and axial\\n T1, sagittal MP-RAGE and multiplanar reconstructions.\\n\\n MRI OF THE HEAD:\\n\\n 3D time-of-flight arteriography was obtained, multiple rotational images were\\n submitted for interpretation as well as the axial source images.\\n\\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect or\\n large territorial infarction. The ventricles and sulci are slightly\\n prominent, likely age-related and involutional in nature.\\n\\n On T2 and FLAIR sequences, there are multiple scattered hyperintense foci\\n likely consistent with chronic microvascular ischemic changes. No diffusion\\n abnormalities are detected. The orbits appear unremarkable, the paranasal\\n sinuses again demonstrate mucus retention cyst in the left maxillary sinus,\\n the mastoid air cells appear unremarkable. After the administration of\\n intravenous gadolinium contrast, there is no evidence of abnormal enhancement.\\n\\n IMPRESSION: There is no evidence of acute ischemic changes. After the\\n administration of gadolinium contrast, there is no evidence of abnormal\\n enhancement. No diffusion abnormalities are detected. Prominence of the\\n (Over)\\n\\n 2:35 PM\\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \\n Reason: eval for acute stroke or for stenosis of intracranial vessel\\n Admitting Diagnosis: WEAKNESS\\n Contrast: MAGNEVIST Amt: 13\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n sulci and ventricles, likely age-related and involutional nature.\\n\\n Unchanged mucus retention cyst noted in the left maxillary sinus.\\n\\n MRA OF THE HEAD.\\n\\n FINDINGS: There is evidence of vascular flow in both internal carotids as\\n well as the vertebrobasilar system. Both medial cerebral arteries\\n demonstrates tortuosity and lack of flow in the M2 and M3 segments, possibly\\n related with arteriosclerotic changes versus artifact, correlation with CTA of\\n the head and neck is recommended if clinically warranted. In the posterior\\n circulation, there is no evidence of stenosis or narrowing of the vessels.\\n\\n IMPRESSION: Possible narrowing of the M2 and M3 segments bilaterally, more\\n evident on the right, possibly arteriosclerotic in nature, however, artifact\\n cannot be completely ruled out, correlation with CTA of the head and neck is\\n recommended if clinically warranted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"MRA BRAIN W/O CONTRAST\",\n \"row_id\": 1035485,\n \"text\": \", S. MED 2:35 PM\\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \\n Reason: eval for acute stroke or for stenosis of intracranial vessel\\n Admitting Diagnosis: WEAKNESS\\n Contrast: MAGNEVIST Amt: 13\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with expressive aphasia in the setting of hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for acute stroke or for stenosis of intracranial vessels. PLEASE PERFORM\\n MRI AND MRA OF HEAD.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n There is no evidence of acute ischemic changes. Prominence of the ventricles\\n and sulci, likely age-related and developmental in nature. There is no shift\\n or normally placed midline structures. M2 segments bilaterally versus\\n artifact.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1035482,\n \"text\": \" 2:34 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for bleed\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with expressive aphasia in setting of hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 7:25 PM\\n No acute intracranial process, including no evidence for hemorrhage, edema,\\n mass effect, or acute ischemia. Please note that MRI is more sensitive for\\n evaluation of ischemia.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old male with expressive aphasia in the setting of\\n hypertension.\\n\\n COMPARISON: CT of chest from .\\n\\n TECHNIQUE: Contiguous axial images were obtained through the brain without\\n administration of IV contrast.\\n\\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\\n infarction. The ventricles and sulci are normal in caliber and configuration.\\n The -white matter differentiation is preserved. Again noted are carotid\\n artery calcifications and a large mucus retention cyst in the left maxillary\\n sinus. Remainder of the paranasal sinuses and mastoid air cells are normally\\n pneumatized and clear.\\n\\n IMPRESSION: No acute intracranial process. However, MRI is more sensitive\\n for acute ischemia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1035483,\n \"text\": \", S. MED 2:34 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for bleed\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with expressive aphasia in setting of hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n No acute intracranial process, including no evidence for hemorrhage, edema,\\n mass effect, or acute ischemia. Please note that MRI is more sensitive for\\n evaluation of ischemia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1036189,\n \"text\": \" 4:06 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Please assess for acute bleed, evidence of stroke.\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with hypotension, confusion and elevated PTT.\\n REASON FOR THIS EXAMINATION:\\n Please assess for acute bleed, evidence of stroke.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:41 PM\\n Noa cute intracranial hemorrhage or large acute infarction. MR is more\\n sensitive for acute ischemia.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 86-year-old male patient, with hypertension, confusion and\\n elevated PTT, to evaluate for acute bleed, evidence of stroke.\\n\\n COMPARISON: CT of the head done on .\\n\\n TECHNIQUE: Non-contrast CT of the head was performed.\\n\\n FINDINGS: There is no acute intracranial hemorrhage, mass effect, shift of\\n normally midline structures, or hydrocephalus. Prominent ventricles, and\\n extra-axial CSF spaces and cerebral sulci are noted, related to mild diffuse\\n parenchymal volume loss, likely age appropriate and are unchanged.\\n Atherosclerotic calcifications are noted in the cavernous segments of the\\n internal carotid arteries and their distal vertebral arteries. No large\\n hypodense areas are seen to suggest large areas of acute infarction.\\n No osseous lytic or sclerotic lesions are noted.\\n\\n IMPRESSION:\\n\\n No acute intracranial hemorrhage. No obvious large acute infarct. However,\\n MRI is more sensitive for acute ischemia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1036190,\n \"text\": \", E. OMED 4:06 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Please assess for acute bleed, evidence of stroke.\\n Admitting Diagnosis: WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 86 year old man with hypotension, confusion and elevated PTT.\\n REASON FOR THIS EXAMINATION:\\n Please assess for acute bleed, evidence of stroke.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Noa cute intracranial hemorrhage or large acute infarction. MR is more\\n sensitive for acute ischemia.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 245346,\n \"text\": \"Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\\nof no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 245347,\n \"text\": \"Sinus rhythm\\nLeft bundle branch block\\nSince previous tracing of the same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 245348,\n \"text\": \"Sinus rhythm\\nLeft bundle branch block\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2123-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 245349,\n \"text\": \"Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\\nof there is no significant diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2123-10-27 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 636216,\n \"text\": \"Progress Note:\\n Spoke briefly with pt\\ns daughter, , who is in the process of trying\\n to arrange for an alternative living situation for her sister who has\\n CP. Currently, she is in the process of applying for Mass Health and\\n meeting with a lawyer to make changes in her father\\ns will. Mr. \\n wants his daughter to remain at home with him and his wife until he\\n dies, but that is not an option. She would like her father to be at\\n home with hospice, but she first needs to know what the financial\\n situation is, as he would need 24-hour care. said that she\\n several in the fire\\n; it seems as though she is trying to resolve\\n this critical matters as quickly as she can.\\n Plan:\\n 1. Pt is being transferred to 7F, so there will be no f/u.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 636457,\n \"text\": \"Chief Complaint: Hypotension\\n HPI:\\n 85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .\\n The patient currently remains asymptomatic. He does not feel confused,\\n felt lightheaded during the episodes but not currently. As above ROS\\n is negative. No F/C.\\n History obtained from Patient\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:00 AM\\n Vancomycin - 09:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:01 PM\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n MM, diagnosed , followed by Heme, on Velcade/mephalan/prednisone\\n for past month , c/b lytic lesions/compression fractures - recnet\\n XRT to spine.\\n BPH (meds were d/c'ed due to hypotension)\\n dyslipidemia\\n X2 : reported normal Echo, unremarkable holter per chart\\n IVCD/LBBB-old\\n LBP- pathological compression fx T12/L1 s/p choley 10years ago\\n lung nodule s/p resection many years ago, reported benign\\n Mother died uterine Ca, Father died PNA, has one brother/one sister who\\n are alive and well at age 80s\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other:\\n Review of systems:\\n Flowsheet Data as of 11:55 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.6\\nC (97.8\\n HR: 87 (77 - 97) bpm\\n BP: 151/96(104) {104/43(58) - 191/142(125)} mmHg\\n RR: 31 (15 - 31) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 913 mL\\n PO:\\n 250 mL\\n TF:\\n IVF:\\n 663 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 850 mL\\n Urine:\\n 850 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 63 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL, Supraclavicular WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Crackles : Bibasilary)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 207 K/uL\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 9 mg/dL\\n 23 mEq/L\\n 105 mEq/L\\n 3.4 mEq/L\\n 134 mEq/L\\n 29.1 %\\n 4.4 K/uL\\n [image002.jpg]\\n \\n 2:33 A9/22/ 12:29 PM\\n \\n 10:20 P9/22/ 01:12 PM\\n \\n 1:20 P9/22/ 01:30 PM\\n \\n 11:50 P9/23/ 04:42 AM\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 9.2\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 85 yo man with MM, neurogenic orthostatics ( autonomic dysfunction),\\n with UTI and now transfered to ICU for hypotension and AMS that are now\\n resolved.\\n .\\n # AMS: Patient with hypotension and AMS that responded to position and\\n 500cc fluid bolus. Patient at baseline on arrival to the ICU. Most\\n likely etiology patient had low fluid intake and got dehydrated.\\n - F/u I/O\\n - F/U JVP\\n - 500cc NS bolus if hypotensive\\n - Move slowly from one position to another (avoid orhtostatics)\\n - Telemetry\\n - EKG\\n .\\n # Multiple myeloma:\\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\\n for T11/sacral spine related to Multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt was going to\\n get radiation today.\\n - F/u BMT recs\\n - Possible radiotherapy tomorrow\\n .\\n # chronic lower back pain:\\n - due to malignant compression fractures multiple\\n myeloma.\\n continue oxycodone prn.\\n .\\n # prophylaxis:\\n - ppi and subcut heparin\\n .\\n # Access: peripherals\\n .\\n #) full code.\\n .\\n # Contact: (wife) \\n .\\n # Dispo: Floor tomorrow morning if stable\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 04:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 636445,\n \"text\": \"Chief Complaint: Altered mental status / low SBP\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 85yo man with a h/o MM, autonomic dysfunction (on florinef, possibly\\n amyloid?), BPH c/b urinary tract obstruction necessitating foley\\n who was admitted with weakness and \\\"near syncope\\\" observed by VNA. male\\n with multiple myeloma and as well as autonomic dysfunction on florinef\\n ? secondary to amyloid.He was on the Medicine floor when on the AM of\\n he developed expressive aphasia while working with PT; SBP found\\n to be ~90. He received a 500cc bolus and his SBP improved to 120 and\\n his aphasia resolved. Unfortunately, his SBP dropped again, aphasia\\n returned and he was transferred to the . He was confused in\\n addition to being aphasic, but otherwise asymptomatic. Neuro evaluated\\n him, head CT, MRI/A were unrevealing for acute pathology. He was found\\n to have a urinary tract infection; with treatment his delirium /\\n aphasia resolved. Returned to the floor on .\\n Unfortunately, on he had recurrence of his neurological symptoms\\n with borderline BP and was again transferred to the for\\n monitoring. This morning he was found to be lethargic and minimally\\n responsive; SBP was 80/60. He became spontaneously responsive and was\\n confused and disoriented. He received a 500cc bolus and SBP increased\\n to 90s but he remained disoriented.\\n No new recent med changes or other localizing symptoms. He did receive\\n an extra dose of Oxycodone 5mg at noon prior to this episode of altered\\n mental status.\\n After arriving in the , his SBP was ~150 and he was at his baseline\\n -- A&Ox 3. He remembers the team members by name. He has no\\n complaints. He doesn't have a clear recollection of the episode of\\n unresponsiveness from this morning.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 07:45 AM\\n Cefipime - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Aspirin 325\\n Finesteride 5\\n Mag sulfate\\n Florinef .1\\n Lipitor 10\\n Eye gtts\\n Heparin subQ\\n Protonix 40 \\n RSSI\\n Oxycodone 2.5-5mg PO Q4hr STANDING and intermittent PRN doses\\n Cefepime\\n Vanc\\n Past medical history:\\n Family history:\\n Social History:\\n 1) Multiple myeloma c/b chronic back pain\\n 2) Dysautonomia (some suspicion of amyloid as the cause?)\\n 3) BPH requiring foley c/b UTIs\\n Mother with uterine cancer, otherwise non-contributory.\\n Occupation: Was a job placement coordinator\\n Drugs: None\\n Tobacco: Quit > 20 years ago\\n Alcohol: None\\n Other: Lives with his wife who is healthy, has a disabled daughter.\\n Review of systems:\\n Constitutional: No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley\\n Integumentary (skin): No(t) Rash\\n Neurologic: No(t) Headache\\n Psychiatric / Sleep: No(t) Suicidal\\n Flowsheet Data as of 06:52 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n HR: 86 (77 - 86) bpm\\n BP: 191/142(125) {157/85(104) - 191/142(125)} mmHg\\n RR: 22 (15 - 22) insp/min\\n SpO2: 100%\\n Total In:\\n 187 mL\\n PO:\\n TF:\\n IVF:\\n 187 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 187 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese, No(t) Anxious\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n Sclera edema\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal), S3, No(t) S4,\\n No(t) Rub, (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\\n Wheezes : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\\n Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 207 K/uL\\n 29.1 %\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 9 mg/dL\\n 23 mEq/L\\n 105 mEq/L\\n 3.4 mEq/L\\n 134 mEq/L\\n 4.4 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n WBC\\n 4.5\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Imaging: Head CT (): No acute process.\\n Microbiology: No new micro data.\\n Assessment and Plan\\n Impression: 85yo man with a h/o MM, autonomic dysfunction (on florinef,\\n possibly amyloid?), BPH c/b urinary tract obstruction necessitating\\n foley who was admitted with weakness and \\\"near syncope\\\" now with a\\n second episode of in-hospital altered mental status / delirium of\\n unclear etiology.\\n 1) Altered mental status: It's difficult to ascribe his altered mental\\n status to transient hypotension alone, however this may be palying a\\n role. It's possible that his opiates precipitated this episode given\\n that he received an extra dose of Oxycodone at noon and was\\n subsequently found to be altered. His SBP may have been decreased due\\n to the extra opiate dose as well. He has no obvious signs of an\\n infectious, cardiac or primary neurologic process causing these\\n symptoms.\\n 2) Pain: Will start a Lidocaine patch in an effort to better treat his\\n pain. Minimizing / avoiding opiates may be warranted given there's a\\n possible association with his delirium.\\n 3) F/E/N: Regular diet. Follow / replete 'lytes.\\n 4) CV: Transient hypotension as above. No EKG e/o infarct. Consider TTE\\n to evaluate although his last TTE in revealed a EF of 50-55%\\n 5) Full code, access pIV, PPI and subQ heparin.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 22 Gauge - 04:30 PM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636517,\n \"text\": \"Chief Complaint: Hypotension\\n 24 Hour Events:\\n CALLED OUT\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:00 AM\\n Vancomycin - 09:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:01 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.4\\nC (95.7\\n HR: 84 (75 - 97) bpm\\n BP: 155/71(92) {104/43(58) - 191/142(125)} mmHg\\n RR: 17 (11 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 915 mL\\n 117 mL\\n PO:\\n 250 mL\\n TF:\\n IVF:\\n 665 mL\\n 117 mL\\n Blood products:\\n Total out:\\n 850 mL\\n 810 mL\\n Urine:\\n 850 mL\\n 810 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 65 mL\\n -693 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Lymphatic: Cervical WNL, Supraclavicular WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 217 K/uL\\n 10.1 g/dL\\n 98 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 3.1 mEq/L\\n 10 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 29.2 %\\n 5.8 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n 04:21 AM\\n WBC\\n 9.2\\n 4.4\\n 5.8\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n 29.2\\n Plt\\n 154\\n 207\\n 217\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n 98\\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 04:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 636535,\n \"text\": \"Chief Complaint: Sepsis\\n Bradycardia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 08:30 AM\\n EKG - At 09:30 AM\\n Patient with improved alterness and responsiveness\\n Pressors required for continued support of blood pressure\\n TTE--Nl LV size and function with dilated hypokinetic RV and mod/seve\\n TR\\n CVO2=78\\n History obtained from Medical records\\n Allergies:\\n Zocor (Oral) (Simvastatin)\\n myalgias;\\n Flagyl (Oral) (Metronidazole)\\n Diarrhea;\\n Last dose of Antibiotics:\\n Vancomycin - 06:57 PM\\n Ceftriaxone - 04:18 PM\\n Metronidazole - 08:00 PM\\n Infusions:\\n Phenylephrine - 1.5 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 10:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Flowsheet Data as of 08:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 56 (45 - 59) bpm\\n BP: 101/38(59) {89/36(54) - 131/54(80)} mmHg\\n RR: 20 (10 - 20) insp/min\\n SpO2: 87%\\n Heart rhythm: SB (Sinus Bradycardia)\\n Height: 61 Inch\\n CVP: 24 (7 - 24)mmHg\\n Mixed Venous O2% Sat: 78 - 78\\n Total In:\\n 3,382 mL\\n 626 mL\\n PO:\\n TF:\\n IVF:\\n 3,382 mL\\n 626 mL\\n Blood products:\\n Total out:\\n 695 mL\\n 350 mL\\n Urine:\\n 695 mL\\n 350 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,687 mL\\n 276 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 87%\\n ABG: 7.30/37/70/17/-7\\n Physical Examination\\n General Appearance: Well nourished\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n Bilaterally, Diminished: )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: 1+, Left: 1+\\n Musculoskeletal: Unable to stand\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 10.1 g/dL\\n 132 K/uL\\n 177 mg/dL\\n 4.2 mg/dL\\n 17 mEq/L\\n 4.5 mEq/L\\n 115 mg/dL\\n 95 mEq/L\\n 127 mEq/L\\n 30.0 %\\n 30.2 K/uL\\n [image002.jpg]\\n 10:06 PM\\n 10:35 PM\\n 12:30 AM\\n 03:46 AM\\n 04:24 AM\\n 08:50 AM\\n 04:26 PM\\n 04:36 PM\\n 04:23 AM\\n 08:29 AM\\n WBC\\n 36.0\\n 30.2\\n Hct\\n 32\\n 31.5\\n 30.0\\n Plt\\n 167\\n 132\\n Cr\\n 4.1\\n 3.9\\n 3.9\\n 4.1\\n 4.2\\n TropT\\n 0.05\\n TCO2\\n 14\\n 17\\n 19\\n 18\\n 19\\n Glucose\\n 150\\n 240\\n 331\\n 175\\n 177\\n Other labs: PT / PTT / INR:17.3//1.6, CK / CKMB /\\n Troponin-T:384/17/0.05, Differential-Neuts:92.0 %, Band:6.0 %,\\n Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, LDH:615\\n IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:6.0 mg/dL\\n Fluid analysis / Other labs: 7.29/35/95\\n 7.30/37/70/19 on 4 liters NC\\n Imaging: CXR--increased right sided pulmonary parenchymal opacities and\\n suggestion of small right sided effusion.\\n Assessment and Plan\\n 67 yo female admit with hypotension and bradycardia now with findings\\n on ECHO to suggest significant impairment in RV function and\\n significant increase in pulmonary artery pressures noted (mod PAH and\\n TR). This in in the setting of persistent bradycardia suggesting\\n possible RV vascular distribution ischemia. In addition the elevations\\n in pulmonary artery pressure remain to be defined in regards to\\n source. Finally--she retains a significant bandemia in the setting of\\n elevated WBC count.\\n The source of persistent hypotension seems in large part to be driven\\n by cardiac compromise (high BNP, ECHO findings) in the setting of\\n persistent bradycardia\\nperhaps increased RV afterload and difficulty\\n with maintenance of effective CO with increased demand in the setting\\n of likely systemic infection with possible urinary source as evidenced\\n by the elevated WBC count and bandemia. GI source with diarrhea\\n suspected but diarrhea not clearly confirmed. The current source of\\n the elevated PA pressures in the setting of preserved LV function\\n remains to be defined.\\n 1)Shock-\\n Vasodilatory Component-\\n -CTX/Flagyl for possible bacterial infection and C. Diff\\n -Neosynephrine/Levophed continue and hope to wean\\n -Cultures pending\\n Cardiogenic Component-\\n -Possible PE raised as source of obstruction, may be tumor embolus as\\n well\\nwould like to treat for possible PE and favor treatment if we can\\n find reassurance that bleeding risk is reasonable and head CT negative\\n for CNS lesion/mass and study for PE is positive\\n -Bradycardia persistent, BNP is up, do not see evidence of acute MI on\\n findings thus far\\nmild elevations in enzymes have decreased and may be\\n evidence of remote insult or current area at risk\\n -Favor change to IV Beta specific agonists for support\\nwith Dopamine\\n representing reasonable compromise as with fixed and impaired RV stroke\\n volume and peripheral beta effects Dobutamine represents a second\\n choice.\\n -LV function is preserved\\n Hypovolemia-\\n -Has been resolved with UVF to the point of likely volume overload\\n 2)Bradycardia-\\n -Telemetry\\n -Consider inotrope and chronotrope support for pressors\\n -Will look to RV leads to help assure no ongoing insult in the setting\\n of stable enzymes\\n 3)Acute Renal Failure-\\n -Likley ATN\\n -Continue support of BP\\n FeNa=low and poor perfusion but now evolving a process consistent with\\n ATN\\n ICU Care\\n Nutrition: Po diet of clears\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Multi Lumen - 07:03 PM\\n Arterial Line - 10:00 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 60 minutes\\n ------ Protected Section ------\\n PATIENT CODE STATUS IS DNR/DNI\\n ------ Protected Section Addendum Entered By: , MD\\n on: 09:18 ------\\n Chief Complaint: Altered Mental Status\\n Hypotension\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n CALLED OUT\\n Patient with much improved stability with IVF given. No evidence of\\n recurrent events with overnight monitoring\\n History obtained from Medical records\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:00 AM\\n Vancomycin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Flowsheet Data as of 09:29 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.8\\nC (96.4\\n HR: 80 (75 - 97) bpm\\n BP: 137/86(99) {104/43(58) - 191/142(125)} mmHg\\n RR: 23 (11 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 915 mL\\n 343 mL\\n PO:\\n 250 mL\\n TF:\\n IVF:\\n 665 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 850 mL\\n 900 mL\\n Urine:\\n 850 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 65 mL\\n -557 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Place and Person, Movement: Purposeful, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.1 g/dL\\n 217 K/uL\\n 98 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 3.1 mEq/L\\n 10 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 29.2 %\\n 5.8 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n 04:21 AM\\n WBC\\n 9.2\\n 4.4\\n 5.8\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n 29.2\\n Plt\\n 154\\n 207\\n 217\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n 98\\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n yo male with recurrent ICU admission with a repeat of similar\\n scenario to prior admission. He has a picture of orthostatic\\n instability and in the setting of mild hypovolemia he has had recurrent\\n altered mental status. In the setting of ongoing treatment--certainly\\n maintenance of optimal volume status is essential.\\n 1)Altered Mental Status-\\n -Orthostatic Hypotension-\\n -Salt Tabs\\n -Fludricort\\n -Maintain optimal fluid status\\n -Rx with Vanco\\n -Return to oncology floor today.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 22 Gauge - 04:30 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition :Transfer to floor\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636441,\n \"text\": \"85 yo male with multiple myeloma as well as autonomic dysfunction on\\n florinef ? secondary to amyloid. He also has BPH and a recent history\\n of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea. On vanco for RX\\n of UTI ( staph).\\n Pt discharged from after he had an episode of expressive\\n aphasia, & SBP 90. Ct scan negative Responded to fld bolus. Aphasia\\n resolved.\\n Today pt found\\nasleep\\n When awakened oriented to person only. SP\\n 84/60, RR 25, HR 75. Sats975 on RA. Given cefipime 2 gm & NS 500 cc\\n with improvement in MS & BP.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert, OX3. Conversing on phone. MEA.\\n Action:\\n Ct scan done prior to ICU admission. Results pnd\\n Response:\\n Oriented\\n Plan:\\n Cont to assess MS, neuro status\\n Hypotension (not Shock)\\n Assessment:\\n Bp 157/86, hr 80\\nS. Receiving maint IVF at 100 c chr X 5 hrs.\\n Action:\\n Ongoing assessment\\n Response:\\n Normotensive at present\\n Plan:\\n Cont to asses BP\\n Urinary tract infection (UTI)\\n Assessment:\\n Afeb, Received dose cefipime prior to ICU transfer. On vanco\\n Action:\\n Response:\\n Afeb\\n Plan:\\n Cont to assess for S&Sx of infection, MS changes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636549,\n \"text\": \"Chief Complaint: Hypotension\\n 24 Hour Events:\\n CALLED OUT\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:00 AM\\n Vancomycin - 09:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:01 PM\\n Heparin Sodium (Prophylaxis) - 12:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:53 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.4\\nC (95.7\\n HR: 84 (75 - 97) bpm\\n BP: 155/71(92) {104/43(58) - 191/142(125)} mmHg\\n RR: 17 (11 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 915 mL\\n 117 mL\\n PO:\\n 250 mL\\n TF:\\n IVF:\\n 665 mL\\n 117 mL\\n Blood products:\\n Total out:\\n 850 mL\\n 810 mL\\n Urine:\\n 850 mL\\n 810 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 65 mL\\n -693 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Lymphatic: Cervical WNL, Supraclavicular WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 217 K/uL\\n 10.1 g/dL\\n 98 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 3.1 mEq/L\\n 10 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 29.2 %\\n 5.8 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n 04:21 AM\\n WBC\\n 9.2\\n 4.4\\n 5.8\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n 29.2\\n Plt\\n 154\\n 207\\n 217\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n 98\\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n 85 yo man with MM, neurogenic orthostatics ( autonomic dysfunction),\\n with UTI and now transfered to ICU for hypotension and AMS that are now\\n resolved.\\n .\\n # AMS: Patient with hypotension and AMS that responded to position and\\n 500cc fluid bolus. Patient at baseline on arrival to the ICU. Most\\n likely etiology patient had low fluid intake and got dehydrated.\\n - F/u I/O\\n - F/U JVP\\n - 500cc NS bolus if hypotensive\\n - Move slowly from one position to another (avoid orhtostatics)\\n - Telemetry\\n - EKG\\n .\\n # Multiple myeloma:\\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\\n for T11/sacral spine related to Multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt was going to\\n get radiation today.\\n - F/u BMT recs\\n - Possible radiotherapy tomorrow\\n .\\n # chronic lower back pain:\\n - due to malignant compression fractures multiple\\n myeloma.\\n continue oxycodone prn.\\n .\\n # prophylaxis:\\n - ppi and subcut heparin\\n .\\n # Access: peripherals\\n .\\n #) full code.\\n .\\n # Contact: (wife) \\n .\\n # Dispo: Floor tomorrow morning if stable\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 04:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 636610,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\\n for T11/sacral spine related to multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt had\\n radiation today no c/o back pain no Oxycodone given\\n Action:\\n Radiation today. Pt on Lidocaine patch 5% for lower back.\\n Response:\\n Tolerated well\\n Plan:\\n Continue radiation Mon-Thursday of next week. Pt called out to\\n Hem/Onc.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\\n 120/64 HR 70\\ns SR no vea noted\\n Action:\\n None required\\n Response:\\n Pt back to baseline mental status\\n Plan:\\n Continue to observe for changes in mental status Florinef increased\\n to .1 mg ?tilt table test to be done inpatient.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley, pt has foley , draining clear yellow\\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\\n cultures done x 2, urine cx sent\\n Action:\\n Vanco \\n Response:\\n Afebrile, no complaints, good urine output 30 cc/hr\\n Plan:\\n Continue with antibx, monitor urine output\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 636611,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\\n for T11/sacral spine related to multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt had\\n radiation today no c/o back pain no Oxycodone given\\n Action:\\n Radiation today. Pt on Lidocaine patch 5% for lower back.\\n Response:\\n Tolerated well\\n Plan:\\n Continue radiation Mon-Thursday of next week. Pt called out to\\n Hem/Onc.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\\n 120/64 HR 70\\ns SR no vea noted\\n Action:\\n None required\\n Response:\\n Pt back to baseline mental status\\n Plan:\\n Continue to observe for changes in mental status Florinef increased\\n to .1 mg ?tilt table test to be done inpatient.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley, pt has foley , draining clear yellow\\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\\n cultures done x 2, urine cx sent\\n Action:\\n Vanco \\n Response:\\n Afebrile, no complaints, good urine output 30 cc/hr\\n Plan:\\n Continue with antibx, monitor urine output\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 635911,\n \"text\": \"Clinician: Attending\\n 85 yo male patient with history of MM and orthostatic hypotension who\\n on the oncology floor was admitted with malaise, fatigue and near\\n sycope. He had evolution of UTI by U/A with staph species identified\\n and despite initial treatment with Cipro has evolved evidence of\\n persistent infection and limited response to ABX treatment to date.\\n On the floor he did evolve an pattern of hypotension which has been\\n raised as concern for both his orthostatic hypotension and persistent\\n infection. In that setting he did develop an expressive aphasia and\\n neurology service was consulted for aid in evlauation and patient\\n transferred to ICU for further care.\\n Here--patient is comfortable, no focal complaints but states \\\"feels\\n lousy\\\"\\n Patient has significant word finding difficulties but not aphasia\\n He is A+O x1 by my exam\\n Lungs-CTA\\n Heart-regular\\n Abd-NT, normal BS\\n 85 yo male with presentation with urinary tract infection and Staph\\n species identified and only recently changed to Vanco/Cefepime for\\n broader coverage. He will be maintained on Florinef for orthostatic\\n hypotension along with NaCl tablets.\\n In regards to his aphasia reported he will have neuro exam on regular\\n basis and in consultation with neurology will pursue MRI/MRA and CT\\n Head to evaluate for region at risk.\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 636601,\n \"text\": \"Chief Complaint: Altered mental status / low SBP\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 85yo man with a h/o MM, autonomic dysfunction (on florinef, possibly\\n amyloid?), BPH c/b urinary tract obstruction necessitating foley\\n who was admitted with weakness and \\\"near syncope\\\" observed by VNA. male\\n with multiple myeloma and as well as autonomic dysfunction on florinef\\n ? secondary to amyloid.He was on the Medicine floor when on the AM of\\n he developed expressive aphasia while working with PT; SBP found\\n to be ~90. He received a 500cc bolus and his SBP improved to 120 and\\n his aphasia resolved. Unfortunately, his SBP dropped again, aphasia\\n returned and he was transferred to the . He was confused in\\n addition to being aphasic, but otherwise asymptomatic. Neuro evaluated\\n him, head CT, MRI/A were unrevealing for acute pathology. He was found\\n to have a urinary tract infection; with treatment his delirium /\\n aphasia resolved. Returned to the floor on .\\n Unfortunately, on he had recurrence of his neurological symptoms\\n with borderline BP and was again transferred to the for\\n monitoring. This morning he was found to be lethargic and minimally\\n responsive; SBP was 80/60. He became spontaneously responsive and was\\n confused and disoriented. He received a 500cc bolus and SBP increased\\n to 90s but he remained disoriented.\\n No new recent med changes or other localizing symptoms. He did receive\\n an extra dose of Oxycodone 5mg at noon prior to this episode of altered\\n mental status.\\n After arriving in the , his SBP was ~150 and he was at his baseline\\n -- A&Ox 3. He remembers the team members by name. He has no\\n complaints. He doesn't have a clear recollection of the episode of\\n unresponsiveness from this morning.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 07:45 AM\\n Cefipime - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Aspirin 325\\n Finesteride 5\\n Mag sulfate\\n Florinef .1\\n Lipitor 10\\n Eye gtts\\n Heparin subQ\\n Protonix 40 \\n RSSI\\n Oxycodone 2.5-5mg PO Q4hr STANDING and intermittent PRN doses\\n Cefepime\\n Vanc\\n Past medical history:\\n Family history:\\n Social History:\\n 1) Multiple myeloma c/b chronic back pain\\n 2) Dysautonomia (some suspicion of amyloid as the cause?)\\n 3) BPH requiring foley c/b UTIs\\n Mother with uterine cancer, otherwise non-contributory.\\n Occupation: Was a job placement coordinator\\n Drugs: None\\n Tobacco: Quit > 20 years ago\\n Alcohol: None\\n Other: Lives with his wife who is healthy, has a disabled daughter.\\n Review of systems:\\n Constitutional: No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley\\n Integumentary (skin): No(t) Rash\\n Neurologic: No(t) Headache\\n Psychiatric / Sleep: No(t) Suicidal\\n Flowsheet Data as of 06:52 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n HR: 86 (77 - 86) bpm\\n BP: 191/142(125) {157/85(104) - 191/142(125)} mmHg\\n RR: 22 (15 - 22) insp/min\\n SpO2: 100%\\n Total In:\\n 187 mL\\n PO:\\n TF:\\n IVF:\\n 187 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 187 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese, No(t) Anxious\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n Sclera edema\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal), S3, No(t) S4,\\n No(t) Rub, (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\\n Wheezes : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\\n Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 207 K/uL\\n 29.1 %\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 9 mg/dL\\n 23 mEq/L\\n 105 mEq/L\\n 3.4 mEq/L\\n 134 mEq/L\\n 4.4 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n WBC\\n 4.5\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Imaging: Head CT (): No acute process.\\n Microbiology: No new micro data.\\n Assessment and Plan\\n Impression: 85yo man with a h/o MM, autonomic dysfunction (on florinef,\\n possibly amyloid?), BPH c/b urinary tract obstruction necessitating\\n foley who was admitted with weakness and \\\"near syncope\\\" now with a\\n second episode of in-hospital altered mental status / delirium of\\n unclear etiology.\\n 1) Altered mental status: It's difficult to ascribe his altered mental\\n status to transient hypotension alone, however this may be palying a\\n role. It's possible that his opiates precipitated this episode given\\n that he received an extra dose of Oxycodone at noon and was\\n subsequently found to be altered. His SBP may have been decreased due\\n to the extra opiate dose as well. He has no obvious signs of an\\n infectious, cardiac or primary neurologic process causing these\\n symptoms.\\n 2) Pain: Will start a Lidocaine patch in an effort to better treat his\\n pain. Minimizing / avoiding opiates may be warranted given there's a\\n possible association with his delirium.\\n 3) F/E/N: Regular diet. Follow / replete 'lytes.\\n 4) CV: Transient hypotension as above. No EKG e/o infarct. Consider TTE\\n to evaluate although his last TTE in revealed a EF of 50-55%\\n 5) Full code, access pIV, PPI and subQ heparin.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 22 Gauge - 04:30 PM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 636602,\n \"text\": \"Chief Complaint: Altered mental status / low SBP\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 85yo man with a h/o MM, autonomic dysfunction (on florinef, possibly\\n amyloid?), BPH c/b urinary tract obstruction necessitating foley\\n who was admitted with weakness and \\\"near syncope\\\" observed by VNA. male\\n with multiple myeloma and as well as autonomic dysfunction on florinef\\n ? secondary to amyloid.He was on the Medicine floor when on the AM of\\n he developed expressive aphasia while working with PT; SBP found\\n to be ~90. He received a 500cc bolus and his SBP improved to 120 and\\n his aphasia resolved. Unfortunately, his SBP dropped again, aphasia\\n returned and he was transferred to the . He was confused in\\n addition to being aphasic, but otherwise asymptomatic. Neuro evaluated\\n him, head CT, MRI/A were unrevealing for acute pathology. He was found\\n to have a urinary tract infection; with treatment his delirium /\\n aphasia resolved. Returned to the floor on .\\n Unfortunately, on he had recurrence of his neurological symptoms\\n with borderline BP and was again transferred to the for\\n monitoring. This morning he was found to be lethargic and minimally\\n responsive; SBP was 80/60. He became spontaneously responsive and was\\n confused and disoriented. He received a 500cc bolus and SBP increased\\n to 90s but he remained disoriented.\\n No new recent med changes or other localizing symptoms. He did receive\\n an extra dose of Oxycodone 5mg at noon prior to this episode of altered\\n mental status.\\n After arriving in the , his SBP was ~150 and he was at his baseline\\n -- A&Ox 3. He remembers the team members by name. He has no\\n complaints. He doesn't have a clear recollection of the episode of\\n unresponsiveness from this morning.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 07:45 AM\\n Cefipime - 10:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Aspirin 325\\n Finesteride 5\\n Mag sulfate\\n Florinef .1\\n Lipitor 10\\n Eye gtts\\n Heparin subQ\\n Protonix 40 \\n RSSI\\n Oxycodone 2.5-5mg PO Q4hr STANDING and intermittent PRN doses\\n Cefepime\\n Vanc\\n Past medical history:\\n Family history:\\n Social History:\\n 1) Multiple myeloma c/b chronic back pain\\n 2) Dysautonomia (some suspicion of amyloid as the cause?)\\n 3) BPH requiring foley c/b UTIs\\n Mother with uterine cancer, otherwise non-contributory.\\n Occupation: Was a job placement coordinator\\n Drugs: None\\n Tobacco: Quit > 20 years ago\\n Alcohol: None\\n Other: Lives with his wife who is healthy, has a disabled daughter.\\n Review of systems:\\n Constitutional: No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\\n Tachycardia, No(t) Orthopnea\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley\\n Integumentary (skin): No(t) Rash\\n Neurologic: No(t) Headache\\n Psychiatric / Sleep: No(t) Suicidal\\n Flowsheet Data as of 06:52 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n HR: 86 (77 - 86) bpm\\n BP: 191/142(125) {157/85(104) - 191/142(125)} mmHg\\n RR: 22 (15 - 22) insp/min\\n SpO2: 100%\\n Total In:\\n 187 mL\\n PO:\\n TF:\\n IVF:\\n 187 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 187 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n ABG: ////\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese, No(t) Anxious\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n Sclera edema\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal), S3, No(t) S4,\\n No(t) Rub, (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\\n Wheezes : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\\n Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 207 K/uL\\n 29.1 %\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 9 mg/dL\\n 23 mEq/L\\n 105 mEq/L\\n 3.4 mEq/L\\n 134 mEq/L\\n 4.4 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n WBC\\n 4.5\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Imaging: Head CT (): No acute process.\\n Microbiology: No new micro data.\\n Assessment and Plan\\n Impression: 85yo man with a h/o MM, autonomic dysfunction (on florinef,\\n possibly amyloid?), BPH c/b urinary tract obstruction necessitating\\n foley who was admitted with weakness and \\\"near syncope\\\" now with a\\n second episode of in-hospital altered mental status / delirium of\\n unclear etiology.\\n 1) Altered mental status: It's difficult to ascribe his altered mental\\n status to transient hypotension alone, however this may be palying a\\n role. It's possible that his opiates precipitated this episode given\\n that he received an extra dose of Oxycodone at noon and was\\n subsequently found to be altered. His SBP may have been decreased due\\n to the extra opiate dose as well. He has no obvious signs of an\\n infectious, cardiac or primary neurologic process causing these\\n symptoms.\\n 2) Pain: Will start a Lidocaine patch in an effort to better treat his\\n pain. Minimizing / avoiding opiates may be warranted given there's a\\n possible association with his delirium.\\n 3) F/E/N: Regular diet. Follow / replete 'lytes.\\n 4) CV: Transient hypotension as above. No EKG e/o infarct. Consider TTE\\n to evaluate although his last TTE in revealed a EF of 50-55%\\n 5) Full code, access pIV, PPI and subQ heparin.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 22 Gauge - 04:30 PM\\n Comments:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n Total time spent:\\n ------ Protected Section ------\\n Agree with assessment and plan as stated above\\n ------ Protected Section Addendum Entered By: , MD\\n on: 18:35 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635956,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse .\\n Altered mental status (not Delirium)\\n Assessment:\\n At start of shift pt A&O x 3. Appropriate with words and responses to\\n questions. Followed all commands, PERRL.\\n Action:\\n Full neuro assessment performed. Head CT and MRI done yesterday on\\n days. Reported results negative.\\n Response:\\n Around midnight MS started to change. Pt had expressive asphasia, was\\n A&O x 2\\n unaware of time as he thought it was ^th. No\\n facial droop noted, followed commands and had adequate strength in all\\n four extremities. Team aware of MS change.\\n Plan:\\n Con\\nt to monitor mental status and reorient pt as needed. Con\\nt to\\n monitor neuro status.\\n Hypotension (not Shock)\\n Assessment:\\n SBP at start of shift up to 170\\ns systolic. Team aware.\\n Action:\\n Started on 200mg PO Labetalol .\\n Response:\\n SBP down to 100\\ns and pt\\ns mental status started to deteriorate as he\\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\\n d/c\\nd. BP has been normotensive throughout noc.\\n Plan:\\n Con\\nt to monitor BP and treat as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635957,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse .\\n Altered mental status (not Delirium)\\n Assessment:\\n At start of shift pt A&O x 3. Appropriate with words and responses to\\n questions. Followed all commands, PERRL.\\n Action:\\n Full neuro assessment performed. Head CT and MRI done yesterday on\\n days. Reported results negative.\\n Response:\\n Around midnight MS started to change. Pt had expressive asphasia, was\\n A&O x 2\\n unaware of time as he thought it was ^th. No\\n facial droop noted, followed commands and had adequate strength in all\\n four extremities. Team aware of MS change.\\n Plan:\\n Con\\nt to monitor mental status and reorient pt as needed. Con\\nt to\\n monitor neuro status.\\n Hypotension (not Shock)\\n Assessment:\\n SBP at start of shift up to 170\\ns systolic. Team aware.\\n Action:\\n Started on 200mg PO Labetalol .\\n Response:\\n SBP down to 100\\ns and pt\\ns mental status started to deteriorate as he\\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\\n d/c\\nd. BP has been normotensive throughout noc.\\n Plan:\\n Con\\nt to monitor BP and treat as needed.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636051,\n \"text\": \"Chief Complaint: 85 yo man with multiple myeloma as well as a history\\n neurogenic presyncope secondary to autonomic dysfunction presenting\\n initially with weakness and UTI, now with aphasia in the setting of\\n hypotension, both have resolved with fluid repletion. Head ct and mri\\n negative so far for evidence of stroke.\\n 24 Hour Events:\\n MAGNETIC RESONANCE IMAGING - At 03:00 PM\\n Head\\n Patient with head ct showing no acute bleed and mri without evidence of\\n acute stroke. Patient vital signs stable. showing signs of delirium\\n with agitation, disorientation. MRA with possible narrowing of m2/m3\\n region bilaterally more on the right\\n possibly arteriosclerotic\\n however cannot rule out artifact.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:23 PM\\n Cefipime - 10:30 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 PM\\n Heparin Sodium (Prophylaxis) - 06:00 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: none\\n Flowsheet Data as of 07:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.6\\n Tcurrent: 35.8\\nC (96.5\\n HR: 81 (70 - 93) bpm\\n BP: 154/82(101) {105/50(65) - 162/97(113)} mmHg\\n RR: 16 (14 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 2,800 mL\\n 500 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 2,560 mL\\n 500 mL\\n Blood products:\\n Total out:\\n 1,295 mL\\n 520 mL\\n Urine:\\n 1,295 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,505 mL\\n -20 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Trace, Left: Trace\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 207 K/uL\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 23 mEq/L\\n 3.4 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 134 mEq/L\\n 29.1 %\\n 4.4 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n WBC\\n 9.2\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 85 yo man with multiple myeloma as well as a history neurogenic\\n presyncope secondary to autonomic dysfunction presenting initially with\\n weakness and UTI, now with aphasia in the setting of hypotension, both\\n have resolved with fluid repletion.\\n .\\n #) Hypotension: low reserve for hypotensive insult given baseline\\n orthostatic hypotension.\\n -likely infection related given + u/a with urine culture growing staph\\n aureus, that is sensitive to vanco. Contact precautions for MRSA but\\n no previous resistent bacteria on previous culture data.\\n - urine culture data:\\n STAPH AUREUS COAG +\\n |\\nGENTAMICIN------------ <=0.5 S\\nLEVOFLOXACIN---------- =>8 R\\nNITROFURANTOIN-------- <=16 S\\nOXACILLIN------------- =>4 R\\nPENICILLIN G---------- =>0.5 R\\nTETRACYCLINE---------- 2 S\\nTRIMETHOPRIM/SULFA---- <=0.5 S\\nVANCOMYCIN------------ <=1 S\\n -vanc 1g IV q12hrs\\n - will d/c cefepime now that sensitives are back\\n - follow CBC / diff\\n -lactate 1.0\\n -rec'd 2 liter bolus IVF, continue at rate of 250cc/hr, now currently\\n normotensive\\n CXr - As compared to the previous examination, there is no relevant\\n change. No\\n newly occurred focal parenchymal opacity suggestive of pneumonia, no\\n overhydration.\\n -resend U/a, ucx\\n -send blood cultures and f/u previously send blood cx\\n -if diarrhea will send C diff\\n -continue florinef at home dose and salt tabs\\n -troponins were negative so unlikely MI\\n .\\n #) Mental Status Changes: apparently these were expressive aphasia. He\\n has no known cerebrovascular disease in the past but given the nature\\n of these episodes he likley has some cerebrovascular stenosis which\\n cause some reversible hypoperfusion during episodes of hypotension.\\n - as patient currently normotensive will hold off on additional fluid\\n bolus at this time\\n -head CT wet read: No acute intracranial process, including no evidence\\n for hemorrhage, edema,\\n mass effect, or acute ischemia. Please note that MRI is more sensitive\\n for\\n evaluation of ischemia.\\n - MRI of head wet read: There is no evidence of acute ischemic changes.\\n Prominence of the ventricles\\n and sulci, likely age-related and developmental in nature. There is no\\n shift\\n or normally placed midline structures. M2 segments bilaterally versus\\n artifact.\\n - started on aspirin 325mg po daily, will follow-up with neurology\\n regarding plan for this , if no acute stroke and no acute MI, then\\n should be changed to 81 mg PO daily instead\\n #) chronic lower back pain:\\n - due to malignant compression fractures multiple myeloma.\\n - MRI l spine - CONCLUSION: Diffuse signal intensity abnormalities in\\n the vertebral bodies\\n compatible with the history of multiple myeloma.\\n No evidence of cauda equina compression.\\n Right-sided disc protrusion at L3-4.\\n - continue oxycodone prn.\\n .\\n #) multiple myeloma:\\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\\n for T11/sacral spine related to Multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression\\n -s/p bone marrow biopsy to evaluate for amyloid, still pending\\n - plan for radiation-oncology today\\n - would consider lumbar puncture if patient does not improve to rule\\n out leptomeningeal disease in the setting of word finding difficulties\\n without MRI findings -\\n .\\n #) prophylaxis:\\n - ppi and subcut heparin\\n .\\n #) full code.\\n #) dispo: call out to OMED today\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 12:55 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 636057,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O back pain\\n Assessment:\\n Chronic back pain due to compression fractures multiple myeloma. No\\n complaints of back pain today. Tolerated oob to chair and stretcher\\n multiple times today. His gait is slow and shuffling, but strength OK.\\n Action:\\n Received planned treatments to T11-sacrum.\\n Response:\\n No c/o back pain.\\n Plan:\\n Continue XRT as ordered and oxycodone prn.\\n Hypotension (not Shock)\\n Assessment:\\n Given labetolol last night for SBP in the 170\\ns but d/c\\nd due to BP\\n dropping to the 100\\ns. Today BP 105-159/48-82; HR 63-81, LBBB no\\n ectopy. Denies dizziness/lightheadedness. No orthostatic BP changes or\\n symptoms noted.\\n Action:\\n Continues on florinef and sodium tabs. No fluid boluses given. Urine\\n output is adequate. Fluid status is +400cc.\\n Response:\\n BP stable, no orthostatic changes.\\n Plan:\\n Continue florinef, sodium tabs, monitor fluid/electrolyte status.\\n Altered mental status (not Delirium)\\n Assessment:\\n Confused overnight and restless at times. A&O X3 most of the day.\\n Mental status waxes and wanes and pt still has trouble with word\\n finding. He is aware of it and expresses frustration. MAE\\ns, no\\n hemiparesis/weakness.\\n Action:\\n Carotid U/S done today, results pending. Head CT and MRI negative for\\n bleed/ischemia, although some artherosclerosis noted. Receiving\\n aspirin, lipitor and heparin sq.\\n Response:\\n Mental status waxes and wanes.\\n Plan:\\n Continue to monitor neuro status and electrolytes. Discuss probable\\n need for increased care and supervision of pt when discharged.\\n Urinary tract infection (UTI)\\n Assessment:\\n +MRSA in urine. Afebrile, wbc\\ns 4.4, blood cultures pending.\\n Action:\\n Receiving vanco/cefipime.\\n Response:\\n Improving\\n Plan:\\n Continue antibiotics. Remove foley and attempt voiding trial, reinsert\\n new foley if unable to void.\\n Demographics\\n Attending MD:\\n S.\\n Admit diagnosis:\\n WEAKNESS\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 65.5 kg\\n Daily weight:\\n Allergies/Reactions:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Precautions: Contact\\n PMH:\\n CV-PMH:\\n Additional history: Multiple myeloma, BPH, dyslipidemia, \\n orthostatic hypotension w/ autonomic dysfunction (reported normal echo,\\n unremarkable holter per chart), IVCD/LBBB, LBP pathological\\n compression fx T12/L1, s/p chole 10 yrs ago, lung nodule s/p resection\\n many years ago reported benign.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:126\\n D:63\\n Temperature:\\n 98\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 73 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 100% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 1,123 mL\\n 24h total out:\\n 730 mL\\n Pertinent Lab Results:\\n Sodium:\\n 134 mEq/L\\n 04:42 AM\\n Potassium:\\n 3.4 mEq/L\\n 04:42 AM\\n Chloride:\\n 105 mEq/L\\n 04:42 AM\\n CO2:\\n 23 mEq/L\\n 04:42 AM\\n BUN:\\n 9 mg/dL\\n 04:42 AM\\n Creatinine:\\n 0.7 mg/dL\\n 04:42 AM\\n Glucose:\\n 97 mg/dL\\n 04:42 AM\\n Hematocrit:\\n 29.1 %\\n 04:42 AM\\n Finger Stick Glucose:\\n 108\\n 12:00 PM\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: Watch\\n Transferred from: \\n Transferred to: 7F\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 636060,\n \"text\": \"Progress Note:\\n Spoke briefly with pt\\ns daughter who is in the process of trying to\\n arrange for alternative living situation for her sister who has CP.\\n Currently, she is in the process of applying for Mass Health and\\n meeting with a lawyer to make changes in her father\\ns will. Mr. \\n wants his daughter remain at home with him and his wife until he dies,\\n but that is not an option.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 636491,\n \"text\": \"Chief Complaint: Hypotension\\n HPI:\\n Mr. is a 85 yo male with multiple myeloma and as well as\\n autonomic dysfunction on florinef ? secondary to amyloid, BPH who was\\n transfered back to the ICU for AMS and hypotension. He was in his prior\\n state of health in the morning, excercised with PT, was mentating fine\\n until ~2:30 when he was found sleepy. He was awakaned and he was\\n disoriented in place and time. His SBP was in the low 80s. He was put\\n in trendelemburg and was given 500cc of NS bolus. After 25 minutes he\\n was still confused with an SBP in the 90s, so he was transfered to the\\n ICU. On arrival he was oriented x3, his SBP was in the 150s and he was\\n absolutely fine.\\n History obtained from Patient\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:00 AM\\n Vancomycin - 09:00 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:01 PM\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n MM, diagnosed , followed by Heme, on Velcade/mephalan/prednisone\\n for past month , c/b lytic lesions/compression fractures - recnet\\n XRT to spine.\\n BPH (meds were d/c'ed due to hypotension)\\n dyslipidemia\\n syncope X2 : reported normal Echo, unremarkable holter per chart\\n IVCD/LBBB-old\\n LBP- pathological compression fx T12/L1 s/p choley 10years ago\\n lung nodule s/p resection many years ago, reported benign\\n Mother died uterine Ca, Father died PNA, has one brother/one sister who\\n are alive and well at age 80s\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other:\\n Review of systems:\\n Flowsheet Data as of 11:55 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.6\\nC (97.8\\n HR: 87 (77 - 97) bpm\\n BP: 151/96(104) {104/43(58) - 191/142(125)} mmHg\\n RR: 31 (15 - 31) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 913 mL\\n PO:\\n 250 mL\\n TF:\\n IVF:\\n 663 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 850 mL\\n Urine:\\n 850 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 63 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 100%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL, Supraclavicular WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Crackles : Bibasilary)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: 1+, Left: 1+\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\\n Labs / Radiology\\n 207 K/uL\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 9 mg/dL\\n 23 mEq/L\\n 105 mEq/L\\n 3.4 mEq/L\\n 134 mEq/L\\n 29.1 %\\n 4.4 K/uL\\n [image002.jpg]\\n \\n 2:33 A9/22/ 12:29 PM\\n \\n 10:20 P9/22/ 01:12 PM\\n \\n 1:20 P9/22/ 01:30 PM\\n \\n 11:50 P9/23/ 04:42 AM\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 9.2\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 85 yo man with MM, neurogenic orthostatics ( autonomic dysfunction),\\n with UTI and now transfered to ICU for hypotension and AMS that are now\\n resolved.\\n .\\n # AMS: Patient with hypotension and AMS that responded to position and\\n 500cc fluid bolus. Patient at baseline on arrival to the ICU. Most\\n likely etiology patient had low fluid intake and got dehydrated.\\n - F/u I/O\\n - F/U JVP\\n - 500cc NS bolus if hypotensive\\n - Move slowly from one position to another (avoid orhtostatics)\\n - Telemetry\\n - EKG\\n .\\n # Multiple myeloma:\\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\\n for T11/sacral spine related to Multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt was going to\\n get radiation today.\\n - F/u BMT recs\\n - Possible radiotherapy tomorrow\\n .\\n # chronic lower back pain:\\n - due to malignant compression fractures multiple\\n myeloma.\\n continue oxycodone prn.\\n .\\n # prophylaxis:\\n - ppi and subcut heparin\\n .\\n # Access: peripherals\\n .\\n #) full code.\\n .\\n # Contact: (wife) \\n .\\n # Dispo: Floor tomorrow morning if stable\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 04:30 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636583,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\\n for T11/sacral spine related to multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt had\\n radiation today no c/o back pain no Oxycodone given\\n Action:\\n Radiation today. Pt on Lidocaine patch 5% for lower back.\\n Response:\\n Tolerated well\\n Plan:\\n Continue radiation Mon-Thursday of next week. Pt called out to\\n Hem/Onc.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\\n 120/64 HR 70\\ns SR no vea noted\\n Action:\\n None required\\n Response:\\n Pt back to baseline mental status\\n Plan:\\n Continue to observe for changes in mental status Florinef increased\\n to .1 mg ?tilt table test to be done inpatient.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley, pt has foley , draining clear yellow\\n urine. Afebrile on Vanco for treatment of a staph UTI,\\n Action:\\n Vanco \\n Response:\\n Afebrile, no complaints, good urine output 30 cc/hr\\n Plan:\\n Continue with antibx, monitor urine output\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636588,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\\n for T11/sacral spine related to multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt had\\n radiation today no c/o back pain no Oxycodone given\\n Action:\\n Radiation today. Pt on Lidocaine patch 5% for lower back.\\n Response:\\n Tolerated well\\n Plan:\\n Continue radiation Mon-Thursday of next week. Pt called out to\\n Hem/Onc.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\\n 120/64 HR 70\\ns SR no vea noted\\n Action:\\n None required\\n Response:\\n Pt back to baseline mental status\\n Plan:\\n Continue to observe for changes in mental status Florinef increased\\n to .1 mg ?tilt table test to be done inpatient.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley, pt has foley , draining clear yellow\\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\\n cultures done x 2, urine cx sent\\n Action:\\n Vanco \\n Response:\\n Afebrile, no complaints, good urine output 30 cc/hr\\n Plan:\\n Continue with antibx, monitor urine output\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 636589,\n \"text\": \"Clinician: Attending Physician Progress Note\\n Chief Complaint: Altered Mental Status\\n Hypotension\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n CALLED OUT\\n Patient with much improved stability with IVF given. No evidence of\\n recurrent events with overnight monitoring\\n History obtained from Medical records\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:00 AM\\n Vancomycin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Flowsheet Data as of 09:29 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.8\\nC (96.4\\n HR: 80 (75 - 97) bpm\\n BP: 137/86(99) {104/43(58) - 191/142(125)} mmHg\\n RR: 23 (11 - 31) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 915 mL\\n 343 mL\\n PO:\\n 250 mL\\n TF:\\n IVF:\\n 665 mL\\n 343 mL\\n Blood products:\\n Total out:\\n 850 mL\\n 900 mL\\n Urine:\\n 850 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 65 mL\\n -557 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///25/\\n Physical Examination\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Absent, Left: Trace\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Place and Person, Movement: Purposeful, Tone:\\n Not assessed\\n Labs / Radiology\\n 10.1 g/dL\\n 217 K/uL\\n 98 mg/dL\\n 0.6 mg/dL\\n 25 mEq/L\\n 3.1 mEq/L\\n 10 mg/dL\\n 105 mEq/L\\n 139 mEq/L\\n 29.2 %\\n 5.8 K/uL\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n 04:21 AM\\n WBC\\n 9.2\\n 4.4\\n 5.8\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n 29.2\\n Plt\\n 154\\n 207\\n 217\\n Cr\\n 0.6\\n 0.7\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n 98\\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\\n Assessment and Plan\\n yo male with recurrent ICU admission with a repeat of similar\\n scenario to prior admission. He has a picture of orthostatic\\n instability and in the setting of mild hypovolemia he has had recurrent\\n altered mental status. In the setting of ongoing treatment--certainly\\n maintenance of optimal volume status is essential.\\n 1)Altered Mental Status-\\n -Orthostatic Hypotension-\\n -Salt Tabs\\n -Fludricort\\n -Maintain optimal fluid status\\n -Rx with Vanco\\n -Return to oncology floor today.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 22 Gauge - 04:30 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition :Transfer to floor\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636591,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\\n for T11/sacral spine related to multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt had\\n radiation today no c/o back pain no Oxycodone given\\n Action:\\n Radiation today. Pt on Lidocaine patch 5% for lower back.\\n Response:\\n Tolerated well\\n Plan:\\n Continue radiation Mon-Thursday of next week. Pt called out to\\n Hem/Onc.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\\n 120/64 HR 70\\ns SR no vea noted\\n Action:\\n None required\\n Response:\\n Pt back to baseline mental status\\n Plan:\\n Continue to observe for changes in mental status Florinef increased\\n to .1 mg ?tilt table test to be done inpatient.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley, pt has foley , draining clear yellow\\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\\n cultures done x 2, urine cx sent\\n Action:\\n Vanco \\n Response:\\n Afebrile, no complaints, good urine output 30 cc/hr\\n Plan:\\n Continue with antibx, monitor urine output\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 636010,\n \"text\": \"Chief Complaint: 85 yo man with multiple myeloma as well as a history\\n neurogenic presyncope secondary to autonomic dysfunction presenting\\n initially with weakness and UTI, now with aphasia in the setting of\\n hypotension, both have resolved with fluid repletion. Head ct and mri\\n negative so far for evidence of stroke.\\n 24 Hour Events:\\n MAGNETIC RESONANCE IMAGING - At 03:00 PM\\n Head\\n Patient with head ct showing no acute bleed and mri without evidence of\\n acute stroke. Patient vital signs stable. showing signs of delirium\\n with agitation, disorientation.\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Vancomycin - 09:23 PM\\n Cefipime - 10:30 PM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:11 PM\\n Heparin Sodium (Prophylaxis) - 06:00 AM\\n Other medications:\\n Changes to medical and family history: none\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: none\\n Flowsheet Data as of 07:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.6\\n Tcurrent: 35.8\\nC (96.5\\n HR: 81 (70 - 93) bpm\\n BP: 154/82(101) {105/50(65) - 162/97(113)} mmHg\\n RR: 16 (14 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 2,800 mL\\n 500 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 2,560 mL\\n 500 mL\\n Blood products:\\n Total out:\\n 1,295 mL\\n 520 mL\\n Urine:\\n 1,295 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,505 mL\\n -20 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right: Trace, Left: Trace\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 207 K/uL\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 23 mEq/L\\n 3.4 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 134 mEq/L\\n 29.1 %\\n 4.4 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n WBC\\n 9.2\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 85 yo man with multiple myeloma as well as a history neurogenic\\n presyncope secondary to autonomic dysfunction presenting initially with\\n weakness and UTI, now with aphasia in the setting of hypotension, both\\n have resolved with fluid repletion.\\n .\\n #) Hypotension: low reserve for hypotensive insult given baseline\\n orthostatic hypotension.\\n -likely infection related given + u/a with urine culture growing staph\\n aureus, f/u sensitivities but currently will cover with vancomycin.\\n Contact precautions for MRSA but no previous resistent bacteria on\\n previous culture data.\\n -vanc 1g IV q12hrs, cefepime 1g q 12 hrs\\n -follow CBC / diff\\n -lactate 1.0\\n -rec'd 2 liter bolus IVF, continue at rate of 250cc/hr, now currently\\n normotensive\\n CXr - As compared to the previous examination, there is no relevant\\n change. No\\n newly occurred focal parenchymal opacity suggestive of pneumonia, no\\n overhydration.\\n -resend U/a, ucx\\n -send blood cultures and f/u previously send blood cx\\n -if diarrhea will send C diff\\n -given staph aureus obtain echo to r/o valvular / regurgitant lesions\\n -continue florinef at home dose and salt tabs\\n -rule out MI with 2 sets of enzymes 12 hours apart\\n .\\n #) Mental Status Changes: apparently these were expressive aphasia. He\\n has no known cerebrovascular disease in the past but given the nature\\n of these episodes he likley has some cerebrovascular stenosis which\\n cause some reversible hypoperfusion during episodes of hypotension.\\n -continue to bolus IVF for hypotension and mental status changes\\n -head CT wet read: No acute intracranial process, including no evidence\\n for hemorrhage, edema,\\n mass effect, or acute ischemia. Please note that MRI is more sensitive\\n for\\n evaluation of ischemia.\\n - MRI of head wet read: There is no evidence of acute ischemic changes.\\n Prominence of the ventricles\\n and sulci, likely age-related and developmental in nature. There is no\\n shift\\n or normally placed midline structures. M2 segments bilaterally versus\\n artifact.\\n -aspirin 325mg po daily\\n #) chronic lower back pain:\\n - due to malignant compression fractures multiple myeloma.\\n - MRI l spine - CONCLUSION: Diffuse signal intensity abnormalities in\\n the vertebral bodies\\n compatible with the history of multiple myeloma.\\n No evidence of cauda equina compression.\\n Right-sided disc protrusion at L3-4.\\n - continue oxycodone prn.\\n .\\n #) multiple myeloma:\\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\\n for T11/sacral spine related to Multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression\\n -s/p bone marrow biopsy to evaluate for amyloid, still pending\\n .\\n #) prophylaxis:\\n - ppi and subcut heparin\\n .\\n #) full code.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 12:55 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 636028,\n \"text\": \"Chief Complaint: Hypotension\\n Aphasia\\n HPI:\\n patient at home with episode of pre-syncope and had \\\"slumping into a\\n chair\\\" reported by VNA and sent to where he was diagnosed with\\n UTI and started on Cipro.\\n During PT evaluation he has difficulty with ambulation with PT eval and\\n upon lying down had SBP=90 and expressive aphasia. This was Rx'd with\\n ICF at 500cc with good improvement in BP and aphasia.\\n Given in instability in BP and neuro exam patient to ICU for further\\n care where ASA was given and CT and MRI pursued.\\n Of note patient urine culture revealed S. Aureus\\n Patient admitted from: \\n History obtained from Medical records\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Cefipime - 10:30 PM\\n Vancomycin - 07:45 AM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 06:00 AM\\n Pantoprazole (Protonix) - 07:46 AM\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Multiple Myeloma-Dx , complicated by Amyloid\\n BPH-chronic indwelling catheter\\n Autonomic Dysfunction--with primary issue orthostatic hypotension\\n LBBB\\n Non-contributory\\n Occupation: Ret'd\\n Drugs: None\\n Tobacco: None\\n Alcohol: None\\n Other:\\n Review of systems:\\n Constitutional: Fatigue\\n Ear, Nose, Throat: Dry mouth\\n Cardiovascular: No(t) Chest pain\\n Respiratory: No(t) Tachypnea\\n Genitourinary: Foley\\n Psychiatric / Sleep: Daytime somnolence\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 09:52 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.6\\n Tcurrent: 35.7\\nC (96.2\\n HR: 76 (70 - 93) bpm\\n BP: 126/48(55) {105/48(55) - 162/97(113)} mmHg\\n RR: 20 (14 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 2,800 mL\\n 730 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 2,560 mL\\n 730 mL\\n Blood products:\\n Total out:\\n 1,295 mL\\n 730 mL\\n Urine:\\n 1,295 mL\\n 730 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,505 mL\\n -1 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Extremities: Right: Absent, Left: Absent\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, not place or year by my exam, Movement:\\n Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 207 K/uL\\n 29.1 %\\n 9.9 g/dL\\n 97 mg/dL\\n 0.7 mg/dL\\n 9 mg/dL\\n 23 mEq/L\\n 105 mEq/L\\n 3.4 mEq/L\\n 134 mEq/L\\n 4.4 K/uL\\n [image002.jpg]\\n 12:29 PM\\n 01:12 PM\\n 01:30 PM\\n 04:42 AM\\n WBC\\n 9.2\\n 4.4\\n Hct\\n 20.6\\n 30.4\\n 29.1\\n Plt\\n 154\\n 207\\n Cr\\n 0.6\\n 0.7\\n TropT\\n <0.01\\n Glucose\\n 123\\n 97\\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\\n Imaging: MRI--Narrowing of M2, M3 noted but will need final read\\n confirmed.\\n CT Head-No acute CVA appreciated\\n Assessment and Plan\\n 85 yo male with presentation with persistence of his autonomic\\n dysfunction and instability of BP with body position change now\\n presenting with aphasia with changes in BP. He has on MRI a suggestion\\n of significant changes in MCA distribution which may represent a marker\\n for risk of vascular disease in a relevant distribution for placing an\\n area at risk for symptomatic ischemia with blood pressure changes.\\n Events have not recurred since admission to ICU.\\n Urinary Tract Infection-\\n -continue Vanco/Cefepime\\n -Continue Foley\\n -Given significant insult from local infection would suggest\\n consideration of alternative therapeutic approach if possible for BPH\\n Aphasia-\\n -Will review with neurology the area at risk as described in MRI\\n findings\\n -Continue with ASA\\n -Will have follow up evaluation for stabilization of perfusion\\n Multiple Myeloma-\\n -Further Rx by oncology service\\n -Expect return to oncology floor today\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines / Intubation:\\n 22 Gauge - 12:55 PM\\n Comments:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636481,\n \"text\": \"Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley. Pt has foley with clear yellow urine. Also\\n on vanco for treatment of a staph uti.\\n Action:\\n Vanco .\\n Response:\\n Is afebrile. No complaints of painful urination. Very good urine\\n output.\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n pt was hypotensive with systolic b/p 84\\n Action:\\n Pt received 500cc of ivf on previous shift.\\n Response:\\n Has not required any ivf or pressors this shift.\\n Plan:\\n Cont to assess b/p.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has remained alert and oriented x3 this entire shift with no\\n confusion noted. Speaking in very pleasant conversation.\\n Action:\\n None required.\\n Response:\\n Pt is back to baseline mental status.\\n Plan:\\n Cont to observe for changes in mental status and infection.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636482,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley. Pt has foley with clear yellow urine. Also\\n on vanco for treatment of a staph uti.\\n Action:\\n Vanco .\\n Response:\\n Is afebrile. No complaints of painful urination. Very good urine\\n output.\\n Plan:\\n Pt may be called back up to the floor.\\n Hypotension (not Shock)\\n Assessment:\\n pt was hypotensive with systolic b/p 84\\n Action:\\n Pt received 500cc of ivf on previous shift.\\n Response:\\n Has not required any ivf or pressors this shift.\\n Plan:\\n Cont to assess b/p.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt has remained alert and oriented x3 this entire shift with no\\n confusion noted. Speaking in very pleasant conversation.\\n Action:\\n None required.\\n Response:\\n Pt is back to baseline mental status.\\n Plan:\\n Cont to observe for changes in mental status and infection.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635995,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse .\\n Altered mental status (not Delirium)\\n Assessment:\\n At start of shift pt A&O x 3. Appropriate with words and responses to\\n questions. Followed all commands, PERRL.\\n Action:\\n Full neuro assessment performed. Head CT and MRI done yesterday on\\n days. Reported results negative.\\n Response:\\n Around midnight MS started to change. Pt had expressive asphasia, was\\n A&O x 2\\n unaware of time as he thought it was ^th. No\\n facial droop noted, followed commands and had equal strength in all\\n four extremities. Team aware of MS change.\\n Plan:\\n Con\\nt to monitor mental status and reorient pt as needed. Con\\nt to\\n monitor neuro status.\\n Hypotension (not Shock)\\n Assessment:\\n SBP at start of shift up to 170\\ns systolic. Team aware.\\n Action:\\n Started on 200mg PO Labetalol .\\n Response:\\n SBP down to 100\\ns and pt\\ns mental status started to deteriorate as he\\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\\n d/c\\nd. BP has been normotensive throughout noc.\\n Plan:\\n Con\\nt to monitor BP and treat as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636417,\n \"text\": \"85 yo male with multiple myeloma as well as autonomic dysfunction on\\n florinef ? secondary to amyloid. He also has BPH and a recent history\\n of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea. On vanco for RX\\n of UTI ( staph).\\n Pt discharged from after he had an episode of expressive\\n aphasia, & SBP 90. Ct scan negative Responded to fld bolus. Aphasia\\n resolved.\\n Today pt found\\nasleep\\n When awakened oriented to person only. SP\\n 84/60, RR 25, HR 75. Sats975 on RA. Given cefipime 2 gm & NS 500 cc\\n with improvement in MS & BP.\\n Altered mental status (not Delirium)\\n Assessment:\\n Alert, OX3. Conversing on phone. MEA.\\n Action:\\n Ct scan done prior to ICU admission. Results pnd\\n Response:\\n Oriented\\n Plan:\\n Cont to assess MS, neuro status\\n Hypotension (not Shock)\\n Assessment:\\n Bp 157/86, hr 80\\nS. Receiving maint IVF at 100 c chr X 5 hrs.\\n Action:\\n Ongoing assessment\\n Response:\\n Normotensive at present\\n Plan:\\n Cont to asses BP\\n Urinary tract infection (UTI)\\n Assessment:\\n Afeb, Received dose cefipime prior to ICU transfer. On vanco\\n Action:\\n Response:\\n Afeb\\n Plan:\\n Cont to assess for S&Sx of infection, MS changes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636570,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednision , s/p XRT\\n for T11/sacral\\n Action:\\n Response:\\n Plan:\\n Altered mental status (not Delirium)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 636622,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n .\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\\n Assessment:\\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\\n for T11/sacral spine related to multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression. Pt had\\n radiation today no c/o back pain no Oxycodone given\\n Action:\\n Radiation today. Pt on Lidocaine patch 5% for lower back.\\n Response:\\n Tolerated well\\n Plan:\\n Continue radiation Mon-Thursday of next week. Pt called out to\\n Hem/Onc.\\n Altered mental status (not Delirium)\\n Assessment:\\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\\n 120/64 HR 70\\ns SR no vea noted\\n Action:\\n None required\\n Response:\\n Pt back to baseline mental status\\n Plan:\\n Continue to observe for changes in mental status Florinef increased\\n to .1 mg ?tilt table test to be done inpatient.\\n Urinary tract infection (UTI)\\n Assessment:\\n Has hx of long term foley, pt has foley , draining clear yellow\\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\\n cultures done x 2, urine cx sent\\n Action:\\n Vanco \\n Response:\\n Afebrile, no complaints, good urine output 30 cc/hr\\n Plan:\\n Continue with antibx, monitor urine output\\n Demographics\\n Attending MD:\\n E.\\n Admit diagnosis:\\n WEAKNESS\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 65.5 kg\\n Daily weight:\\n Allergies/Reactions:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Multiple myeloma, BPH, dyslipidemia, \\n orthostatic hypotension w/ autonomic dysfunction (reported normal echo,\\n unremarkable holter per chart), IVCD/LBBB, LBP pathological\\n compression fx T12/L1, s/p chole 10 yrs ago, lung nodule s/p resection\\n many years ago reported benign.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:160\\n D:84\\n Temperature:\\n 98.8\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 72 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 1,185 mL\\n 24h total out:\\n 1,510 mL\\n Pertinent Lab Results:\\n Sodium:\\n 139 mEq/L\\n 04:21 AM\\n Potassium:\\n 3.5 mEq/L\\n 02:59 PM\\n Chloride:\\n 105 mEq/L\\n 04:21 AM\\n CO2:\\n 25 mEq/L\\n 04:21 AM\\n BUN:\\n 10 mg/dL\\n 04:21 AM\\n Creatinine:\\n 0.6 mg/dL\\n 04:21 AM\\n Glucose:\\n 98 mg/dL\\n 04:21 AM\\n Hematocrit:\\n 29.2 %\\n 04:21 AM\\n Finger Stick Glucose:\\n 109\\n 10:00 PM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: \\n Transferred to: 7SOUTH\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 636413,\n \"text\": \"85 yo male with multiple myeloma as well as autonomic dysfunction on\\n florinef ? secondary to amyloid. He also has BPH and a recent history\\n of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea. On vanco for RX\\n of UTI ( staph).\\n Pt discharged from after he had an episode of expressive\\n aphasia, & SBP 90. Ct scan negative Responded to fld bolus. Aphasia\\n resolved.\\n Today pt found\\nasleep\\n When awakened oriented to person only. SP\\n 84/60, RR 25, HR 75. Sats975 on RA. Given cefipime 2 gm & NS 500 cc\\n with improvement in MS & BP.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 635881,\n \"text\": \"Chief Complaint: hypotension\\n HPI:\\n 85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse . The patient generally\\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\\n cough, no abdominal pain, no constipation or diarrhea.\\n The a.m. of transfer to the he was standing participating in\\n physical therapy when he was noted to have difficulty speaking, he\\n demonstrated expressive aphasia. He was brought to bed and a supine\\n blood pressure was systolic 90. He was given 500cc of NS and SBP\\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\\n 110 and his aphasia returned. A code stroke was called and the patient\\n was given an additional 500cc NS. Patient has a baseline SBP while\\n supine of 170 and while standing drops to sbp 120. Per his daughter he\\n has been more confused lately (difficulty writing checks, able to feed\\n himself, but due to weakness lately difficulty bathing). His daughter\\n states that his orthostatic hypotension has also been worsening lately\\n and on Friday he had syncopized while in a chair. Also per the\\n daughter has had delerium and difficulty speaking related to\\n electrolyte abnormalities.\\n The patient currently remains asymptomatic. He does not feel confused,\\n felt lightheaded during the episodes but not currently. As above ROS\\n is negative. No F/C.\\n Patient admitted from: \\n History obtained from Patient, Family / Friend\\n Allergies:\\n Sulfa (Sulfonamides)\\n Hives; Rash;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Meds:\\n Atorvastatin 10 mg daily\\n Docusate Sodium 100 mg \\n Senna 8.6 mg Tablet prn\\n Acetaminophen 325 mg Tablet 2 tabs q6h prn\\n Latanoprost 0.005 % Drops Sig qhs\\n Dorzolamide-Timolol 2-0.5 % Drops \\n Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO HS\\n Oxycodone 5 mg Tablet Sig: 0.5 Tablet q6h prn\\n Sodium Chloride 1 gram Tablet tid\\n Finasteride 5 mg daily\\n Fludrocortisone 0.1 mg prn\\n .\\n Transfer Medications:\\n Finasteride 5 mg daily\\n Fludrocortisone 0.1 mg prn\\n Oxycodone 5 mg Tablet q4prn\\n Atorvastatin 10 mg daily\\n Docusate Sodium 100 mg \\n Senna 8.6 mg Tablet prn\\n Acetaminophen 325 mg Tablet 2 tabs q6h prn\\n Latanoprost 0.005 % Drops Sig qhs\\n Dorzolamide-Timolol 2-0.5 % Drops \\n Cipro 500mg po q12hrs\\n (given cefepime / vanc on transfer)\\n Past medical history:\\n Family history:\\n Social History:\\n MM, diagnosed , followed by Heme, on Velcade/mephalan/prednisone\\n for past month , c/b lytic lesions/compression fractures - recnet\\n XRT to spine.\\n BPH (meds were d/c'ed due to hypotension)\\n dyslipidemia\\n X2 : reported normal Echo, unremarkable holter per chart\\n IVCD/LBBB-old\\n LBP- pathological compression fx T12/L1 s/p choley 10years ago\\n lung nodule s/p resection many years ago, reported benign\\n Mother died uterine Ca, Father died PNA, has one brother/one sister who\\n are alive and well at age 80s\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as job placement coordinator\\n Lives with wife of 55+ years and disabled daughter (cerebral palsy). He\\n is the primary caretaker of his daughter. Lives in single family home\\n with approx three flights of stairs. Bedroom is on . wife,\\n 2 daughters wife is HCP\\n Quit tobacco > 20yrs ago, denies etoh\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Orthopnea\\n Respiratory: No(t) Cough, No(t) Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Flowsheet Data as of 02:56 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.5\\n Tcurrent: 36.4\\nC (97.5\\n HR: 92 (85 - 92) bpm\\n BP: 147/81(97) {141/74(95) - 154/84(97)} mmHg\\n RR: 20 (19 - 24) insp/min\\n SpO2: 98%\\n Heart rhythm: LBBB (Left Bundle Branch Block)\\n Total In:\\n 1,429 mL\\n PO:\\n TF:\\n IVF:\\n 1,429 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 1,129 mL\\n Respiratory\\n SpO2: 98%\\n ABG: ///23/\\n Physical Examination\\n T 95.8 HR 85 BP 158/74 O2 100% RA\\n GEN: cachectic elderly male, AOx2 (date- , )\\n HEENT: EOMI, PERRL, sclera anicteric, dry MM, OP Clear\\n NECK: JVP 10cm, no bruits, trachea midline\\n COR: RRR, no M/G/R, normal S1 S2, soft heart sounds\\n PULM: Lungs CTAB, no W/R/R\\n ABD: Soft, NT, ND, +BS, no HSM, no masses, rectal soft brown stool,\\n guiac negative\\n EXT: No C/C/E, no palpable cords\\n NEURO: alert, oriented to person, place, not to time. CN II\\n XII\\n grossly intact. 5/5 strength in UE deltoid, bicep, tricep, wrist flex /\\n ext, normal grip stregnth. stregnth in lower ext- quad, hamstring,\\n dorsiflexion / plantarflexion. Normal sensation to light touch bilat\\n symmetrical. cerebellar testing is normal. Reflexes normal\\n throughout. Babinski equivocal.\\n Labs / Radiology\\n 154 K/uL\\n 7.0 g/dL\\n 123 mg/dL\\n 0.6 mg/dL\\n 11 mg/dL\\n 23 mEq/L\\n 104 mEq/L\\n 2.9 mEq/L\\n 137 mEq/L\\n 30.4 %\\n 9.2 K/uL\\n [image002.jpg]\\n \\n 2:33 A9/22/ 12:29 PM\\n \\n 10:20 P9/22/ 01:12 PM\\n \\n 1:20 P9/22/ 01:30 PM\\n \\n 11:50 P\\n \\n 1:20 A\\n \\n 7:20 P\\n 1//11/006\\n 1:23 P\\n \\n 1:20 P\\n \\n 11:20 P\\n \\n 4:20 P\\n WBC\\n 9.2\\n Hct\\n 20.6\\n 30.4\\n Plt\\n 154\\n Cr\\n 0.6\\n Glucose\\n 123\\n Other labs: Alk Phos / T Bili:/0.6, Differential-Neuts:90.3 %,\\n Lymph:3.0 %, Mono:6.1 %, Eos:0.6 %, Lactic Acid:1.0 mmol/L, LDH:190\\n IU/L\\n Fluid analysis / Other labs: u/a: >50wbc, + nitrite, sm Leuk esterase.\\n coag + staph aureus, 10,000-100,000.\\n Imaging: CXR: minimal volume overload. minimal pleural effusion on R\\n side.\\n Microbiology: 6:48 pm URINE Source: Catheter.\\n URINE CULTURE (Preliminary):\\n STAPH AUREUS COAG +.\\n 10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.\\n ECG: EKG: sinus. rate 85. LBBB, no ST T wave changes when compared to\\n previous.\\n Assessment and Plan\\n assessment and plan:\\n 85 yo man with multiple myeloma as well as a history neurogenic\\n presyncope secondary to autonomic dysfunction presenting initially with\\n weakness and UTI, now with aphasia in the setting of hypotension, both\\n have resolved with fluid repletion.\\n .\\n #) Hypotension: low reserve for hypotensive insult given baseline\\n orthostatic hypotension.\\n -likely infection related given + u/a with urine culture growing staph\\n aureus, f/u sensitivities but currently will cover with vancomycin.\\n Contact precautions for MRSA but no previous resistent bacteria on\\n previous culture data.\\n -vanc 1g IV q12hrs, cefepime 1g q 12 hrs\\n -resend CBC / diff\\n -send lactate\\n -keep SBP > 110, has rec'd 2 liter bolus IVF, continue at rate of\\n 250cc/hr\\n -f/u CXR\\n -resend U/a, ucx\\n -send blood cultures and f/u previously send blood cx\\n -if diarrhea will send C diff\\n -given staph aureus obtain echo to r/o valvular / regurgitant lesions\\n -continue florinef at home dose and salt tabs\\n -rule out MI with 2 sets of enzymes 12 hours apart\\n .\\n #) Mental Status Changes: apparently these were expressive aphasia. He\\n has no known cerebrovascular disease in the past but given the nature\\n of these episodes he likley has some cerebrovascular stenosis which\\n cause some reversible hypoperfusion during episodes of hypotension.\\n -continue to bolus IVF for hypotension and mental status changes\\n -when stable will send for CT head without contrast, then carotid\\n ultrasound and MRA / MRI of the head (no contrast)\\n -aspirin 325mg po daily\\n #) chronic lower back pain:\\n - due to malignant compression fractures multiple\\n myeloma.\\n continue oxycodone prn.\\n .\\n #) multiple myeloma:\\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\\n for T11/sacral spine related to Multiple myeloma, recent MRI for\\n urinary retention negative for spinal cord compression\\n -s/p bone marrow biopsy to evaluate for amyloid, will need to f/u these\\n results\\n .\\n #) prophylaxis:\\n - ppi and subcut heparin\\n .\\n #) full code.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635971,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse .\\n Altered mental status (not Delirium)\\n Assessment:\\n At start of shift pt A&O x 3. Appropriate with words and responses to\\n questions. Followed all commands, PERRL.\\n Action:\\n Full neuro assessment performed. Head CT and MRI done yesterday on\\n days. Reported results negative.\\n Response:\\n Around midnight MS started to change. Pt had expressive asphasia, was\\n A&O x 2\\n unaware of time as he thought it was ^th. No\\n facial droop noted, followed commands and had equal strength in all\\n four extremities. Team aware of MS change.\\n Plan:\\n Con\\nt to monitor mental status and reorient pt as needed. Con\\nt to\\n monitor neuro status.\\n Hypotension (not Shock)\\n Assessment:\\n SBP at start of shift up to 170\\ns systolic. Team aware.\\n Action:\\n Started on 200mg PO Labetalol .\\n Response:\\n SBP down to 100\\ns and pt\\ns mental status started to deteriorate as he\\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\\n d/c\\nd. BP has been normotensive throughout noc.\\n Plan:\\n Con\\nt to monitor BP and treat as needed.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2123-10-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 635924,\n \"text\": \"85 yo male with multiple myeloma and as well as autonomic dysfunction\\n on florinef ? secondary to amyloid. He also has BPH and a recent\\n history of urinary obstruction requring long term foley presenting with\\n weakness and per a visiting nurse .\\n Urinary tract infection (UTI)\\n Assessment:\\n +staph in urine, wbc\\ns 9.2, lactic acid 1.0\\n Action:\\n Contact precautions for possible MRSA, BC X2 sent, CXR; pt started on\\n vanco/cefapime for ? urosepsis.\\n Response:\\n T 95-97; given Tylenol on 7F prior to coming to MICU.\\n Plan:\\n Continue antibiotics, follow cultures, wbc\\n Hypotension (not Shock)\\n Assessment:\\n NBP 141-156/74-96 while in bed; HR 80-92, LBBB.\\n Action:\\n Pt received total of 2L of fluid since arrival to MICU. Receiving\\n florinef.\\n Response:\\n BP stable.\\n Plan:\\n Monitor orthostatic BP, continue florinef, IV fluid boluses for\\n hypotension.\\n Altered mental status (not Delirium)\\n Assessment:\\n A&O X2, slow to respond but usually knows where he is and the date.\\n Moves all extremities\\n Action:\\n Head CT and MRI done. Receiving ASA.\\n Response:\\n No acute bleed seen.\\n Plan:\\n Monitor neuro status, follow neuro recs, continue ASA\\n .H/O electrolyte & fluid disorder, other\\n Assessment:\\n Na 137, K 2.9\\n Action:\\n Receiving sodium tabs and received 40meq KCL/1L at 250/hr.\\n Response:\\n Pending.\\n Plan:\\n Monitor lytes q 12hrs, replete per onc sliding scale.\\n\"\n }\n]"}}},{"rowIdx":24292,"cells":{"subject_id":{"kind":"number","value":51834,"string":"51,834"},"hadm_id":{"kind":"number","value":148768,"string":"148,768"},"target_text":{"kind":"string","value":"The patient was admitted to the hospital after bronchoscopy with BAL, which showed diffuse alveolar hemorrhage, for monitoring in the MICU. BAL fluid cultures for bacteria and fungi were sent and home medications were stopped. In the MICU simvastatin was restarted and a number of tests including antibody panels, viral cultures, and serologies were sent. His hematocrit dropped significantly from 27.9 to 22.5 and he was transfused with two units of packed red blood cells restoring it to 29.7. After this he remained stable and was transferred to the general medicine floor the next day. The most likely etiology of his DAH was thought to be from concurrent coumadin and aspirin treatment. Given his clinical stability and lack of other organ system involvement, other etiologies such as vasculitis were considered less likely although anti-GBM Ab, , ANCA, C2 were all sent. On the medicine floor, his INR declined from 2.5 on to 1.2 on off of coumadin. Given his history of sudden cardiac arrest and CAD, his aspirin was continued at 81 mg. His hematocrit was largely stable (27.4 at discharge). CBC, iron studies, and reticulocyte count (4.0, index 2.67 on ) indicated that his anemia was most consistent with acute blood loss. Overnight his O2 desaturated to 90%, requiring 2L O2, but recovering to 92% on RA by morning. A CXR and CT scan were ordered to rule out bleeding. The CXR showed no change from previously and the CT showed only a small amount of increased hemorrhage, and was reassuring overall. Echocardiogram showed a reduced ejection fraction of 30-35%, mild pulmonary hypertension, and some mitral regurgitation consistent patient's history of myocardial infarction. On , his oxygen saturation fell to 86% while climbing stairs and he continued in the hospital in order to assess his stability. On , his resting saturation increased to 100% RA, which was his highest since admission. Saturation during a six minute walk test remained above 90% and it stayed above 93% while climbing four flights of stairs and subsequently thereafter when ambulating. Pulmonary followed the patient throughout his hospital course and given his dramatic improvement, felt that he was safe to discharge home with close follow up the following week once the remainder of his test results became available. At the time of discharge, all cultures and serologies were negative except for the acid fast culture which showed no growth to date, but was not yet final. was negative, but ANCA and anti-GBM antibody and C2 studies were still pending. Based on persistently high fasting blood sugars, we ordered a hemoglobin A1c measurement and obtained previous records from . The A1c was 6.2, however, his historical fasting glucose measurements have remained above 130 since . Based on this, we made a diagnosis of Type II Diabetes Mellitus. We prescribed a glucometer and taught him and his wife how to use it instructing him to keep a diary of glucose levels to share with his PCP. also prescribed metformin to help improve his glucose control at home. His lisinopril was restarted at a reduced dose of 5mg prior to discharge. He was instructed not to restart warfarin without consulting with his cardiologist and pulmonologist as it was the most likely cause of his hemoptysis, though other etiologies may also have been involved. Given his CHADS2 score of 2, history of hypertension and new diagnosis of diabetes, he is considered at intermediate risk and aspirin only anticoagulation is acceptable."},"extractive_notes_summ":{"kind":"string","value":"Diffuse GGO/hazy opacities compatible with alveolar hemorrhage. The aortic root and ascending aorta are mildly dilated.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Mildlydilated ascending aorta. There is mildpulmonary artery systolic hypertension. The right ventricular cavity is mildly dilated with moderate globalfree wall hypokinesis. Mild to moderate [+] TR.Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Intra-atrial conduction delay.Consider prior inferior myocardial infarction, although it is non-diagnosticand may be within normal limits. No LVmass/thrombus.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo; basal inferior - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. There is moderate regional left ventricular systolicdysfunction with hypokinesis of the basal inferior wall and septum. Normal descending aorta diameter. Moderate global RV free wallhypokinesis.AORTA: Mildy dilated aortic root. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No 2D or Dopplerevidence of distal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Superimposed on these abnormalities, there is mild interlobar septal thickening with mild vascular congestion. There is no pericardial effusion.IMPRESSION: Normal left ventricular cavity size with regional systolicdysfunction c/w CAD. Mild mitral annularcalcification. Evaluate for valve diseaseHeight: (in) 67Weight (lb): 160BSA (m2): 1.84 m2BP (mm Hg): 116/62HR (bpm): 61Status: InpatientDate/Time: at 15:54Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Normal LV wall thickness and cavity size. A small hiatus hernia is seen. acute changes, fluid PFI REPORT No change in bilateral diffuse alveolar opacities. ST-T wave abnormalities are non-specific.Clinical correlation is suggested. The mitral valve leaflets are mildlythickened. Mild-moderate mitral regurgitation. Mild to moderate (+) mitral regurgitation is seen. There is hazy bilateral vasculature and some areas of patchy alveolar infiltrate. There are small mediastinal lymph nodes which do not meet CT size criteria for pathologic enlargement. Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed without intravenous or oral contrast. Moderate regional LVsystolic dysfunction. Otherwise, non-contrast examination of the heart and great vessels are unremarkable. Calcification of the aortic annulus is also noted. acute changes, fluid PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj MON 2:03 PM No change in bilateral diffuse alveolar opacities. The airways are patent to a subsegmental level. Sinus rhythm with A-V conduction delay. IMPRESSION: No change in bilateral diffuse alveolar opacities. PATIENT/TEST INFORMATION:Indication: Murmur. Estimated cardiac index is normal (>=2.5L/min/m2). Vascular clips from prior CABG are seen. The estimated cardiacindex is normal (>=2.5L/min/m2). Dilated ascendingaorta. Focal calcifications in aortic root. (Over) 6:06 PM CT CHEST W/O CONTRAST Clip # Reason: ?change since prior scan Admitting Diagnosis: PULMONARY HEMORRHAGE FINAL REPORT (Cont) Otherwise, the visualized portions of the liver, spleen and kidneys are unremarkable in appearance. FINAL REPORT CHEST ON HISTORY: Diffuse alveolar hemorrhage. Calcification of the splenic artery is noted. FINDINGS: Diffuse bilateral alveolar infiltrates are not significantly changed since the prior study, no effusion or pneumothorax is present. IMPRESSION: Further interval progression of the diffuse bilateral ground-glass opacities with areas of frank consolidation seen in the apices bilaterally and superior segment of the right lower lobe. Pacemaker leads are seen in the expected positions overlying the right atrium and right ventricle. Severe coronary artery, splenic artery vascular calcs. The heart and mediastinal contours are normal. Left ventricular wall thicknesses andcavity size are normal. On review of the lung windows, there has been further progression of the diffuse bilateral ground-glass opacities with progression in some areas to frank consolidation. COMPARISON: Reference CT chest . There is a dual-lead pacemaker in situ. , R. MED CC7A 9:29 AM CHEST (PORTABLE AP) Clip # Reason: ? Appearances could be consistent with resorption of intra-alveolar hemorrhage; however, superimposed infection cannot be excluded and cryptogenic organizing pneumonia is also a possibility. FINDINGS: The visualized portions of the thyroid gland and supraclavicular regions are unremarkable in appearance. Sternotomy wires are intact. FINAL REPORT INDICATION: Diffuse alveolar hemorrhage, desaturation overnight. Pulmonary artery hypertension.CLINICAL IMPLICATIONS:The left ventricular ejection fraction is <40%, a threshold for which thepatient may benefit from a beta blocker and an ACE inhibitor or .Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Sternal wires and mediastinal clips are seen. This appearance may be the end point of resorption of hemorrhage; however, superimposed infection cannot be excluded and cryptogenic organizing pneumonia is also a possibility. No pericardial or pleural effusions. It is unclear if this is due to the known alveolar hemorrhage or if there is an overlying element of fluid overload or infection."},"n_notes":{"kind":"number","value":6,"string":"6"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2116-01-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1176501,"text":" 6:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: consolidation\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage s/p bronch.\n REASON FOR THIS EXAMINATION:\n consolidation\n ______________________________________________________________________________\n WET READ: ENYa FRI 8:30 PM\n No definite evidence of focal air-space consolidation. Diffuse GGO/hazy\n opacities compatible with alveolar hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Diffuse alveolar hemorrhage.\n\n FINDINGS:\n\n There are no old films available for comparison. A pacemaker is visualized\n with leads projecting over the expected locations of the heart. The heart is\n mildly enlarged. Sternal wires and mediastinal clips are seen. There is hazy\n bilateral vasculature and some areas of patchy alveolar infiltrate. It is\n unclear if this is due to the known alveolar hemorrhage or if there is an\n overlying element of fluid overload or infection.\n\n"},{"category":"Radiology","chartdate":"2116-01-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1176789,"text":" 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute changes, fluid\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage and desaturation overnight\n REASON FOR THIS EXAMINATION:\n ? acute changes, fluid\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj MON 2:03 PM\n No change in bilateral diffuse alveolar opacities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diffuse alveolar hemorrhage, desaturation overnight.\n\n COMPARISON: .\n\n FINDINGS: Diffuse bilateral alveolar infiltrates are not significantly\n changed since the prior study, no effusion or pneumothorax is present. The\n heart and mediastinal contours are normal. Sternotomy wires are intact.\n Vascular clips from prior CABG are seen. Pacemaker leads are seen in the\n expected positions overlying the right atrium and right ventricle.\n\n IMPRESSION: No change in bilateral diffuse alveolar opacities.\n\n\n"},{"category":"Radiology","chartdate":"2116-01-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1176790,"text":", R. MED CC7A 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute changes, fluid\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage and desaturation overnight\n REASON FOR THIS EXAMINATION:\n ? acute changes, fluid\n ______________________________________________________________________________\n PFI REPORT\n No change in bilateral diffuse alveolar opacities.\n\n\n"},{"category":"Radiology","chartdate":"2116-01-20 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1176881,"text":" 6:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?change since prior scan\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage of unknown etiology\n REASON FOR THIS EXAMINATION:\n ?change since prior scan\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 6:49 PM\n Only slight increase fof the diffuse pulmonary hemorrhage, predominantly in\n the basal segments of the left lower lobe and a more consolidated (rather than\n diffuse) appearance of the hemorrhage at the lung apices compared to prior CT\n (OSH CT). No pericardial or pleural effusions. Severe coronary artery,\n splenic artery vascular calcs.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with diffuse alveolar hemorrhage of unknown\n etiology, query change.\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n without intravenous or oral contrast. Images are presented for display in the\n axial plane at 1.25- and 5-mm collimation. A series of multiplanar\n reformations were also submitted for review.\n\n COMPARISON: Reference CT chest .\n\n FINDINGS: The visualized portions of the thyroid gland and supraclavicular\n regions are unremarkable in appearance. There are small mediastinal lymph\n nodes which do not meet CT size criteria for pathologic enlargement. The\n largest is an 8-mm pre-tracheal node (2:15). A small hiatus hernia is seen.\n The patient has had a previous coronary artery bypass graft and there are\n multiple surgical clips in the mediastinum as well as calcification of the\n coronary arteries. Calcification of the aortic annulus is also noted. There\n is a dual-lead pacemaker in situ. Otherwise, non-contrast examination of the\n heart and great vessels are unremarkable. No pleural effusion, no pericardial\n effusion.\n\n The airways are patent to a subsegmental level. On review of the lung\n windows, there has been further progression of the diffuse bilateral\n ground-glass opacities with progression in some areas to frank consolidation.\n This is most apparent in the superior segment of the right lower lobe (4:94),\n at the right apex (4:37) and left apex (4:45). This appearance may be the end\n point of resorption of hemorrhage; however, superimposed infection cannot be\n excluded and cryptogenic organizing pneumonia is also a possibility.\n Superimposed on these abnormalities, there is mild interlobar septal\n thickening with mild vascular congestion.\n\n This study is not tailored for evaluation of the subdiaphragmatic organs. The\n adrenal glands are unremarkable in appearance. Calcification of the splenic\n artery is noted. The spleen is borderline enlarged measuring 16 cm.\n (Over)\n\n 6:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?change since prior scan\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Otherwise, the visualized portions of the liver, spleen and kidneys are\n unremarkable in appearance.\n\n BONY STRUCTURES: Degenerative changes noted in the left shoulder. No\n destructive lytic or sclerotic bony lesions are seen.\n\n IMPRESSION: Further interval progression of the diffuse bilateral\n ground-glass opacities with areas of frank consolidation seen in the apices\n bilaterally and superior segment of the right lower lobe. Appearances could\n be consistent with resorption of intra-alveolar hemorrhage; however,\n superimposed infection cannot be excluded and cryptogenic organizing pneumonia\n is also a possibility.\n\n"},{"category":"Echo","chartdate":"2116-01-20 00:00:00.000","description":"Report","row_id":92825,"text":"PATIENT/TEST INFORMATION:\nIndication: Murmur. Evaluate for valve disease\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 116/62\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 15:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction. Estimated cardiac index is normal (>=2.5L/min/m2). No LV\nmass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; basal inferior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Mildy dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta. Normal descending aorta diameter. No 2D or Doppler\nevidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction with hypokinesis of the basal inferior wall and septum. The\nremaining segments contract normally (LVEF = 30-35 %). The estimated cardiac\nindex is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left\nventricle. The right ventricular cavity is mildly dilated with moderate global\nfree wall hypokinesis. The aortic root and ascending aorta are mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size with regional systolic\ndysfunction c/w CAD. Mild-moderate mitral regurgitation. Dilated ascending\naorta. Pulmonary artery hypertension.\n\nCLINICAL IMPLICATIONS:\nThe left ventricular ejection fraction is <40%, a threshold for which the\npatient may benefit from a beta blocker and an ACE inhibitor or .\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"},{"category":"ECG","chartdate":"2116-01-19 00:00:00.000","description":"Report","row_id":256755,"text":"Sinus rhythm with A-V conduction delay. Intra-atrial conduction delay.\nConsider prior inferior myocardial infarction, although it is non-diagnostic\nand may be within normal limits. ST-T wave abnormalities are non-specific.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-01-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1176501,\n \"text\": \" 6:45 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: consolidation\\n Admitting Diagnosis: PULMONARY HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with diffuse alveolar hemorrhage s/p bronch.\\n REASON FOR THIS EXAMINATION:\\n consolidation\\n ______________________________________________________________________________\\n WET READ: ENYa FRI 8:30 PM\\n No definite evidence of focal air-space consolidation. Diffuse GGO/hazy\\n opacities compatible with alveolar hemorrhage.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Diffuse alveolar hemorrhage.\\n\\n FINDINGS:\\n\\n There are no old films available for comparison. A pacemaker is visualized\\n with leads projecting over the expected locations of the heart. The heart is\\n mildly enlarged. Sternal wires and mediastinal clips are seen. There is hazy\\n bilateral vasculature and some areas of patchy alveolar infiltrate. It is\\n unclear if this is due to the known alveolar hemorrhage or if there is an\\n overlying element of fluid overload or infection.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-01-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1176789,\n \"text\": \" 9:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? acute changes, fluid\\n Admitting Diagnosis: PULMONARY HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with diffuse alveolar hemorrhage and desaturation overnight\\n REASON FOR THIS EXAMINATION:\\n ? acute changes, fluid\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj MON 2:03 PM\\n No change in bilateral diffuse alveolar opacities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Diffuse alveolar hemorrhage, desaturation overnight.\\n\\n COMPARISON: .\\n\\n FINDINGS: Diffuse bilateral alveolar infiltrates are not significantly\\n changed since the prior study, no effusion or pneumothorax is present. The\\n heart and mediastinal contours are normal. Sternotomy wires are intact.\\n Vascular clips from prior CABG are seen. Pacemaker leads are seen in the\\n expected positions overlying the right atrium and right ventricle.\\n\\n IMPRESSION: No change in bilateral diffuse alveolar opacities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-01-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1176790,\n \"text\": \", R. MED CC7A 9:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? acute changes, fluid\\n Admitting Diagnosis: PULMONARY HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with diffuse alveolar hemorrhage and desaturation overnight\\n REASON FOR THIS EXAMINATION:\\n ? acute changes, fluid\\n ______________________________________________________________________________\\n PFI REPORT\\n No change in bilateral diffuse alveolar opacities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2116-01-20 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1176881,\n \"text\": \" 6:06 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ?change since prior scan\\n Admitting Diagnosis: PULMONARY HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with diffuse alveolar hemorrhage of unknown etiology\\n REASON FOR THIS EXAMINATION:\\n ?change since prior scan\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JBRe MON 6:49 PM\\n Only slight increase fof the diffuse pulmonary hemorrhage, predominantly in\\n the basal segments of the left lower lobe and a more consolidated (rather than\\n diffuse) appearance of the hemorrhage at the lung apices compared to prior CT\\n (OSH CT). No pericardial or pleural effusions. Severe coronary artery,\\n splenic artery vascular calcs.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 73-year-old man with diffuse alveolar hemorrhage of unknown\\n etiology, query change.\\n\\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\\n without intravenous or oral contrast. Images are presented for display in the\\n axial plane at 1.25- and 5-mm collimation. A series of multiplanar\\n reformations were also submitted for review.\\n\\n COMPARISON: Reference CT chest .\\n\\n FINDINGS: The visualized portions of the thyroid gland and supraclavicular\\n regions are unremarkable in appearance. There are small mediastinal lymph\\n nodes which do not meet CT size criteria for pathologic enlargement. The\\n largest is an 8-mm pre-tracheal node (2:15). A small hiatus hernia is seen.\\n The patient has had a previous coronary artery bypass graft and there are\\n multiple surgical clips in the mediastinum as well as calcification of the\\n coronary arteries. Calcification of the aortic annulus is also noted. There\\n is a dual-lead pacemaker in situ. Otherwise, non-contrast examination of the\\n heart and great vessels are unremarkable. No pleural effusion, no pericardial\\n effusion.\\n\\n The airways are patent to a subsegmental level. On review of the lung\\n windows, there has been further progression of the diffuse bilateral\\n ground-glass opacities with progression in some areas to frank consolidation.\\n This is most apparent in the superior segment of the right lower lobe (4:94),\\n at the right apex (4:37) and left apex (4:45). This appearance may be the end\\n point of resorption of hemorrhage; however, superimposed infection cannot be\\n excluded and cryptogenic organizing pneumonia is also a possibility.\\n Superimposed on these abnormalities, there is mild interlobar septal\\n thickening with mild vascular congestion.\\n\\n This study is not tailored for evaluation of the subdiaphragmatic organs. The\\n adrenal glands are unremarkable in appearance. Calcification of the splenic\\n artery is noted. The spleen is borderline enlarged measuring 16 cm.\\n (Over)\\n\\n 6:06 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ?change since prior scan\\n Admitting Diagnosis: PULMONARY HEMORRHAGE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Otherwise, the visualized portions of the liver, spleen and kidneys are\\n unremarkable in appearance.\\n\\n BONY STRUCTURES: Degenerative changes noted in the left shoulder. No\\n destructive lytic or sclerotic bony lesions are seen.\\n\\n IMPRESSION: Further interval progression of the diffuse bilateral\\n ground-glass opacities with areas of frank consolidation seen in the apices\\n bilaterally and superior segment of the right lower lobe. Appearances could\\n be consistent with resorption of intra-alveolar hemorrhage; however,\\n superimposed infection cannot be excluded and cryptogenic organizing pneumonia\\n is also a possibility.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2116-01-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 92825,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Murmur. Evaluate for valve disease\\nHeight: (in) 67\\nWeight (lb): 160\\nBSA (m2): 1.84 m2\\nBP (mm Hg): 116/62\\nHR (bpm): 61\\nStatus: Inpatient\\nDate/Time: at 15:54\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\\nsystolic dysfunction. Estimated cardiac index is normal (>=2.5L/min/m2). No LV\\nmass/thrombus.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\\ninferoseptal - hypo; basal inferior - hypo;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\\nhypokinesis.\\n\\nAORTA: Mildy dilated aortic root. Focal calcifications in aortic root. Mildly\\ndilated ascending aorta. Normal descending aorta diameter. No 2D or Doppler\\nevidence of distal arch coarctation.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Mild to moderate (+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\\nMild PA systolic hypertension.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\\ncavity size are normal. There is moderate regional left ventricular systolic\\ndysfunction with hypokinesis of the basal inferior wall and septum. The\\nremaining segments contract normally (LVEF = 30-35 %). The estimated cardiac\\nindex is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left\\nventricle. The right ventricular cavity is mildly dilated with moderate global\\nfree wall hypokinesis. The aortic root and ascending aorta are mildly dilated.\\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\\npulmonary artery systolic hypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Normal left ventricular cavity size with regional systolic\\ndysfunction c/w CAD. Mild-moderate mitral regurgitation. Dilated ascending\\naorta. Pulmonary artery hypertension.\\n\\nCLINICAL IMPLICATIONS:\\nThe left ventricular ejection fraction is <40%, a threshold for which the\\npatient may benefit from a beta blocker and an ACE inhibitor or .\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2116-01-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256755,\n \"text\": \"Sinus rhythm with A-V conduction delay. Intra-atrial conduction delay.\\nConsider prior inferior myocardial infarction, although it is non-diagnostic\\nand may be within normal limits. ST-T wave abnormalities are non-specific.\\nClinical correlation is suggested. No previous tracing available for\\ncomparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24293,"cells":{"subject_id":{"kind":"number","value":17707,"string":"17,707"},"hadm_id":{"kind":"number","value":102227,"string":"102,227"},"target_text":{"kind":"string","value":"The patient was admitted to the hospital on , after undergoing a right thoracotomy and a T11 vertebrectomy. She tolerated the procedure well with no apparent intraoperative complications. A chest tube was placed. Due to the extensive restrictive lung disease, she was subsequently monitored in the Post Anesthesia Care Unit in an intubated status pending planned posterior procedure three days later. The patient was able to be extubated prior to her second procedure. She was subsequently taken back to the operating room on , for attempted posterior spinal osteotomy with posterior spinal fusion and instrumentation for correction of her kyphoscoliosis. Intraoperatively, she was noted to have marked dural ectasia with subsequent durotomies times two with cerebrospinal fluid leak while attempting to place posterior spinal instrumentation. Given the marked atrophic nature of her dural tissue and significant difficulty in repairing the dural leaks, it was felt that it was inadvisable to proceed with attempted posterior osteotomy given that hardware placement would be significantly difficult and the risk of creating multiple additional durotomies with persistent cerebrospinal fluid leaks was likely. As such, the fusion mass was further explored and an in situ fusion was performed. The posterior most segmental hardware could not be removed due to the extensive amount of fusion mass which had embedded the hooks. Again, due to significant risks for further dural injury, the hardware was left. The patient was then transferred to the Surgical Intensive Care Unit for attempted extubation. The patient had an extensive Intensive Care Unit course lasting nearly two weeks with daily attempts at weaning off the ventilator. It was not until two weeks postoperatively that the patient was eventually extubated secondary to her significant restrictive lung disease and underlying CO2 retention. Following extubation, she was transferred to the Orthopedic floor in stable condition. Of note, the patient did have persistent intermittent drainage from her postoperative wound while in the Intensive Care Unit. She was treated with Ancef empirically during this period of drainage. Compressive and frequent dressing changes were applied in hopes that the drainage would stop. There was no evidence of wound infection at that time. After transfer to the Orthopedic floor, however, the patient was noted to have a significant increase in her postoperative wound drainage with signs of wound breakdown. She was subsequently taken back to the operating room on , and underwent irrigation and debridement of her postoperative wound. Intraoperatively, it was noted that there was a significant purulence present consistent with postoperative wound infection. There was additionally noted recurrence of the cerebrospinal fluid leak at the most distal durotomy site in the vicinity of L5. This cerebrospinal fluid leak was again repaired and a thorough irrigation and debridement was performed. Postoperative drains were placed and the patient had multiple intraoperative cultures obtained. Following the procedure, the patient was returned to the Orthopedic floor in extubated status. Intraoperative wound cultures eventually grew E. coli and bacteroides. The patient was seen by infectious disease and appropriate antibiotic regimens were instituted per their recommendations. The patient had been placed on Vancomycin empirically following her irrigation and debridement procedure followed by institution of Ceftazidime given initial gram stain results. Eventually the patient was placed on Ceftriaxone and Flagyl after cultures and sensitivities were obtained. A PICC line was placed for planned long term intravenous antibiotic therapy. The patient was maintained with postoperative drains for greater than one week until the drainage had dropped off significantly. The drains were subsequently removed and within two days the patient was again noted to have a significant accumulation of wound drainage with subsequent breakdown of her wound. The patient was taken back to the operating room on , and underwent repeat irrigation and debridement procedure. It was again noted that the previous durotomy site at L5 was again with evidence of recurrent cerebrospinal fluid leak. A third attempt at repair was performed utilizing suture, Duragen, to seal and following these procedures, a fascial fat graft was placed over the cerebrospinal fluid leak site. Cultures were again obtained intraoperatively and sent. The patient was subsequently transferred back to the Orthopedic floor, again in stable condition and again extubated. She was maintained in a supine position, flat bedrest for approximately one week in attempts to allow the cerebrospinal fluid leak to heal. Drains were maintained for nearly two weeks postoperatively until drainage was 30cc per shift prior to removal. Staples were allowed to remain in place to allow adequate healing of the wound. Following the second irrigation and debridement procedure, the wound remained clean, dry and intact and without any evidence of erythema or evidence of wound breakdown. Following removal of the drains, the wound continued to remain intact and she was felt to be stable for discharge home with close follow-up care. In addition, arrangements for VNA to observe the wound and assist with daily care was arranged. Plan will be to remain on Ceftriaxone and Flagyl intravenously for a period of eight weeks postoperatively. She should have a complete blood count with differential, ESR, CRP, and liver function tests obtained on a weekly basis and faxed to her primary care physician and the infectious disease clinic. The patient was seen by nutritionist during her hospitalization with subsequent calorie counts and supplementation as needed for postoperative nutrition. She otherwise remained medically stable throughout her hospitalization. She was felt to be medically stable for discharge home on ."},"extractive_notes_summ":{"kind":"string","value":"There is again demonstrated a deformity with reduced size of the right hemithorax. Dural ectasia and leak x2 repaired intraop FINAL REPORT HISTORY: Scoliosis. CONCLUSION: Single rod placement related to the scoliosis as described. There has been interval placement of a nasogastric tube with the tip terminating in the distal esophagus. LUMBAR SPINE W/O CONTRAST: Post surgical changes and susceptibility artifact are present. Final chest image demonstrated appropriate position of the PICC tip in the distal superior vena cava. COMPARISON: Comparison made to prior study of , CHEST AP: There is again note of a marked kyphoscoliosis. Marked scoliotic deformity as before including orthopedic hardware for scoliosis support. lacking detail demonstrates a single rod stabilizing the scoliosis related to the anterior fusion. Bilateral small pleural effusions are again demonstrated. There marked thoracic scoliosis convex to right with rod fixation. IMPRESSION: 1) Bilateral effusions with right middle and lower lobe opacities. This is most consistent with a pseudomeningocele. There has been interval placement of an endotracheal tube which is grossly unremarkable. INDICATION: Scoliosis, status post right thoracotomy and chest tube placement. IMPRESSION: 1) Right PICC line likely terminates at the junction of superior vena cava and right atrium, although distal tip is difficult to definitively visualize. On the frontal radiograph, it is visualized to the level of the junction of the right subclavian and right brachiocephalic veins, and subsequently obscured by a fixation hardware device related to the spine. Probable right lower lobe atelectasis and effusion. IMPRESSION: 1) Interval placement of right-sided chest tube with no pneumothorax identified. 2) Limited examination secondary to baseline deformity and suboptimal view. Sinus rhythm.Septal and lateral ST-T changes are nonspecificLow QRS voltages in precordial leads Mild (1+) mitral regurgitation is seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Resp Care,Pt. ATTEMPT TO WEAN PS AGAIN THIS AM. CONT VENT WEAN AS . RESTART AS PT . PULM HYGIENE. RESTART ANTIHYPERTENSIVES. pt.on cpap+ps , bs coarse, sx for tan secretions, rsbi-64.3, abg alkalotic, will wean as . ASSESS FOR H/A. Resp. POST EXTUBATION ABG WNL. MONITOR RESP STATUS. FOLLOWS COMMANDS.CV-HRR. FIB IN PLACE. Effect (P).P: Monitor resp status. LS CTA briefly. SKIN W+D. VENT WEAN STARTED AGAIN. HR/BP STABLE, SEE FLOWSHEET FOR ALL VS. REATTEMPT IPS WEAN IN AM. FOCUS: STATUS UPDATEDATA:PT ALERT AND ORIENTED X3. LS OCCAS COARSE, REQUIRED MIN SUCTIONING. CONT PER CURRENT MGMT. CONT PER CURRENT MGMT. PBOOTS ON. MONITOR VS AND RESP STATUS. RSBI attempted this am, pt. ADAT. WEAN VENT AS ORDERED AS TOL. PERRL. LAST BM, COLACE GIVEN. Cont PSV wean as tolerated. See carevue for settings/ABG. SPONT/PURP MOVING UPPER EXTREMITIES, NEEDS MIN ASSISTANCE TO MOVE LOWER EXTREMETIES.CV: HR 78-94, NSR, NO ECTOPY. Assist with C&DB, repositioning. CONTINUES ON IV CEFAZOLIN, AFEBRILE. CONT PAIN MGMT. PAIN IMPROVED PER PT REPORT.RESP: LS CTA. PT USING PCA APPROPRIATELY. EASILY AWAKENED WHEN GTT D/C'D. RETURNED TO WITH IMPROVEMENT IN VS, REPEAT ABG PENDING.CV: TMAX 99. +PP. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFCS.NEURO: ALERT. FEEDING TUBE THUS D/C'D. DULC SUPP GIVEN, EFFECT PENDING.GU: CLEAR YELLOW U/O VIA FOLEY.PLAN: RECHECK ABG. MD' AND LI PRESENT. CONT PER POST OP PROTOCOLS. ALINE D/C'D. CONTINUE WITH CURRENT MONITORING AND TREATMENT. PER DR. , PT GET OOB WITH PHYS THERAPY & ACTIVITY AS TOLERATED. pt.remains on mmv, see flowsheet for further info, sx for tan secretion, abg acidotic, will wean as tol., rsbi-41.7 LAST ABG IMPROVED-7.40/54/175/35/7/99.GI: ABD SOFTLY DISTENDED, +BS, TOLERATING TF IMPACT W/ FIBER AT GOAL AT 60CC/HR VIA POST PYLORIC DOBHOFF. Dr. to examine pt. DENIES CARDIAC COMPLAINTS.RESP-EXTUBATED THIS AM. lytes repleated. WILL MONITOR. PAIN WELL CONTROLLED WITH DILAUDID PCA. CONDITION UPDATEASSESSMENT:NEURO INTACT, COMMUNICATING BY MOUTHING WORDS & WRITING. +BS. + BS. CVP ~ 12.GI: NPO. RELIEVED WITH ZOFRAN. SBP 110-130's A-line slightly dampened. IVF KVO'D.GI: ABD SOFT. +diuresis.GI: +BS, abdomen softly distended. LG LIQUID BM THIS AM. normal affect.Good sensory respond from ext. TF'S HELD. Resp. Resp. Continues to use dilaudid PCA. RESTART TF'S SLOWLY WHEN PT ABLE TO . Tolerate t-piece for 1 hr - ABG - resp acidiotic (no sob). Plan to cont psv wean as tolerated. +flatus, pt. small drainage in proximal area of back - serosangious - DSD intact. c/o heartburn->zofran given w/ relief x1. CONT HOB FLAT. DRG CONTS, BUT IN DECREASED AMTS.RESP: LS CLEAR BUT DIM. MIN SECRETIONS. Clear upper lobes, dimish at bases. BP STABLE. MD INFORMED. LICSW # BS's ess clear. temp max 99.1. warm, dry, slight general edema.resp; clear in upper lobes. Wearing pboots.RESP: Lung sounds clear, coarse at times, dim to L. base. ATTEMPT VENT WEAN AS . ABG's with good oxygenation, slight resp acidosis. rectal bag replace. ABGs acceptable.Suctioned for white coarse secretions.CV: Afebrile. SIMV tolerated - ABG - better than prior, please see flow sheet.gu/gi; soft abd. PERRLA. Sxing small amts secretions from ETT. CONT PER CURRENT MGMT. Afebrile. Diamox x1 given. Cont. Cont. flowsheet. USING PCA MORE FREQUENTLY WITH STATED RELIEF. BS's clear. Extubate in AM? Lasix 20mg IV x1 w/excellent diuresis. soft abd, +BSX4. See flowsheet for pt data.Plan: Attempt weaning slowly. Good pain control with PCA.cv; NSR without ectopy. Et tube was rotated and retayped, SX mod amout thick white. extremities warm with palpable periferal pulses.RESP: lungs clear to dim at bases. heartburn X2 per pt - reglan given - good effect. alkalosis, resp. Sxing small amts thick white secretions from ETT. Neuro: Pt alert and oriented X3, mouthing words and able to write to make needs known.CV: Low grade temp 99.2, HR 60-80's NSR with no ectopy. to reflect met. RESPIRATORY CARE:Pt remains intubated, vent supported. Dobhoff - positive placement. Lytes replace.Plan; Continue to monitor. PERLA. PERLA. NSR. Care NotePt remains intubated and vented on settings as per resp."},"n_notes":{"kind":"number","value":51,"string":"51"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2154-02-05 00:00:00.000","description":"O LUMBAR SP,SINGLE FILM IN O.R.","row_id":812411,"text":" 10:11 AM\n LUMBAR SP,SINGLE FILM IN O.R. Clip # \n Reason: SCOLIOSIS,FUSION ANT. T-L SPINE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Back pain scoliosis effusion anterior T and L-spine\n\n Single portable film from the O.R. lacking detail demonstrates a single rod\n stabilizing the scoliosis related to the anterior fusion.\n\n CONCLUSION: Single rod placement related to the scoliosis as described.\n\n\n"},{"category":"Radiology","chartdate":"2154-02-25 00:00:00.000","description":"CHEST (PA & LAT)","row_id":814611,"text":" 9:57 AM\n CHEST (PA & LAT) Clip # \n Reason: fever, eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with prolonged intubation in unit, recent extubation\n\n REASON FOR THIS EXAMINATION:\n fever, eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n PA & LATERAL RADIOGRAPHS:\n\n COMPARISON: and .\n\n FINDINGS: The patient is markedly scoliotic convex to the right, with a rod\n fixator. There is resultant asymmetry of the thorax. Allowing for this, the\n lungs appear clear with no effusions or focal consolidations. There is no\n CHF.\n\n IMPRESSION: No acute cardiopulmonary process. Thoracic deformity unchanged\n in appearance.\n\n"},{"category":"Radiology","chartdate":"2154-02-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812792,"text":" 2:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess NGT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n assess NGT position\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: S/P NG tube placement.\n\n COMPARISON: Comparison made to prior study of ,\n\n CHEST AP: There is again note of a marked kyphoscoliosis. There has been\n interval placement of a nasogastric tube with the tip terminating in the\n distal esophagus. The superior portion of the film suggests that there may be\n coiling of the tube within the pharynx. There is a right internal jugular\n catheter present with its tip projecting over the right lung apex. There is\n no evidence of pneumothorax. There is probable atelectasis at the right lung\n and associated effusion. There are surgical staples noted along the entire\n extent of the visualized spine.\n\n IMPRESSION:\n 1. Nasogastric tube present with the tip in the distal esophagus and possible\n coiling in the pharynx.\n 2. Probable right lower lobe atelectasis and effusion.\n 3. Marked deformity limiting evaluation of the chest.\n\n"},{"category":"Radiology","chartdate":"2154-02-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812469,"text":" 5:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate et tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis\n\n REASON FOR THIS EXAMINATION:\n evaluate et tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New tracheal tube placed. Check position. Patient is severely\n scoliotic.\n\n CHEST: The tip of the endotracheal tube lies 3.5 cm from the carina angle.\n Visualized portions of the left lung appear normal.\n\n IMPRESSION: Endotracheal tube in satisfactory position.\n\n"},{"category":"Radiology","chartdate":"2154-02-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812436,"text":" 1:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p r thoracotomy ct placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis\n REASON FOR THIS EXAMINATION:\n s/p r thoracotomy ct placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY.\n\n INDICATION: Scoliosis, status post right thoracotomy and chest tube\n placement.\n\n Comparison is made to the prior chest x-ray on .\n\n AP OF THE CHEST: There is a known marked kyphoscoliosis convex to the right\n based on prior chest x-ray. The current study is extremely rotated. There\n has been interval placement of an endotracheal tube which is grossly\n unremarkable. There also appears to be a right internal jugular central\n venous catheter with its tip likely terminating in the distal SVC. There has\n been interval placement of a right-sided chest tube with its tip projecting\n over the right lung apex. There is no evidence of a pneumothorax. There is\n again demonstrated a deformity with reduced size of the right hemithorax.\n There is rod which projects over the right chest wall on this\n oblique view.\n\n IMPRESSION:\n\n 1) Interval placement of right-sided chest tube with no pneumothorax\n identified.\n\n 2) Limited examination secondary to baseline deformity and suboptimal view.\n\n"},{"category":"Radiology","chartdate":"2154-02-12 00:00:00.000","description":"N-G TUBE PLACEMENT (W/ FLUORO)","row_id":813249,"text":" 3:54 PM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: please place postpyloric dobhoff\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with kyphoscoliosis s/p attempt at fusion with no success;\n now unable to wean off vent\n REASON FOR THIS EXAMINATION:\n please place postpyloric dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49 year old woman with kyphoscoliosis status post attempted\n fusion, unable to wean off ventilator.\n\n NG TUBE PLACEMENT:\n\n Under fluoroscopic guidance, an 8 FR - tube was advanced with\n its tip in the second portion of the duodenum. Position was confirmed with\n Conray contrast. There were no immediate post procedure complications.\n\n IMPRESSION: Successful placement of NG feeding tube.\n\n"},{"category":"Radiology","chartdate":"2154-03-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":815327,"text":" 11:32 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: R picc placed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n R picc placed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old with scoliosis S/P right PICC placement.\n\n COMPARISON: .\n\n SINGLE PORTABLE CHEST: The tip of the PICC wire is seen to the right of mid-\n line. The course of the PICC catheter cannot be definitively determined\n because of an overlying catheter. It was recommended to the IV team to obtain\n additional views after the removal of the external catheter. There are new\n bilateral pleural effusions and there are increasing opacities in the right\n middle and lower lobe. These opacities could represent atelectasis however\n early pneumonia can't be excluded. There is significant scoliosis.\n\n IMPRESSION: 1) Bilateral effusions with right middle and lower lobe\n opacities. The latter may relate to atelectasis, but underlying infection is\n not excluded.\n\n 2) Additional views after the removal of external catheters is recommended to\n assess for the tip of the right PICC line.\n\n"},{"category":"Radiology","chartdate":"2154-03-04 00:00:00.000","description":"CHEST (PA & LAT)","row_id":815403,"text":" 7:01 PM\n CHEST (PA & LAT) Clip # \n Reason: R picc placed please page with \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with prolonged intubation in unit, recent extubation\n\n REASON FOR THIS EXAMINATION:\n R picc placed please page with \n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n CLINICAL INDICATION: PICC line placement.\n\n Comparison is made to previous portable chest radiograph of earlier the same\n date. A right PICC line is present. On the frontal radiograph, it is\n visualized to the level of the junction of the right subclavian and right\n brachiocephalic veins, and subsequently obscured by a fixation hardware device\n related to the spine. On the lateral view, the catheter is identified\n coursing to the region of the junction of the superior vena cava and right\n atrium although the distal tip is not definitively visualized.\n\n Cardiac and mediastinal contours are stable in the interval. There is\n improving aeration in the right middle and both lower lobes with residual\n patchy opacities remaining. Bilateral small pleural effusions are again\n demonstrated.\n\n IMPRESSION:\n 1) Right PICC line likely terminates at the junction of superior vena cava\n and right atrium, although distal tip is difficult to definitively visualize.\n 2) Improving aeration in the right middle and both lower lobes.\n 3) Persistent small bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2154-03-05 00:00:00.000","description":"MR CERVICAL SPINE","row_id":815514,"text":" 5:51 PM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n MR L SPINE SCAN\n Reason: recurrent wound drainage, previous csf leak (repaired)-- \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with recurrent wound drainage\n REASON FOR THIS EXAMINATION:\n recurrent wound drainage, previous csf leak (repaired)-- eval for csf leak\n ______________________________________________________________________________\n FINAL REPORT\n MR C, T, AND L SPINE .\n\n HISTORY: Recurrent wound drainage status post repair of CSF leak.\n\n Sagittal long TR, long TE, fast spin-echo and inversion recovery imaging was\n performed through the inferior spine. No contrast was administered.\n Comparisn to a study of .\n\n FINDINGS: The study is severely limited by the patient's severe scoliosis.\n This necessitated a suboptimally large field of view which limits the spatial\n resolution. On a number of the images, only a portion of the spine is\n included. The findings suggest an increase in the volume of fluid posterior\n to the spinal column. However, it is impossible to be certain that images of\n the same portions of the soft tissues posterior to the spine have been\n included in the current and the previous study. For this reason, even this\n finding is uncertain.\n\n CONCLUSION: Extremely limited study due to severe scoliosis and consequent\n technical limitation. Suggestion an increase in the volume of fluid in the\n tissues posterior to the spinal column. However, this is not a definite\n change since .\n\n"},{"category":"Radiology","chartdate":"2154-03-05 00:00:00.000","description":"REPOSITION CENTRAL VENOUS CATH W/FLUORO","row_id":815493,"text":" 3:55 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: current PICC in subclavian\n ********************************* CPT Codes ********************************\n * REPOSITION CENTRAL VENOUS CATH FLUORO 1 HR W/RADIOLOGIST *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with Post op wound infection, requires 6 weeks iv abx.\n Unsucessful PICC placement on floor\n REASON FOR THIS EXAMINATION:\n current PICC in subclavian\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 49-year-old woman with wound infection requiring IV antibiotics.\n She had a bedside PICC place with tip in the subclavian vein.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and \n who was present and supervising. The patient's right arm was prepped and\n draped in standard sterile fashion. Under fluoroscopic guidance, an 018 glide\n wire was advanced through the PICC causing the tip to flip into the superior\n vena cava. The wire was removed. The line was flushed and hep-locked and\n secured with a Stat-lock. Final chest image demonstrated appropriate position\n of the PICC tip in the distal superior vena cava.\n\n IMPRESSION: Successful repositioning of single-lumen PICC with tip in the\n superior vena cava. The line is ready for use.\n\n\n"},{"category":"Radiology","chartdate":"2154-02-26 00:00:00.000","description":"MR CERVICAL SPINE","row_id":814822,"text":" 9:03 PM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n MR L SPINE SCAN; -52 REDUCED SERVICES\n Reason: eval for persistant csf leak/ pseudomeningoceal. Dural ecta\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with polio, wound drainage, HA postop\n REASON FOR THIS EXAMINATION:\n eval for persistant csf leak/ pseudomeningoceal. Dural ectasia and leak x2\n repaired intraop\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Scoliosis. Status post fusion.\n\n TECHNIQUE: Multiplanar MR images of the thoracolumbar spine were obtained.\n True cardinal planes were difficult to obtain due to the patient's severe\n scoliosis.\n\n FINDINGS:\n MR SPINE W/O CONTRAST: Evaluation is extremely limited secondary to large\n field of view, oblique imaging planes, and susceptibility artifact.\n\n There is diffuse edema involving the soft tissues of the neck. No CSF\n collection in the soft tissues surrounding the cervical spine is noted. High\n signal within the vertebral body of C3 on T1W images is a nonspecific finding\n and of uncertain significance. No definite evidence of a pseudomeningocele in\n the cervical region is appreciated.\n\n Limited views of the brain and nasopharynx are unremarkable.\n\n LUMBAR SPINE W/O CONTRAST: Post surgical changes and susceptibility artifact\n are present. There is an extensive fluid collection with an air-fluid level\n extending approximately 18 cm along the posterior thoracolumbar spine and\n surgical bed. This is most consistent with a pseudomeningocele. Follow-up is\n recommended to assess for interval change.\n\n Diffuse edema is present in the subcutaneous soft tissues overlying the\n thoracolumbar spine.\n\n IMPRESSION:\n\n Extremely limited examination.\n\n Pseudomeningocele. Followup is recommended to assess for interval change.\n\n\n"},{"category":"Radiology","chartdate":"2154-02-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":812674,"text":" 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Female patient with scoliosis. Follow up of chest tube placement.\n\n FINDINGS: The AP single view is obtained with patient in supine position and\n analyzed in direct comparison with a similar film dated .\n Position of the ETT remains unchanged terminating approximately 3 cm above the\n carina. Marked scoliotic deformity as before including orthopedic hardware for\n scoliosis support. A right sided chest tube remains in place. No new\n parenchymal infiltrates can be identified on this single view examination.\n\n"},{"category":"Radiology","chartdate":"2154-02-21 00:00:00.000","description":"CHEST (PA & LAT)","row_id":814245,"text":" 10:52 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p extubation, cough\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with prolonged intubation in unit, recent extubation\n REASON FOR THIS EXAMINATION:\n s/p extubation, cough\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-extubation and cough\n\n AP and lateral views of the chest dated is compared with the\n prior PA and lateral radiograph dated .\n\n There marked thoracic scoliosis convex to right with rod fixation.\n Multiple staples overlie the soft tissues of the back. The left lung appears\n clear. The cardiac and mediastinal contours are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease. Chest deformity,\n unchanged.\n\n"},{"category":"Echo","chartdate":"2154-03-11 00:00:00.000","description":"Report","row_id":75618,"text":"PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Endocarditis. Pericardial effusion.\nHeight: (in) 56\nWeight (lb): 150\nBSA (m2): 1.57 m2\nBP (mm Hg): 122/69\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 10:34\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na low risk (prophylaxis not recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets appear structurally normal with good leaflet excursion. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\nThere is an anterior space which most likely represents a fat pad.\n\nIMPRESSION: Mild mitral regurgitation with grossly normal morphology.\nPreserved global and regional biventricular systolic function.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"},{"category":"ECG","chartdate":"2154-02-05 00:00:00.000","description":"Report","row_id":181592,"text":"Sinus rhythm.\nSeptal and lateral ST-T changes are nonspecific\nLow QRS voltages in precordial leads\n\n"},{"category":"Nursing/other","chartdate":"2154-02-07 00:00:00.000","description":"Report","row_id":1494782,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 49 Y/O FEMALE S/P ANTERIOR THORACIC T3-PELVIS FUSION ON /O4. PT HAS BEEN IN PACU SINCE POST OP. PT EXTUBATED IN PACU THIS AM AND REINTUBATED A FEW HRS LATER. PT ADMITTED TO ICU AT 17:30 FOR MONITORING. PE AS FOLLOWS:\n\nNEURO-PT AWAKE, ALERT, MOUTHS WORDS, NODS APPROP. PT PARAPLEGIC AT BASELINE. FOLLOWS COMMANDS.\n\nCV-TEMP 101.4. PT PAN CX IN PACU. HR/BP STABLE. SKIN W+D. +PP. TEDS ON. AWAITING ARRIVAL OF PBOOT MACHINE.\n\nRESP-REMAINS VENTED ON CPAP. TOL WELL. WILL FOLLOW ABG. SXN FOR SM AMT THIN WHITE SPUTUM. PT ALSO WITH MOD AMT ORAL SECRETIONS. USING YANKEAR I. LS COARSE. CT TO SXN WITH SEROUSSANG DRG. NO LEAK NOTED.\n\nGI-ABD OBESE, SOFT, NT/ND. NPO.\n\nGU-VOIDING VIA FOLEY ADEQ AMT CL AMBER URINE.\n\nCOMFORT-USING DILAUDID PCA WITH EFFECT.\n\n-DSG INTACT.\n\nPLAN-CON'T WITH CURRENT PLAN. FOLLOW LABS. TO OR IN AM FOR POSTERIOR APPROACH.\n"},{"category":"Nursing/other","chartdate":"2154-02-08 00:00:00.000","description":"Report","row_id":1494783,"text":"Resp Care Note, Decreased RR for ABG resp alk. Suctioned for sml amts thick white secretions. RSBI not done due to no spont resp.Getting pain med.Will cont to monitor resp status for further weaning.\n"},{"category":"Nursing/other","chartdate":"2154-02-11 00:00:00.000","description":"Report","row_id":1494796,"text":"CONDITION UPDATE:\nD/A: T MAX 100.5\n\nNEURO: UNCHANGED. PAIN WELL CONTROLLED WITH DILAUDID PCA. PER DR. , SLOWLY ELEVATE HOB OVERNIGHT. IF PT BEGINS TO GET A HEADACHE OR HAS A WORSENING HEADACHE, DO NOT ELEVATE HEAD ANY HIGHER. IF PT HAS ANY SIGNS OF CSF LEAK ON DRESSING, DO NOT ELEVATE HOB.\n\nRESP: LS COARSE, HOWEVER WITH AMBU, LAVAGE, SX MINIMAL SECRETIONS OBTAINED. VENT WEAN STARTED AGAIN. CURRENTLY ON CPAP, PS 50%, 5 PEEP 8 PS WITH LAST ABG: 7.28, 56, 174, -1, 98%.\n\nCV: HR 80'S-110, NSR ST. FLUID BOLUS 250 CC'S X1 FOR CONSISTENT BP ~ 88/50, HR > 100. SLIGHT + EFFECT. CVP ~ 12.\n\nGI: NPO. + BS. GLUCOSE LEVEL WNL'S. IVF INCREASED.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: MOTHER AND FRIEND VISITING MOST OF DAY.\n\nR: RESP ACIDOSIS, DIFFICULT VENT WEAN.\n\nP: CONTINUE ATTEMPTS TO WEAN. IF UNABLE TO EXTUBATE IN AM, REVISIT PLACING A NGT/PEDI TUBE FOR NUTRITION. PT AND FAMILY SUPPORT. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\n"},{"category":"Nursing/other","chartdate":"2154-02-13 00:00:00.000","description":"Report","row_id":1494797,"text":"FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X3. VERY PLEASANT AND COOPERATIVE. COMMUNICATES BY WRITING.\nLUNGS COARSE. CONTINUES VENTILATED, UNABLE TO WEAN OFF VENT D/T POOR ABG'S. ON MMV VENT MODE WITH IMPROVED ABG.\nTO FLUORO FOR POSTPYLORIC FT PLACEMENT.\n\nPLAN:\nSTART TF.\n\n"},{"category":"Nursing/other","chartdate":"2154-02-13 00:00:00.000","description":"Report","row_id":1494798,"text":"CONDITION UPDATE\nASSESSMENT:\n PT SLEEPING ON/OFF, APPEARS ORIENTED X3. FOLLOWING ALL COMMANDS AND ABLE TO COMMUNICATE BY WRITING/MOUTHING WORDS.\nCV- HR/BP STABLE, SEE FLOWSHEET FOR VITALS AND DETAILS. CVP 12-18.\nRESP- LS OCCAS COARSE, SUCTIONED FOR THICK TAN SPUTUM. REMAINS ON MMV, NO VENT CHANGES MADE.\nGU- MAINTAINING ADEQ HRLY U/O, CLEAR YELLOW.\nGI- ABDOMEN SOFT, ? LAST BM, COLACE GIVEN. IMPACT WITH FIBER STARTED (POST-PYLORIC TUBE) @ 10CC/HR.\nINTEG- SKIN WARM & PINK. BACK DSG INTACT, NO DRAINAGE. RIGHT THORACOTOMY SIGHT WITH STERI-STRIPS, C/D/I. C/O BACK PAIN, INCREASES WITH MOVEMENT. PT USING PCA APPROPRIATELY. HOB < 30 DEGREES, BUT GRADUALLY INCREASING SINCE AM AND PT TOLERATING.\nPLAN:\nADVANCE TF TO GOAL RATE OF 65CC/HR AS TOLERATES. ATTEMPT TO WEAN PS AGAIN THIS AM. CONTINUE WITH CURRENT MONITORING AND TREATMENT.\n"},{"category":"Nursing/other","chartdate":"2154-02-13 00:00:00.000","description":"Report","row_id":1494799,"text":"pt.remains on mmv, see flowsheet for further info, sx for tan secretion, abg acidotic, will wean as tol., rsbi-41.7\n"},{"category":"Nursing/other","chartdate":"2154-02-13 00:00:00.000","description":"Report","row_id":1494800,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFCS.\nNEURO: ALERT. ORIENTED X 3. COMMUNICATES VIA MOUTHING AND WRITING. HOB UP TO 30 DEGREES, C/O SL H/A, HOB DOWN TO 15 DEGREES WITH SOME RELIEF. HYDROMORPHONE PCA DOSE DECREASED TO .25MG Q6MIN WITH ADEQUATE PAIN CONTROL PER PT REPORT.\nRESP: LS CLEAR TO COARSE. SM AMTS THICK TAN SPUTUM. VENT WEAN ATTEMPTED, BUT PT RETAINING CO2 AND BECOMMING LETHARGIC WITH DECREASED IPS.\nCV: AFEBRILE. NSR. BP STABLE 90-130 SYS. NO FLUID BOLUSES THIS SHIFT. IVF CONTS AT 80CC/H.\nGI: ABD SOFT. TF'S SLOWLY ADVANCED TOWARD GOAL, BUT PT C/O NAUSEA WITH TF'S UP TO 40CC/H X ~3HOURS. RELIEVED WITH ZOFRAN. TF'S HELD FOR NOW.\nGU: CLEAR YELLOW U/O, INITIALLY > 20CC/HOUR, INCREASING TO >30CC/HOUR THIS EVE.\nSKIN: THORACOTOMY WOUND CLEAN AND DRY WITH STERISTRIPS INTACT. NO DRG NOTED FROM BACK INC, DSD CLEAN AND DRY.\nPLAN. REATTEMPT IPS WEAN IN AM. CONT PAIN MGMT. RESTART AS PT . MONITOR FOR SIGNS OF INFECTION. CONT PER CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2154-02-18 00:00:00.000","description":"Report","row_id":1494815,"text":"nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3. FOLLOWS COMMANDS.\n\nCV-HRR. SBP STABLE. ALINE D/C'D. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-EXTUBATED THIS AM. WELL THUS FAR. POST EXTUBATION ABG WNL. LS COARSE. PT WITH CONGESTED COUGH, USING YANKEAR I. O2 WEANED TO 2L NC. O2 SAT 99%.\n\nGI-ABD SOFT, NT/ND. +BS. CON'T WITH LIQ BROWN STOOL. FIB IN PLACE. PT REQUESTED TUBE D/C'D DESPITE INFORMATION FROM DR. AND THIS RN ABOUT IMPORTANCE OF KEEPING FEEDING TUBE AT THIS TIME. PT VERBALIZED AND STILL REQUESTED TUBE TO BE REMOVED. FEEDING TUBE THUS D/C'D. ABLE TO PILLS WITHOUT INCIDENT. ?ADAT.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-REPOSITIONED FREQ.\n\nCOMFORT-REPORTS ADEQ PAIN RELIEF WITH VICODIN PRN. ALSO ON FENT PATCH.\n\nID-TMAX 100, NOW DOWN TO 98.6. CON'T ON KEFZOL.\n\n-RIGHT FLANK WITH STERISTRIPS C/D/I. BACK INCISION WITH STAPLES, PINK, WITH MOD AMT SEROUSSANG DRG. DSG CHANGED. DR. IN TO EVAL. WILL MONITOR.\n\n MOTHER AND SISTER IN TO VISIT FREQ. SW FOLLOWING.\n\nPLAN-CON'T WITH CURRENT PLAN. PULM HYGIENE. ASSESS PAIN. MONITOR FOR CHANGES. ? ADAT. SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2154-02-19 00:00:00.000","description":"Report","row_id":1494816,"text":"CONDITION UPDATE\nASSESSMENT:\nPT DOZING ON/OFF OVERNIGHT, NO ACUTE NEURO DEFICITS. BACK INCISION WITH STAPLES OOZING MOD AMTS BROWN/OLD SEROSANG DRAINAGE, DSD CHANGED. CONTINUES ON IV CEFAZOLIN, AFEBRILE. RIGHT THORACOTOMY INCISION WITH STERISTRIPS INTACT, NO DRAINAGE. HR/BP STABLE, SEE FLOWSHEET FOR ALL VS. BREATHING EVEN/UNLABORED @ REST, SP02 100% WITH NASAL CANNULA, LS CLEAR. GIVEN VICODIN FOR BACK PAIN; PT STATES SHE DOES NOT LIKE VICODIN (MAKES HER CONFUSED). PT GIVEN TYLENOL WITH ADEQ RELIEF OF PAIN; ALSO CONTS ON FENT PATCH. TOLERATING CLEAR LIQUIDS, IVF KVO.\nPLAN:\nADVANCE DIET TO REG. ? TRANSFER TO FLOOR TODAY. PULMONARY HYGEINE. PHYS THERAPY, INCREASE ACTIVITY.\n"},{"category":"Nursing/other","chartdate":"2154-02-19 00:00:00.000","description":"Report","row_id":1494817,"text":"Addendum to Nursing Transfer Note A:\nD: O2sat 98-100%. HR 100's. BP stable. Weak cough. Coarse LS through out. Very weak cough.\nA: Gentle CPT provided. Per pt request hot tea provided. Declined NTsx. Gag reflex stimulated with yankeur with good effect. LS CTA briefly. Dr. to examine pt. Guaifenison 10cc provided. Effect (P).\nP: Monitor resp status. Assist with C&DB, repositioning.\n"},{"category":"Nursing/other","chartdate":"2154-02-08 00:00:00.000","description":"Report","row_id":1494784,"text":"Neuro: Alert and oriented. Able to follow directions. Having mod amount of pain at R CT insertion site. Using dilaudid PCA appropriately and requesting dilaudid coverage 0.5mg Q2hr with effect.\nCV: Temp 99.0, HR 80's NSR with no ectopy, SBP 90-120's. lytes repleated. Recieved 20mg lasix at 12am with good effect.\nRESP: lungs coarse through-out. requiring occasional suctioning of thick white sputum. O2 sats >98%. Vent setting changed this am. for Pco2 31. Resp rate decreased to 16.\nGI: NPO No stool tonight.\nGU:foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars wnl no coverage required.\nPLAN: to OR this am for posterior approach of spinal fusion.\n"},{"category":"Nursing/other","chartdate":"2154-02-08 00:00:00.000","description":"Report","row_id":1494785,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nPT TO OR AT APPROX 0730 THIS AM FOR T3 TO PELVIS FUSION. RETURNED APPROX 1200 S/P REMOVAL OF HARDWARE, REMOVAL OF CHEST TUBE, T3 TO L4 FUSION.\nNEURO: PT SEDATED ON PROPOFOL GTT ON ARRIVAL. EASILY AWAKENED WHEN GTT D/C'D. MOVES UPPER EXTREMTITES WELL. PERRL. MOUTHING WORDS APPROPRIATELY. C/O PAIN. MD' AND LI PRESENT. DILAUDID BOLUS GIVEN AND PCA DOSE INCREASED AS ORDERED. PAIN IMPROVED PER PT REPORT.\nRESP: LS CTA. ARRIVED INTUBATED ON IMV 16 X 400, IPS 10. ABG'S STABLE. ET SUCTIONED FOR SCANT AMTS BLOOD TINGED SPUTUM.\nGI: ABD SOFT. C/O NAUSEA ON ARRIVAL TO UNIT, RESOLVED WITHOUT INTERVENTION. NGT PLACEMENT ATTEMPTED, BUT UNABLE TO VISUALIZE TIP IN STOMACH ON CXR X2 (DESPITE FAR ADVANCEMENT), ? COILED IN PHARYNX. PLACEMENT BY MD , BUT UNSUCCESSFUL.\nGU: CLEAR, TINTED U/O VIA FOLEY. >30CC/HOUR.\nSKIN: R FLANK INCISION OTA WITH STERI-STRIPS INTACT. NO DRG. BACK ELASTOPLAST DSG CDI.\nPLAN: PAIN MGMT. REVERSE T- TO PREVENT RISK OF ASPIRATION AS TOLERATED. MED FOR NAUSEA. MONITOR VS AND RESP STATUS. WEAN VENT AS ORDERED AS TOL. CONT PER POST OP PROTOCOLS.\n"},{"category":"Nursing/other","chartdate":"2154-02-09 00:00:00.000","description":"Report","row_id":1494786,"text":"NEURO; ALERT X 1, WRITES NOTES TO COMMUNICATE, WIGGLES TOES BOTH FEET, AND MOVES THEM SLIGHTLY, USING DILAUDID PCA PUMP WITH ENCOURAGEMENT,\nPT MAINTAINED FLAT IN BED, LOG ROLLED PRN\n\nCARDIOVASCULAR; HR 90'S SR, SYS LOW 100'S, CVP 8-13, TEMP 100, EXTREMITIES EDEMATOUS, ESP EYELIDS,\n\nRESPIR; REMAINS ON CIMV, ABGS STABLE THIS AM, SUCTIONED FOR SMALL AMTS THIN WHITE SECRETIONS, FREQUENTLY USES YANKHAUER HERSELF AND SUCTIONS OCCAS THICK BLOODY MUCOUS\n\nWOUND; ACE DSG D/I TO THORACO-LUMBAR AREA, STERI-STRIPS INTACT FROM FORMER RT THORACOTOMY,\n"},{"category":"Nursing/other","chartdate":"2154-02-09 00:00:00.000","description":"Report","row_id":1494787,"text":"Resp Care,\nPt. remains intubated overnoc, no vent changes this shift. See carevue for settings/ABG. RSBI attempted this am, pt. had a prlonged period of apnea. Will try again later this am.\n"},{"category":"Nursing/other","chartdate":"2154-02-09 00:00:00.000","description":"Report","row_id":1494788,"text":"Resp. Care Note\nPt received intubated and vented on settings SIMV 400x 16x 50% peep 5 psv 10. Pt changed over to PSV 15 peep 5 and 505 and has tolerated wean to PSV 12. Good ABG on current settings of PSV 12 peep 5 and 50%. Cont PSV wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2154-02-14 00:00:00.000","description":"Report","row_id":1494801,"text":"pt.on cpap+ps , bs coarse, sx for tan secretions, rsbi-64.3, abg alkalotic, will wean as .\n"},{"category":"Nursing/other","chartdate":"2154-02-14 00:00:00.000","description":"Report","row_id":1494802,"text":"CONDITION UPDATE\nASSESSMENT:\nNEURO INTACT, COMMUNICATING BY MOUTHING WORDS & WRITING. USING PCA APPROPRIATELY FOR BACK PAIN. PER DR. , PT GET OOB WITH PHYS THERAPY & ACTIVITY AS TOLERATED. BACK DSG INTACT, NO DRAINAGE. RIGHT THORACOTOMY INCISION WITH SS INTACT. NO VENT CHANGES MADE OVERNIGHT, FAILED SPONT BREATHING TRIAL IN AM. LS OCCAS COARSE, REQUIRED MIN SUCTIONING. IMPACT WITH FIBER ADVANCED OVERNIGHT, PT TOLERATING. ABDOMEN SOFTLY DISTENDED, DENIES NAUSEA. HEMODYNAMICS STABLE, SEE FLOWSHEET FOR VITALS AND FULL PHYS ASSESSMENT.\nPLAN:\nCONTINUE WITH CURRENT MONITORING AND TREATMENT. ? ATTEMPT TO WEAN PRESS SUPPORT TODAY. INCREASE & ASSIST WITH ACTIVITY AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2154-02-14 00:00:00.000","description":"Report","row_id":1494803,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: ALERT AND ORIENTED X3. SLEEPY AT TIMES, BUT EASILY AWAKENS. PCA DOSE DECREASED, WITH ADEQUATE PAIN CONTROL. C/O PERSISTENT MILD H/A, UNCHANGED FROM PREVIOUS REPORT PER PT. C/ EARACHE, MD INFORMED AND TO EXAMINE WITH OTOSCOPE.\nRESP: LS CLEAR TO COARSE WHEN ET SUCTION NEEDED, SM AMT THICK WHITE TO TAN SPUTUM. VENT WEANED TO 10 PS, 5 PEEP. ABG SHOWS PCO2 UP TO 50S, BUT PT COMPENSATING WITH TCO2 UP TO 34, PH STABLE AT 7.39. WHEN WEAN TO ATTEMPTED, PT BECAME HYPERTENSIVE TO 190S SYS, TACHYCARDIC TO 110S, AND TACHYPNEIC WITH INCREASED WOB. RETURNED TO WITH IMPROVEMENT IN VS, REPEAT ABG PENDING.\nCV: TMAX 99. SBP 140S TO 150S. ? RESTART ANTIHYPERTENSIVES. ALINE RESITED TO L-RAD DUE TO MALFUNCTION. IVF CONTS AT 80CC/HOUR.\nGI: ABD SOFTLY DISTENDED. TF'S AT GOAL. C/O SL NAUSEA AND FULLNESS. DULC SUPP GIVEN, EFFECT PENDING.\nGU: CLEAR YELLOW U/O VIA FOLEY.\nPLAN: RECHECK ABG. MONITOR RESP STATUS. CONT VENT WEAN AS . PAIN MGMT. OOB TO CHAIR TOMORROW. ASSESS FOR H/A. CONT PER CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2154-02-15 00:00:00.000","description":"Report","row_id":1494804,"text":"NEURO: A&O X3, COMMUNICATES BY MOUTHING WORDS OR WRITING, APPROPRIATE. SPONT/PURP MOVING UPPER EXTREMITIES, NEEDS MIN ASSISTANCE TO MOVE LOWER EXTREMETIES.\n\nCV: HR 78-94, NSR, NO ECTOPY. SBP 121-151.\n\nRESP: VENT SETTINGS NOT TOLERATED ON CPAP+PS, MULT ABG'S DRAWN W/ INC PCO2 TO 64, DR. INFORMED. PT SWITCHED BACK TO SIMV 5 PEEP, 10 PS, TV 400'S, RR 14, FIO2 50%. LAST ABG IMPROVED-7.40/54/175/35/7/99.\n\nGI: ABD SOFTLY DISTENDED, +BS, TOLERATING TF IMPACT W/ FIBER AT GOAL AT 60CC/HR VIA POST PYLORIC DOBHOFF. HAD SMALL BM AFTER RECEIVING DULCOLAX SUPPOSITORY.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR YELLOW URINE. PT IS CURRENTLY MENSTRUATING.\n\nID: TMAX 98.9\n\nPAIN: GOOD PAIN CONTROL ACHIVED W/ DILAUDID PCA.\n\nPLAN: MONITOR RESP STATUS, IF UNABLE TO WEAN VENT ?TRACH. MONITOR PAIN.\n\n"},{"category":"Nursing/other","chartdate":"2154-02-15 00:00:00.000","description":"Report","row_id":1494805,"text":"Respiratory Care\nPt remain intubated and on vent support, Paco2 issue that pressist and din not change alot despit the vent setting change Paco2 remain in the 50's. Et tube was rotated and retayped, SX mod amout thick white.\n"},{"category":"Nursing/other","chartdate":"2154-02-10 00:00:00.000","description":"Report","row_id":1494792,"text":"Nursing note:\nNEURO: A/Ox3, writing on message board to make needs known. PERRLA 2-3mm and brisk bilat. Wiggles toes bilat , follows commands. C/O mild headache r/t dural tears per team. Using Dilaudid PCA w/fair relief of back pain and headache.\nCV: Afebrile. SR in 70s-80s, no ectopy. SBP 120-140s. Wearing pboots.\nRESP: Lung sounds clear, coarse at times, dim to L. base. Suctioned infrequently for thick white secretions. No vent changes today, ABGS cont. to reflect met. alkalosis, resp. acidosis. Diamox x1 given. +diuresis.\nGI: +BS, abdomen softly distended. -stool. +flatus, pt. c/o feeling bloated/constipated.\nGU: Foley patent for adequate amount amber urine. +diuresis.\nSOCIAL: Husband and mom @ bedside most of day.\n\nA/P: Stable s/p back/pelvic fusion surgery, now slow to wean off vent. Cont. gentle diuresis, follow ABGs, pain control, skin care and vent wean.To remain flat for more days. Cont. current plan of care.\n"},{"category":"Nursing/other","chartdate":"2154-02-10 00:00:00.000","description":"Report","row_id":1494793,"text":"Resp. Care Note\nPt remains intubated and vented on settings as per resp. flowsheet. No vent changes made today, plan was to cont diuresis and Rx met. alkalosis with diamox. Assess weaning parameters in AM and cont with PSV wean with hopes to extubate tomorrow.\n"},{"category":"Nursing/other","chartdate":"2154-02-11 00:00:00.000","description":"Report","row_id":1494794,"text":"data/action: vss, using pca dilaudid w/ good relief of back pain.\nrr-16-20 on cpap w/ ips 12 o/n w/ morning abg's acidotic 7.22/pc02 64\nvent mode changed to simv12 w/ improvement in abg's 7.42/pc02 36.\nsx'd thin pale tan/white q3hr. bs 51 this am amp d50 iv given-bs pending. alert writing in notebook for needs. c/o heartburn->zofran given w/ relief x1.\n"},{"category":"Nursing/other","chartdate":"2154-02-11 00:00:00.000","description":"Report","row_id":1494795,"text":"Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. PSV level decreased today from 12-10-8. ABG's with good oxygenation, slight resp acidosis. Plan to cont psv wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2154-02-17 00:00:00.000","description":"Report","row_id":1494811,"text":"Neuro: Alert and oriented X3. Continues to use dilaudid PCA. attempting to wean off and use vicodin per dopoff. having some noted effect on pain with vicodin. back incision continues to drain small amounts of sero-sang drg from proximal end of incision.\nCV: afebrile, HR 80's NSR with no ectopy. SBP 100-120's A-line very dampended. extremities warm with palpable periferal pusles. repleated K+ X2.\nRESP: pt vent changed to CPAP 5&5 with acceptable ABG. Requiring occasional suctioning of thick white sputum. lungs clear to dim at bases.\nGI: tube feed with no cramping but some \"heartburn\" slightly improved with reglan, zofran and protonix.\nGU: foley draining adequate amounts of clear yellow urine.\n\n"},{"category":"Nursing/other","chartdate":"2154-02-15 00:00:00.000","description":"Report","row_id":1494806,"text":"CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: ALERT AND ORIENTED. USING PCA MORE FREQUENTLY WITH STATED RELIEF. LG AMT SEROSANG DRG FROM SPINAL INC. SICU TEAM INFORMED AND SHOWN. DSD CHANGED. PT DENIES H/A. HOB FLAT. DRG CONTS, BUT IN DECREASED AMTS.\nRESP: LS CLEAR BUT DIM. MIN SECRETIONS. NO VENT CHANGES TODAY.\nCV: TMAX 99.4. NSR. BP STABLE. 10MG IV LASIX GIVEN AS ORDERED WITH DIURESIS. PT STILL POS >1L SINCE MN. ADDITIONAL 20MG ORDERED AND GIVEN. PHOS REPLETED WITH NAPHOS AS ORDERED. IVF KVO'D.\nGI: ABD SOFT. LG LIQUID BM THIS AM. PT C/O INCREASING ABD FULLNESS AND NAUSEA. TF'S HELD. PT REFUSING RESTART. MD INFORMED. IVF INCREASED TO 60CC/HOUR UNTIL TF'S RESTARTED.\nGU: CLEAR YELLOW U/O.\nPLAN: CONT TO MONITOR. CONT HOB FLAT. MONITOR FOR DRG FROM SPINAL INCISION. RESTART TF'S SLOWLY WHEN PT ABLE TO . ATTEMPT VENT WEAN AS . CONT PER CURRENT MGMT.\n"},{"category":"Nursing/other","chartdate":"2154-02-16 00:00:00.000","description":"Report","row_id":1494807,"text":"Respiratory care\nPt remain intubated and on vent support no vent changes.\n"},{"category":"Nursing/other","chartdate":"2154-02-16 00:00:00.000","description":"Report","row_id":1494808,"text":"Neuro: Pt alert and oriented X3, mouthing words and able to write to make needs known.\nCV: Low grade temp 99.2, HR 60-80's NSR with no ectopy. SBP 110-130's A-line slightly dampened. CVP>20. extremities warm with palpable periferal pulses.\nRESP: lungs clear to dim at bases. No vent changes. O2 sats 100%.\nGI: NPO per pt. request due to abd cramping from tube feeds. No stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nendocrine: blood sugars wnl.\n"},{"category":"Nursing/other","chartdate":"2154-02-17 00:00:00.000","description":"Report","row_id":1494809,"text":"7p-7a; Full assessment in flow sheet.\n\nneuro: A+OX3. Mouth and write words. MAE - stronger in upper than lower ext. Good gag and cough reflex. Follow commands. normal affect.\nGood sensory respond from ext. PERLA. Good pain control with PCA.\n\ncv; NSR without ectopy. VSS. temp max 99.1. warm, dry, slight general edema.\n\nresp; clear in upper lobes. dimish at bases. Strong - productive cough - white/thick sputum. SIMV tolerated - ABG - better than prior, please see flow sheet.\n\ngu/gi; soft abd. +BSX4. no flatus. no bm. heartburn X2 per pt - reglan given - good effect. restarted TF slowly - no pain cramp or nausea per pt. Dobhoff - positive placement. foley patent - clear yellow urine.\n\nSkin intact except for back dressing - serous/serousangious dressing in upper part of back - reinforce dressing.\n\nAM lab . Lytes replace.\n\nPlan; Continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2154-02-17 00:00:00.000","description":"Report","row_id":1494810,"text":"RESPIRATORY CARE:\n\nPt remains ess unchanged, supported on SIMV thru noc. Sxing small amts thick white secretions from ETT. BS's ess clear. See flowsheet for pt data.\nPlan: Attempt weaning slowly.\n"},{"category":"Nursing/other","chartdate":"2154-02-09 00:00:00.000","description":"Report","row_id":1494789,"text":"Nursing note:\nNEURO: A/Ox3, communicating via gestures and writing on message board. PERRLA. Able to wiggle toes easily. Using Dilaudid PCA for adequate pain control.\nRESP: Lung sounds coarse, weaned to CPAP w/10 IPS. ABGs acceptable.\nSuctioned for white coarse secretions.\nCV: Afebrile. SBP 120s. SR in 80s, no ectopy. No cardiac issues. Lasix 20mg IV x1 w/excellent diuresis. K+ replaced w/60meq total IV.\nGI: +BS, abdomen soft, no stool or flatus. No n/v. Remains NPO.\nGU: Foley patent adequate amount amber urine.\nENDO: Glucose stable.\nWound: Ace dressing d/i to thoraco-lumbar area, steris intact from former R. thoracotomy.\nA/P: Stable s/p spinal /pelvic fusion, tolerating vent wean.\n"},{"category":"Nursing/other","chartdate":"2154-02-10 00:00:00.000","description":"Report","row_id":1494790,"text":"NEURO; WRITES NOTES APPROPRIATELY, MOUTHES WORDS, USES DILAUDID PCA PUMP PRN,\nPT REMAINS FLAT IN BED\n\nCARDIOVASCULAR; HR 90'S SR, SYS BP 120-140'S, CVP 12-15, AFEBRILE, EDEMA OF ALL EXTREMITIES,\n\nRESPIR; SUCTIONED FOR SMALL AMTS THIN WHITE SECRETIONS, OCCAS BLOOD TINGED SECRETIONS ORALLY BUT HAS DECREASED SINCE YESTERDAY, ABGS REFLECT RESPIR ACIDOSIS\n\nRENAL; LASIX 20 IV ON EVES WITH FAIR DIURESIS,\n"},{"category":"Nursing/other","chartdate":"2154-02-10 00:00:00.000","description":"Report","row_id":1494791,"text":"RESPIRATORY CARE\nPt remain intubated no respiratory issue overnight Sx samll white thick ,Pt is aweak amd responsive , remain flat on her back.\n"},{"category":"Nursing/other","chartdate":"2154-02-18 00:00:00.000","description":"Report","row_id":1494812,"text":"7p-7a; Full assessment in flow sheet.\n\nA+OX3. Mouth words and write need. Follow commands. MAE - stronger in upper than lower ext. PERLA. Good cough and gag reflex. Pain in back - relief with PCA - PCA d/ MD order - vicodin po started - not as effective per pt - also causes inc HR and feeling of being very warm per pt (no change in HR or temp per monitor). Slept on/off most of the night. VSS (except when increase with activities and t-piece trial). Afebrile. warm, dry, no edema. Clear upper lobes, dimish at bases. Tolerate t-piece for 1 hr - ABG - resp acidiotic (no sob). Return to CPAP 5/5 to rest for the night. soft abd, +BSX4. loose brown bm - negative guiac. rectal bag replace. skin intact. small drainage in proximal area of back - serosangious - DSD intact. AM lab done.\n\nPlan; Continue to monitor. Extubate in AM?\n"},{"category":"Nursing/other","chartdate":"2154-02-18 00:00:00.000","description":"Report","row_id":1494813,"text":"RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Pt had trache mask trial x45mins overnoc, tired towards end. Sxing small amts secretions from ETT. BS's clear. RSBI=58.\nPlan: Extubate?\n"},{"category":"Nursing/other","chartdate":"2154-02-18 00:00:00.000","description":"Report","row_id":1494814,"text":"Social Work\nSpoke with pt's sister and mother at bedside to assist with handicapped accessible lodging and transport. Family has been dissatisfied with limited transport options avail to area hotels. However, family is pleased with pt's progress; pt is awake, alert, smiling, pleased with recent extubation and cont progress. SW will remain avail for cont support/resources assistance as needed.\n\n LICSW #\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-05 00:00:00.000\",\n \"description\": \"O LUMBAR SP,SINGLE FILM IN O.R.\",\n \"row_id\": 812411,\n \"text\": \" 10:11 AM\\n LUMBAR SP,SINGLE FILM IN O.R. Clip # \\n Reason: SCOLIOSIS,FUSION ANT. T-L SPINE\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Back pain scoliosis effusion anterior T and L-spine\\n\\n Single portable film from the O.R. lacking detail demonstrates a single rod\\n stabilizing the scoliosis related to the anterior fusion.\\n\\n CONCLUSION: Single rod placement related to the scoliosis as described.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-25 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 814611,\n \"text\": \" 9:57 AM\\n CHEST (PA & LAT) Clip # \\n Reason: fever, eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with prolonged intubation in unit, recent extubation\\n\\n REASON FOR THIS EXAMINATION:\\n fever, eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever.\\n\\n PA & LATERAL RADIOGRAPHS:\\n\\n COMPARISON: and .\\n\\n FINDINGS: The patient is markedly scoliotic convex to the right, with a rod\\n fixator. There is resultant asymmetry of the thorax. Allowing for this, the\\n lungs appear clear with no effusions or focal consolidations. There is no\\n CHF.\\n\\n IMPRESSION: No acute cardiopulmonary process. Thoracic deformity unchanged\\n in appearance.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812792,\n \"text\": \" 2:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess NGT position\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with scoliosis s/p NGT placement\\n\\n REASON FOR THIS EXAMINATION:\\n assess NGT position\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: S/P NG tube placement.\\n\\n COMPARISON: Comparison made to prior study of ,\\n\\n CHEST AP: There is again note of a marked kyphoscoliosis. There has been\\n interval placement of a nasogastric tube with the tip terminating in the\\n distal esophagus. The superior portion of the film suggests that there may be\\n coiling of the tube within the pharynx. There is a right internal jugular\\n catheter present with its tip projecting over the right lung apex. There is\\n no evidence of pneumothorax. There is probable atelectasis at the right lung\\n and associated effusion. There are surgical staples noted along the entire\\n extent of the visualized spine.\\n\\n IMPRESSION:\\n 1. Nasogastric tube present with the tip in the distal esophagus and possible\\n coiling in the pharynx.\\n 2. Probable right lower lobe atelectasis and effusion.\\n 3. Marked deformity limiting evaluation of the chest.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812469,\n \"text\": \" 5:44 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate et tube placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with scoliosis\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate et tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: New tracheal tube placed. Check position. Patient is severely\\n scoliotic.\\n\\n CHEST: The tip of the endotracheal tube lies 3.5 cm from the carina angle.\\n Visualized portions of the left lung appear normal.\\n\\n IMPRESSION: Endotracheal tube in satisfactory position.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812436,\n \"text\": \" 1:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p r thoracotomy ct placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with scoliosis\\n REASON FOR THIS EXAMINATION:\\n s/p r thoracotomy ct placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST X-RAY.\\n\\n INDICATION: Scoliosis, status post right thoracotomy and chest tube\\n placement.\\n\\n Comparison is made to the prior chest x-ray on .\\n\\n AP OF THE CHEST: There is a known marked kyphoscoliosis convex to the right\\n based on prior chest x-ray. The current study is extremely rotated. There\\n has been interval placement of an endotracheal tube which is grossly\\n unremarkable. There also appears to be a right internal jugular central\\n venous catheter with its tip likely terminating in the distal SVC. There has\\n been interval placement of a right-sided chest tube with its tip projecting\\n over the right lung apex. There is no evidence of a pneumothorax. There is\\n again demonstrated a deformity with reduced size of the right hemithorax.\\n There is rod which projects over the right chest wall on this\\n oblique view.\\n\\n IMPRESSION:\\n\\n 1) Interval placement of right-sided chest tube with no pneumothorax\\n identified.\\n\\n 2) Limited examination secondary to baseline deformity and suboptimal view.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-12 00:00:00.000\",\n \"description\": \"N-G TUBE PLACEMENT (W/ FLUORO)\",\n \"row_id\": 813249,\n \"text\": \" 3:54 PM\\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \\n Reason: please place postpyloric dobhoff\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with kyphoscoliosis s/p attempt at fusion with no success;\\n now unable to wean off vent\\n REASON FOR THIS EXAMINATION:\\n please place postpyloric dobhoff\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 49 year old woman with kyphoscoliosis status post attempted\\n fusion, unable to wean off ventilator.\\n\\n NG TUBE PLACEMENT:\\n\\n Under fluoroscopic guidance, an 8 FR - tube was advanced with\\n its tip in the second portion of the duodenum. Position was confirmed with\\n Conray contrast. There were no immediate post procedure complications.\\n\\n IMPRESSION: Successful placement of NG feeding tube.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-03-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 815327,\n \"text\": \" 11:32 AM\\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: R picc placed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with scoliosis s/p NGT placement\\n\\n REASON FOR THIS EXAMINATION:\\n R picc placed\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 49-year-old with scoliosis S/P right PICC placement.\\n\\n COMPARISON: .\\n\\n SINGLE PORTABLE CHEST: The tip of the PICC wire is seen to the right of mid-\\n line. The course of the PICC catheter cannot be definitively determined\\n because of an overlying catheter. It was recommended to the IV team to obtain\\n additional views after the removal of the external catheter. There are new\\n bilateral pleural effusions and there are increasing opacities in the right\\n middle and lower lobe. These opacities could represent atelectasis however\\n early pneumonia can't be excluded. There is significant scoliosis.\\n\\n IMPRESSION: 1) Bilateral effusions with right middle and lower lobe\\n opacities. The latter may relate to atelectasis, but underlying infection is\\n not excluded.\\n\\n 2) Additional views after the removal of external catheters is recommended to\\n assess for the tip of the right PICC line.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-03-04 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 815403,\n \"text\": \" 7:01 PM\\n CHEST (PA & LAT) Clip # \\n Reason: R picc placed please page with \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with prolonged intubation in unit, recent extubation\\n\\n REASON FOR THIS EXAMINATION:\\n R picc placed please page with \\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST:\\n\\n CLINICAL INDICATION: PICC line placement.\\n\\n Comparison is made to previous portable chest radiograph of earlier the same\\n date. A right PICC line is present. On the frontal radiograph, it is\\n visualized to the level of the junction of the right subclavian and right\\n brachiocephalic veins, and subsequently obscured by a fixation hardware device\\n related to the spine. On the lateral view, the catheter is identified\\n coursing to the region of the junction of the superior vena cava and right\\n atrium although the distal tip is not definitively visualized.\\n\\n Cardiac and mediastinal contours are stable in the interval. There is\\n improving aeration in the right middle and both lower lobes with residual\\n patchy opacities remaining. Bilateral small pleural effusions are again\\n demonstrated.\\n\\n IMPRESSION:\\n 1) Right PICC line likely terminates at the junction of superior vena cava\\n and right atrium, although distal tip is difficult to definitively visualize.\\n 2) Improving aeration in the right middle and both lower lobes.\\n 3) Persistent small bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-03-05 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 815514,\n \"text\": \" 5:51 PM\\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \\n MR L SPINE SCAN\\n Reason: recurrent wound drainage, previous csf leak (repaired)-- \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with recurrent wound drainage\\n REASON FOR THIS EXAMINATION:\\n recurrent wound drainage, previous csf leak (repaired)-- eval for csf leak\\n ______________________________________________________________________________\\n FINAL REPORT\\n MR C, T, AND L SPINE .\\n\\n HISTORY: Recurrent wound drainage status post repair of CSF leak.\\n\\n Sagittal long TR, long TE, fast spin-echo and inversion recovery imaging was\\n performed through the inferior spine. No contrast was administered.\\n Comparisn to a study of .\\n\\n FINDINGS: The study is severely limited by the patient's severe scoliosis.\\n This necessitated a suboptimally large field of view which limits the spatial\\n resolution. On a number of the images, only a portion of the spine is\\n included. The findings suggest an increase in the volume of fluid posterior\\n to the spinal column. However, it is impossible to be certain that images of\\n the same portions of the soft tissues posterior to the spine have been\\n included in the current and the previous study. For this reason, even this\\n finding is uncertain.\\n\\n CONCLUSION: Extremely limited study due to severe scoliosis and consequent\\n technical limitation. Suggestion an increase in the volume of fluid in the\\n tissues posterior to the spinal column. However, this is not a definite\\n change since .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-03-05 00:00:00.000\",\n \"description\": \"REPOSITION CENTRAL VENOUS CATH W/FLUORO\",\n \"row_id\": 815493,\n \"text\": \" 3:55 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: current PICC in subclavian\\n ********************************* CPT Codes ********************************\\n * REPOSITION CENTRAL VENOUS CATH FLUORO 1 HR W/RADIOLOGIST *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with Post op wound infection, requires 6 weeks iv abx.\\n Unsucessful PICC placement on floor\\n REASON FOR THIS EXAMINATION:\\n current PICC in subclavian\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 49-year-old woman with wound infection requiring IV antibiotics.\\n She had a bedside PICC place with tip in the subclavian vein.\\n\\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and \\n who was present and supervising. The patient's right arm was prepped and\\n draped in standard sterile fashion. Under fluoroscopic guidance, an 018 glide\\n wire was advanced through the PICC causing the tip to flip into the superior\\n vena cava. The wire was removed. The line was flushed and hep-locked and\\n secured with a Stat-lock. Final chest image demonstrated appropriate position\\n of the PICC tip in the distal superior vena cava.\\n\\n IMPRESSION: Successful repositioning of single-lumen PICC with tip in the\\n superior vena cava. The line is ready for use.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-26 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 814822,\n \"text\": \" 9:03 PM\\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \\n MR L SPINE SCAN; -52 REDUCED SERVICES\\n Reason: eval for persistant csf leak/ pseudomeningoceal. Dural ecta\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with polio, wound drainage, HA postop\\n REASON FOR THIS EXAMINATION:\\n eval for persistant csf leak/ pseudomeningoceal. Dural ectasia and leak x2\\n repaired intraop\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Scoliosis. Status post fusion.\\n\\n TECHNIQUE: Multiplanar MR images of the thoracolumbar spine were obtained.\\n True cardinal planes were difficult to obtain due to the patient's severe\\n scoliosis.\\n\\n FINDINGS:\\n MR SPINE W/O CONTRAST: Evaluation is extremely limited secondary to large\\n field of view, oblique imaging planes, and susceptibility artifact.\\n\\n There is diffuse edema involving the soft tissues of the neck. No CSF\\n collection in the soft tissues surrounding the cervical spine is noted. High\\n signal within the vertebral body of C3 on T1W images is a nonspecific finding\\n and of uncertain significance. No definite evidence of a pseudomeningocele in\\n the cervical region is appreciated.\\n\\n Limited views of the brain and nasopharynx are unremarkable.\\n\\n LUMBAR SPINE W/O CONTRAST: Post surgical changes and susceptibility artifact\\n are present. There is an extensive fluid collection with an air-fluid level\\n extending approximately 18 cm along the posterior thoracolumbar spine and\\n surgical bed. This is most consistent with a pseudomeningocele. Follow-up is\\n recommended to assess for interval change.\\n\\n Diffuse edema is present in the subcutaneous soft tissues overlying the\\n thoracolumbar spine.\\n\\n IMPRESSION:\\n\\n Extremely limited examination.\\n\\n Pseudomeningocele. Followup is recommended to assess for interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 812674,\n \"text\": \" 1:39 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o chf\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with scoliosis\\n\\n REASON FOR THIS EXAMINATION:\\n r/o chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST AP PORTABLE SINGLE VIEW.\\n\\n INDICATION: Female patient with scoliosis. Follow up of chest tube placement.\\n\\n FINDINGS: The AP single view is obtained with patient in supine position and\\n analyzed in direct comparison with a similar film dated .\\n Position of the ETT remains unchanged terminating approximately 3 cm above the\\n carina. Marked scoliotic deformity as before including orthopedic hardware for\\n scoliosis support. A right sided chest tube remains in place. No new\\n parenchymal infiltrates can be identified on this single view examination.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2154-02-21 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 814245,\n \"text\": \" 10:52 AM\\n CHEST (PA & LAT) Clip # \\n Reason: s/p extubation, cough\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with prolonged intubation in unit, recent extubation\\n REASON FOR THIS EXAMINATION:\\n s/p extubation, cough\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Post-extubation and cough\\n\\n AP and lateral views of the chest dated is compared with the\\n prior PA and lateral radiograph dated .\\n\\n There marked thoracic scoliosis convex to right with rod fixation.\\n Multiple staples overlie the soft tissues of the back. The left lung appears\\n clear. The cardiac and mediastinal contours are unremarkable.\\n\\n IMPRESSION: No evidence of acute cardiopulmonary disease. Chest deformity,\\n unchanged.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2154-03-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 75618,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Abnormal ECG. Endocarditis. Pericardial effusion.\\nHeight: (in) 56\\nWeight (lb): 150\\nBSA (m2): 1.57 m2\\nBP (mm Hg): 122/69\\nHR (bpm): 89\\nStatus: Inpatient\\nDate/Time: at 10:34\\nTest: TTE (Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\\n\\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Left ventricular wall thickness, cavity size, and systolic function\\nare normal (LVEF>55%). Due to suboptimal technical quality, a focal wall\\nmotion abnormality cannot be fully excluded.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\\nleaflet excursion. No aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Based on\\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\\na low risk (prophylaxis not recommended). Clinical decisions regarding the\\nneed for prophylaxis should be based on clinical and echocardiographic data.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\\nquality, a focal wall motion abnormality cannot be fully excluded. Right\\nventricular chamber size and free wall motion are normal. The aortic valve\\nleaflets appear structurally normal with good leaflet excursion. No aortic\\nregurgitation is seen. The mitral valve leaflets are structurally normal.\\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\\nThere is an anterior space which most likely represents a fat pad.\\n\\nIMPRESSION: Mild mitral regurgitation with grossly normal morphology.\\nPreserved global and regional biventricular systolic function.\\n\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate a low risk (prophylaxis not recommended). Clinical decisions\\nregarding the need for prophylaxis should be based on clinical and\\nechocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2154-02-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 181592,\n \"text\": \"Sinus rhythm.\\nSeptal and lateral ST-T changes are nonspecific\\nLow QRS voltages in precordial leads\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494782,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nPT IS A 49 Y/O FEMALE S/P ANTERIOR THORACIC T3-PELVIS FUSION ON /O4. PT HAS BEEN IN PACU SINCE POST OP. PT EXTUBATED IN PACU THIS AM AND REINTUBATED A FEW HRS LATER. PT ADMITTED TO ICU AT 17:30 FOR MONITORING. PE AS FOLLOWS:\\n\\nNEURO-PT AWAKE, ALERT, MOUTHS WORDS, NODS APPROP. PT PARAPLEGIC AT BASELINE. FOLLOWS COMMANDS.\\n\\nCV-TEMP 101.4. PT PAN CX IN PACU. HR/BP STABLE. SKIN W+D. +PP. TEDS ON. AWAITING ARRIVAL OF PBOOT MACHINE.\\n\\nRESP-REMAINS VENTED ON CPAP. TOL WELL. WILL FOLLOW ABG. SXN FOR SM AMT THIN WHITE SPUTUM. PT ALSO WITH MOD AMT ORAL SECRETIONS. USING YANKEAR I. LS COARSE. CT TO SXN WITH SEROUSSANG DRG. NO LEAK NOTED.\\n\\nGI-ABD OBESE, SOFT, NT/ND. NPO.\\n\\nGU-VOIDING VIA FOLEY ADEQ AMT CL AMBER URINE.\\n\\nCOMFORT-USING DILAUDID PCA WITH EFFECT.\\n\\n-DSG INTACT.\\n\\nPLAN-CON'T WITH CURRENT PLAN. FOLLOW LABS. TO OR IN AM FOR POSTERIOR APPROACH.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494783,\n \"text\": \"Resp Care Note, Decreased RR for ABG resp alk. Suctioned for sml amts thick white secretions. RSBI not done due to no spont resp.Getting pain med.Will cont to monitor resp status for further weaning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494796,\n \"text\": \"CONDITION UPDATE:\\nD/A: T MAX 100.5\\n\\nNEURO: UNCHANGED. PAIN WELL CONTROLLED WITH DILAUDID PCA. PER DR. , SLOWLY ELEVATE HOB OVERNIGHT. IF PT BEGINS TO GET A HEADACHE OR HAS A WORSENING HEADACHE, DO NOT ELEVATE HEAD ANY HIGHER. IF PT HAS ANY SIGNS OF CSF LEAK ON DRESSING, DO NOT ELEVATE HOB.\\n\\nRESP: LS COARSE, HOWEVER WITH AMBU, LAVAGE, SX MINIMAL SECRETIONS OBTAINED. VENT WEAN STARTED AGAIN. CURRENTLY ON CPAP, PS 50%, 5 PEEP 8 PS WITH LAST ABG: 7.28, 56, 174, -1, 98%.\\n\\nCV: HR 80'S-110, NSR ST. FLUID BOLUS 250 CC'S X1 FOR CONSISTENT BP ~ 88/50, HR > 100. SLIGHT + EFFECT. CVP ~ 12.\\n\\nGI: NPO. + BS. GLUCOSE LEVEL WNL'S. IVF INCREASED.\\n\\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\\n\\nSX: MOTHER AND FRIEND VISITING MOST OF DAY.\\n\\nR: RESP ACIDOSIS, DIFFICULT VENT WEAN.\\n\\nP: CONTINUE ATTEMPTS TO WEAN. IF UNABLE TO EXTUBATE IN AM, REVISIT PLACING A NGT/PEDI TUBE FOR NUTRITION. PT AND FAMILY SUPPORT. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494797,\n \"text\": \"FOCUS: STATUS UPDATE\\nDATA:\\nPT ALERT AND ORIENTED X3. VERY PLEASANT AND COOPERATIVE. COMMUNICATES BY WRITING.\\nLUNGS COARSE. CONTINUES VENTILATED, UNABLE TO WEAN OFF VENT D/T POOR ABG'S. ON MMV VENT MODE WITH IMPROVED ABG.\\nTO FLUORO FOR POSTPYLORIC FT PLACEMENT.\\n\\nPLAN:\\nSTART TF.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494798,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\n PT SLEEPING ON/OFF, APPEARS ORIENTED X3. FOLLOWING ALL COMMANDS AND ABLE TO COMMUNICATE BY WRITING/MOUTHING WORDS.\\nCV- HR/BP STABLE, SEE FLOWSHEET FOR VITALS AND DETAILS. CVP 12-18.\\nRESP- LS OCCAS COARSE, SUCTIONED FOR THICK TAN SPUTUM. REMAINS ON MMV, NO VENT CHANGES MADE.\\nGU- MAINTAINING ADEQ HRLY U/O, CLEAR YELLOW.\\nGI- ABDOMEN SOFT, ? LAST BM, COLACE GIVEN. IMPACT WITH FIBER STARTED (POST-PYLORIC TUBE) @ 10CC/HR.\\nINTEG- SKIN WARM & PINK. BACK DSG INTACT, NO DRAINAGE. RIGHT THORACOTOMY SIGHT WITH STERI-STRIPS, C/D/I. C/O BACK PAIN, INCREASES WITH MOVEMENT. PT USING PCA APPROPRIATELY. HOB < 30 DEGREES, BUT GRADUALLY INCREASING SINCE AM AND PT TOLERATING.\\nPLAN:\\nADVANCE TF TO GOAL RATE OF 65CC/HR AS TOLERATES. ATTEMPT TO WEAN PS AGAIN THIS AM. CONTINUE WITH CURRENT MONITORING AND TREATMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494799,\n \"text\": \"pt.remains on mmv, see flowsheet for further info, sx for tan secretion, abg acidotic, will wean as tol., rsbi-41.7\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494800,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFCS.\\nNEURO: ALERT. ORIENTED X 3. COMMUNICATES VIA MOUTHING AND WRITING. HOB UP TO 30 DEGREES, C/O SL H/A, HOB DOWN TO 15 DEGREES WITH SOME RELIEF. HYDROMORPHONE PCA DOSE DECREASED TO .25MG Q6MIN WITH ADEQUATE PAIN CONTROL PER PT REPORT.\\nRESP: LS CLEAR TO COARSE. SM AMTS THICK TAN SPUTUM. VENT WEAN ATTEMPTED, BUT PT RETAINING CO2 AND BECOMMING LETHARGIC WITH DECREASED IPS.\\nCV: AFEBRILE. NSR. BP STABLE 90-130 SYS. NO FLUID BOLUSES THIS SHIFT. IVF CONTS AT 80CC/H.\\nGI: ABD SOFT. TF'S SLOWLY ADVANCED TOWARD GOAL, BUT PT C/O NAUSEA WITH TF'S UP TO 40CC/H X ~3HOURS. RELIEVED WITH ZOFRAN. TF'S HELD FOR NOW.\\nGU: CLEAR YELLOW U/O, INITIALLY > 20CC/HOUR, INCREASING TO >30CC/HOUR THIS EVE.\\nSKIN: THORACOTOMY WOUND CLEAN AND DRY WITH STERISTRIPS INTACT. NO DRG NOTED FROM BACK INC, DSD CLEAN AND DRY.\\nPLAN. REATTEMPT IPS WEAN IN AM. CONT PAIN MGMT. RESTART AS PT . MONITOR FOR SIGNS OF INFECTION. CONT PER CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494815,\n \"text\": \"nsg note\\nSEE FLOWSHEET FOR SPECIFICS.\\n\\nNEURO-PT A+OX3. FOLLOWS COMMANDS.\\n\\nCV-HRR. SBP STABLE. ALINE D/C'D. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\\n\\nRESP-EXTUBATED THIS AM. WELL THUS FAR. POST EXTUBATION ABG WNL. LS COARSE. PT WITH CONGESTED COUGH, USING YANKEAR I. O2 WEANED TO 2L NC. O2 SAT 99%.\\n\\nGI-ABD SOFT, NT/ND. +BS. CON'T WITH LIQ BROWN STOOL. FIB IN PLACE. PT REQUESTED TUBE D/C'D DESPITE INFORMATION FROM DR. AND THIS RN ABOUT IMPORTANCE OF KEEPING FEEDING TUBE AT THIS TIME. PT VERBALIZED AND STILL REQUESTED TUBE TO BE REMOVED. FEEDING TUBE THUS D/C'D. ABLE TO PILLS WITHOUT INCIDENT. ?ADAT.\\n\\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\\n\\nACT-REPOSITIONED FREQ.\\n\\nCOMFORT-REPORTS ADEQ PAIN RELIEF WITH VICODIN PRN. ALSO ON FENT PATCH.\\n\\nID-TMAX 100, NOW DOWN TO 98.6. CON'T ON KEFZOL.\\n\\n-RIGHT FLANK WITH STERISTRIPS C/D/I. BACK INCISION WITH STAPLES, PINK, WITH MOD AMT SEROUSSANG DRG. DSG CHANGED. DR. IN TO EVAL. WILL MONITOR.\\n\\n MOTHER AND SISTER IN TO VISIT FREQ. SW FOLLOWING.\\n\\nPLAN-CON'T WITH CURRENT PLAN. PULM HYGIENE. ASSESS PAIN. MONITOR FOR CHANGES. ? ADAT. SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494816,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\nPT DOZING ON/OFF OVERNIGHT, NO ACUTE NEURO DEFICITS. BACK INCISION WITH STAPLES OOZING MOD AMTS BROWN/OLD SEROSANG DRAINAGE, DSD CHANGED. CONTINUES ON IV CEFAZOLIN, AFEBRILE. RIGHT THORACOTOMY INCISION WITH STERISTRIPS INTACT, NO DRAINAGE. HR/BP STABLE, SEE FLOWSHEET FOR ALL VS. BREATHING EVEN/UNLABORED @ REST, SP02 100% WITH NASAL CANNULA, LS CLEAR. GIVEN VICODIN FOR BACK PAIN; PT STATES SHE DOES NOT LIKE VICODIN (MAKES HER CONFUSED). PT GIVEN TYLENOL WITH ADEQ RELIEF OF PAIN; ALSO CONTS ON FENT PATCH. TOLERATING CLEAR LIQUIDS, IVF KVO.\\nPLAN:\\nADVANCE DIET TO REG. ? TRANSFER TO FLOOR TODAY. PULMONARY HYGEINE. PHYS THERAPY, INCREASE ACTIVITY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494817,\n \"text\": \"Addendum to Nursing Transfer Note A:\\nD: O2sat 98-100%. HR 100's. BP stable. Weak cough. Coarse LS through out. Very weak cough.\\nA: Gentle CPT provided. Per pt request hot tea provided. Declined NTsx. Gag reflex stimulated with yankeur with good effect. LS CTA briefly. Dr. to examine pt. Guaifenison 10cc provided. Effect (P).\\nP: Monitor resp status. Assist with C&DB, repositioning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494784,\n \"text\": \"Neuro: Alert and oriented. Able to follow directions. Having mod amount of pain at R CT insertion site. Using dilaudid PCA appropriately and requesting dilaudid coverage 0.5mg Q2hr with effect.\\nCV: Temp 99.0, HR 80's NSR with no ectopy, SBP 90-120's. lytes repleated. Recieved 20mg lasix at 12am with good effect.\\nRESP: lungs coarse through-out. requiring occasional suctioning of thick white sputum. O2 sats >98%. Vent setting changed this am. for Pco2 31. Resp rate decreased to 16.\\nGI: NPO No stool tonight.\\nGU:foley draining adequate amounts of clear yellow urine.\\nEndocrine: blood sugars wnl no coverage required.\\nPLAN: to OR this am for posterior approach of spinal fusion.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494785,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nPT TO OR AT APPROX 0730 THIS AM FOR T3 TO PELVIS FUSION. RETURNED APPROX 1200 S/P REMOVAL OF HARDWARE, REMOVAL OF CHEST TUBE, T3 TO L4 FUSION.\\nNEURO: PT SEDATED ON PROPOFOL GTT ON ARRIVAL. EASILY AWAKENED WHEN GTT D/C'D. MOVES UPPER EXTREMTITES WELL. PERRL. MOUTHING WORDS APPROPRIATELY. C/O PAIN. MD' AND LI PRESENT. DILAUDID BOLUS GIVEN AND PCA DOSE INCREASED AS ORDERED. PAIN IMPROVED PER PT REPORT.\\nRESP: LS CTA. ARRIVED INTUBATED ON IMV 16 X 400, IPS 10. ABG'S STABLE. ET SUCTIONED FOR SCANT AMTS BLOOD TINGED SPUTUM.\\nGI: ABD SOFT. C/O NAUSEA ON ARRIVAL TO UNIT, RESOLVED WITHOUT INTERVENTION. NGT PLACEMENT ATTEMPTED, BUT UNABLE TO VISUALIZE TIP IN STOMACH ON CXR X2 (DESPITE FAR ADVANCEMENT), ? COILED IN PHARYNX. PLACEMENT BY MD , BUT UNSUCCESSFUL.\\nGU: CLEAR, TINTED U/O VIA FOLEY. >30CC/HOUR.\\nSKIN: R FLANK INCISION OTA WITH STERI-STRIPS INTACT. NO DRG. BACK ELASTOPLAST DSG CDI.\\nPLAN: PAIN MGMT. REVERSE T- TO PREVENT RISK OF ASPIRATION AS TOLERATED. MED FOR NAUSEA. MONITOR VS AND RESP STATUS. WEAN VENT AS ORDERED AS TOL. CONT PER POST OP PROTOCOLS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494786,\n \"text\": \"NEURO; ALERT X 1, WRITES NOTES TO COMMUNICATE, WIGGLES TOES BOTH FEET, AND MOVES THEM SLIGHTLY, USING DILAUDID PCA PUMP WITH ENCOURAGEMENT,\\nPT MAINTAINED FLAT IN BED, LOG ROLLED PRN\\n\\nCARDIOVASCULAR; HR 90'S SR, SYS LOW 100'S, CVP 8-13, TEMP 100, EXTREMITIES EDEMATOUS, ESP EYELIDS,\\n\\nRESPIR; REMAINS ON CIMV, ABGS STABLE THIS AM, SUCTIONED FOR SMALL AMTS THIN WHITE SECRETIONS, FREQUENTLY USES YANKHAUER HERSELF AND SUCTIONS OCCAS THICK BLOODY MUCOUS\\n\\nWOUND; ACE DSG D/I TO THORACO-LUMBAR AREA, STERI-STRIPS INTACT FROM FORMER RT THORACOTOMY,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494787,\n \"text\": \"Resp Care,\\nPt. remains intubated overnoc, no vent changes this shift. See carevue for settings/ABG. RSBI attempted this am, pt. had a prlonged period of apnea. Will try again later this am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494788,\n \"text\": \"Resp. Care Note\\nPt received intubated and vented on settings SIMV 400x 16x 50% peep 5 psv 10. Pt changed over to PSV 15 peep 5 and 505 and has tolerated wean to PSV 12. Good ABG on current settings of PSV 12 peep 5 and 50%. Cont PSV wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494801,\n \"text\": \"pt.on cpap+ps , bs coarse, sx for tan secretions, rsbi-64.3, abg alkalotic, will wean as .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494802,\n \"text\": \"CONDITION UPDATE\\nASSESSMENT:\\nNEURO INTACT, COMMUNICATING BY MOUTHING WORDS & WRITING. USING PCA APPROPRIATELY FOR BACK PAIN. PER DR. , PT GET OOB WITH PHYS THERAPY & ACTIVITY AS TOLERATED. BACK DSG INTACT, NO DRAINAGE. RIGHT THORACOTOMY INCISION WITH SS INTACT. NO VENT CHANGES MADE OVERNIGHT, FAILED SPONT BREATHING TRIAL IN AM. LS OCCAS COARSE, REQUIRED MIN SUCTIONING. IMPACT WITH FIBER ADVANCED OVERNIGHT, PT TOLERATING. ABDOMEN SOFTLY DISTENDED, DENIES NAUSEA. HEMODYNAMICS STABLE, SEE FLOWSHEET FOR VITALS AND FULL PHYS ASSESSMENT.\\nPLAN:\\nCONTINUE WITH CURRENT MONITORING AND TREATMENT. ? ATTEMPT TO WEAN PRESS SUPPORT TODAY. INCREASE & ASSIST WITH ACTIVITY AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494803,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: ALERT AND ORIENTED X3. SLEEPY AT TIMES, BUT EASILY AWAKENS. PCA DOSE DECREASED, WITH ADEQUATE PAIN CONTROL. C/O PERSISTENT MILD H/A, UNCHANGED FROM PREVIOUS REPORT PER PT. C/ EARACHE, MD INFORMED AND TO EXAMINE WITH OTOSCOPE.\\nRESP: LS CLEAR TO COARSE WHEN ET SUCTION NEEDED, SM AMT THICK WHITE TO TAN SPUTUM. VENT WEANED TO 10 PS, 5 PEEP. ABG SHOWS PCO2 UP TO 50S, BUT PT COMPENSATING WITH TCO2 UP TO 34, PH STABLE AT 7.39. WHEN WEAN TO ATTEMPTED, PT BECAME HYPERTENSIVE TO 190S SYS, TACHYCARDIC TO 110S, AND TACHYPNEIC WITH INCREASED WOB. RETURNED TO WITH IMPROVEMENT IN VS, REPEAT ABG PENDING.\\nCV: TMAX 99. SBP 140S TO 150S. ? RESTART ANTIHYPERTENSIVES. ALINE RESITED TO L-RAD DUE TO MALFUNCTION. IVF CONTS AT 80CC/HOUR.\\nGI: ABD SOFTLY DISTENDED. TF'S AT GOAL. C/O SL NAUSEA AND FULLNESS. DULC SUPP GIVEN, EFFECT PENDING.\\nGU: CLEAR YELLOW U/O VIA FOLEY.\\nPLAN: RECHECK ABG. MONITOR RESP STATUS. CONT VENT WEAN AS . PAIN MGMT. OOB TO CHAIR TOMORROW. ASSESS FOR H/A. CONT PER CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494804,\n \"text\": \"NEURO: A&O X3, COMMUNICATES BY MOUTHING WORDS OR WRITING, APPROPRIATE. SPONT/PURP MOVING UPPER EXTREMITIES, NEEDS MIN ASSISTANCE TO MOVE LOWER EXTREMETIES.\\n\\nCV: HR 78-94, NSR, NO ECTOPY. SBP 121-151.\\n\\nRESP: VENT SETTINGS NOT TOLERATED ON CPAP+PS, MULT ABG'S DRAWN W/ INC PCO2 TO 64, DR. INFORMED. PT SWITCHED BACK TO SIMV 5 PEEP, 10 PS, TV 400'S, RR 14, FIO2 50%. LAST ABG IMPROVED-7.40/54/175/35/7/99.\\n\\nGI: ABD SOFTLY DISTENDED, +BS, TOLERATING TF IMPACT W/ FIBER AT GOAL AT 60CC/HR VIA POST PYLORIC DOBHOFF. HAD SMALL BM AFTER RECEIVING DULCOLAX SUPPOSITORY.\\n\\nGU: FOLEY DRAINING ADEQ U/O, CLEAR YELLOW URINE. PT IS CURRENTLY MENSTRUATING.\\n\\nID: TMAX 98.9\\n\\nPAIN: GOOD PAIN CONTROL ACHIVED W/ DILAUDID PCA.\\n\\nPLAN: MONITOR RESP STATUS, IF UNABLE TO WEAN VENT ?TRACH. MONITOR PAIN.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494805,\n \"text\": \"Respiratory Care\\nPt remain intubated and on vent support, Paco2 issue that pressist and din not change alot despit the vent setting change Paco2 remain in the 50's. Et tube was rotated and retayped, SX mod amout thick white.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494792,\n \"text\": \"Nursing note:\\nNEURO: A/Ox3, writing on message board to make needs known. PERRLA 2-3mm and brisk bilat. Wiggles toes bilat , follows commands. C/O mild headache r/t dural tears per team. Using Dilaudid PCA w/fair relief of back pain and headache.\\nCV: Afebrile. SR in 70s-80s, no ectopy. SBP 120-140s. Wearing pboots.\\nRESP: Lung sounds clear, coarse at times, dim to L. base. Suctioned infrequently for thick white secretions. No vent changes today, ABGS cont. to reflect met. alkalosis, resp. acidosis. Diamox x1 given. +diuresis.\\nGI: +BS, abdomen softly distended. -stool. +flatus, pt. c/o feeling bloated/constipated.\\nGU: Foley patent for adequate amount amber urine. +diuresis.\\nSOCIAL: Husband and mom @ bedside most of day.\\n\\nA/P: Stable s/p back/pelvic fusion surgery, now slow to wean off vent. Cont. gentle diuresis, follow ABGs, pain control, skin care and vent wean.To remain flat for more days. Cont. current plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494793,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as per resp. flowsheet. No vent changes made today, plan was to cont diuresis and Rx met. alkalosis with diamox. Assess weaning parameters in AM and cont with PSV wean with hopes to extubate tomorrow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494794,\n \"text\": \"data/action: vss, using pca dilaudid w/ good relief of back pain.\\nrr-16-20 on cpap w/ ips 12 o/n w/ morning abg's acidotic 7.22/pc02 64\\nvent mode changed to simv12 w/ improvement in abg's 7.42/pc02 36.\\nsx'd thin pale tan/white q3hr. bs 51 this am amp d50 iv given-bs pending. alert writing in notebook for needs. c/o heartburn->zofran given w/ relief x1.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494795,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as charted on resp flowsheet. PSV level decreased today from 12-10-8. ABG's with good oxygenation, slight resp acidosis. Plan to cont psv wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494811,\n \"text\": \"Neuro: Alert and oriented X3. Continues to use dilaudid PCA. attempting to wean off and use vicodin per dopoff. having some noted effect on pain with vicodin. back incision continues to drain small amounts of sero-sang drg from proximal end of incision.\\nCV: afebrile, HR 80's NSR with no ectopy. SBP 100-120's A-line very dampended. extremities warm with palpable periferal pusles. repleated K+ X2.\\nRESP: pt vent changed to CPAP 5&5 with acceptable ABG. Requiring occasional suctioning of thick white sputum. lungs clear to dim at bases.\\nGI: tube feed with no cramping but some \\\"heartburn\\\" slightly improved with reglan, zofran and protonix.\\nGU: foley draining adequate amounts of clear yellow urine.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494806,\n \"text\": \"CONDITION UPDATE\\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\\nNEURO: ALERT AND ORIENTED. USING PCA MORE FREQUENTLY WITH STATED RELIEF. LG AMT SEROSANG DRG FROM SPINAL INC. SICU TEAM INFORMED AND SHOWN. DSD CHANGED. PT DENIES H/A. HOB FLAT. DRG CONTS, BUT IN DECREASED AMTS.\\nRESP: LS CLEAR BUT DIM. MIN SECRETIONS. NO VENT CHANGES TODAY.\\nCV: TMAX 99.4. NSR. BP STABLE. 10MG IV LASIX GIVEN AS ORDERED WITH DIURESIS. PT STILL POS >1L SINCE MN. ADDITIONAL 20MG ORDERED AND GIVEN. PHOS REPLETED WITH NAPHOS AS ORDERED. IVF KVO'D.\\nGI: ABD SOFT. LG LIQUID BM THIS AM. PT C/O INCREASING ABD FULLNESS AND NAUSEA. TF'S HELD. PT REFUSING RESTART. MD INFORMED. IVF INCREASED TO 60CC/HOUR UNTIL TF'S RESTARTED.\\nGU: CLEAR YELLOW U/O.\\nPLAN: CONT TO MONITOR. CONT HOB FLAT. MONITOR FOR DRG FROM SPINAL INCISION. RESTART TF'S SLOWLY WHEN PT ABLE TO . ATTEMPT VENT WEAN AS . CONT PER CURRENT MGMT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494807,\n \"text\": \"Respiratory care\\nPt remain intubated and on vent support no vent changes.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494808,\n \"text\": \"Neuro: Pt alert and oriented X3, mouthing words and able to write to make needs known.\\nCV: Low grade temp 99.2, HR 60-80's NSR with no ectopy. SBP 110-130's A-line slightly dampened. CVP>20. extremities warm with palpable periferal pulses.\\nRESP: lungs clear to dim at bases. No vent changes. O2 sats 100%.\\nGI: NPO per pt. request due to abd cramping from tube feeds. No stool today.\\nGU: foley draining adequate amounts of clear yellow urine.\\nendocrine: blood sugars wnl.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494809,\n \"text\": \"7p-7a; Full assessment in flow sheet.\\n\\nneuro: A+OX3. Mouth and write words. MAE - stronger in upper than lower ext. Good gag and cough reflex. Follow commands. normal affect.\\nGood sensory respond from ext. PERLA. Good pain control with PCA.\\n\\ncv; NSR without ectopy. VSS. temp max 99.1. warm, dry, slight general edema.\\n\\nresp; clear in upper lobes. dimish at bases. Strong - productive cough - white/thick sputum. SIMV tolerated - ABG - better than prior, please see flow sheet.\\n\\ngu/gi; soft abd. +BSX4. no flatus. no bm. heartburn X2 per pt - reglan given - good effect. restarted TF slowly - no pain cramp or nausea per pt. Dobhoff - positive placement. foley patent - clear yellow urine.\\n\\nSkin intact except for back dressing - serous/serousangious dressing in upper part of back - reinforce dressing.\\n\\nAM lab . Lytes replace.\\n\\nPlan; Continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494810,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remains ess unchanged, supported on SIMV thru noc. Sxing small amts thick white secretions from ETT. BS's ess clear. See flowsheet for pt data.\\nPlan: Attempt weaning slowly.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494789,\n \"text\": \"Nursing note:\\nNEURO: A/Ox3, communicating via gestures and writing on message board. PERRLA. Able to wiggle toes easily. Using Dilaudid PCA for adequate pain control.\\nRESP: Lung sounds coarse, weaned to CPAP w/10 IPS. ABGs acceptable.\\nSuctioned for white coarse secretions.\\nCV: Afebrile. SBP 120s. SR in 80s, no ectopy. No cardiac issues. Lasix 20mg IV x1 w/excellent diuresis. K+ replaced w/60meq total IV.\\nGI: +BS, abdomen soft, no stool or flatus. No n/v. Remains NPO.\\nGU: Foley patent adequate amount amber urine.\\nENDO: Glucose stable.\\nWound: Ace dressing d/i to thoraco-lumbar area, steris intact from former R. thoracotomy.\\nA/P: Stable s/p spinal /pelvic fusion, tolerating vent wean.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494790,\n \"text\": \"NEURO; WRITES NOTES APPROPRIATELY, MOUTHES WORDS, USES DILAUDID PCA PUMP PRN,\\nPT REMAINS FLAT IN BED\\n\\nCARDIOVASCULAR; HR 90'S SR, SYS BP 120-140'S, CVP 12-15, AFEBRILE, EDEMA OF ALL EXTREMITIES,\\n\\nRESPIR; SUCTIONED FOR SMALL AMTS THIN WHITE SECRETIONS, OCCAS BLOOD TINGED SECRETIONS ORALLY BUT HAS DECREASED SINCE YESTERDAY, ABGS REFLECT RESPIR ACIDOSIS\\n\\nRENAL; LASIX 20 IV ON EVES WITH FAIR DIURESIS,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494791,\n \"text\": \"RESPIRATORY CARE\\nPt remain intubated no respiratory issue overnight Sx samll white thick ,Pt is aweak amd responsive , remain flat on her back.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494812,\n \"text\": \"7p-7a; Full assessment in flow sheet.\\n\\nA+OX3. Mouth words and write need. Follow commands. MAE - stronger in upper than lower ext. PERLA. Good cough and gag reflex. Pain in back - relief with PCA - PCA d/ MD order - vicodin po started - not as effective per pt - also causes inc HR and feeling of being very warm per pt (no change in HR or temp per monitor). Slept on/off most of the night. VSS (except when increase with activities and t-piece trial). Afebrile. warm, dry, no edema. Clear upper lobes, dimish at bases. Tolerate t-piece for 1 hr - ABG - resp acidiotic (no sob). Return to CPAP 5/5 to rest for the night. soft abd, +BSX4. loose brown bm - negative guiac. rectal bag replace. skin intact. small drainage in proximal area of back - serosangious - DSD intact. AM lab done.\\n\\nPlan; Continue to monitor. Extubate in AM?\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494813,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remains intubated, vent supported. Pt had trache mask trial x45mins overnoc, tired towards end. Sxing small amts secretions from ETT. BS's clear. RSBI=58.\\nPlan: Extubate?\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2154-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1494814,\n \"text\": \"Social Work\\nSpoke with pt's sister and mother at bedside to assist with handicapped accessible lodging and transport. Family has been dissatisfied with limited transport options avail to area hotels. However, family is pleased with pt's progress; pt is awake, alert, smiling, pleased with recent extubation and cont progress. SW will remain avail for cont support/resources assistance as needed.\\n\\n LICSW #\\n\"\n }\n]"}}},{"rowIdx":24294,"cells":{"subject_id":{"kind":"number","value":3145,"string":"3,145"},"hadm_id":{"kind":"number","value":169807,"string":"169,807"},"target_text":{"kind":"string","value":"49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from hospital with acute hepatic failure. She was admitted with acute alcoholic hepatitis and hypotension and had gradually worsening liver function with a rising bilirubin. She was also initially in renal failure but responded to albumin. Two days prior to expiring, she developed acutely worsening hypoxia with bilateral infiltrates and ARDS requiring intubation. She required high levels of peep and an esophogeal balloon was placed. She was also profoundly hypotensive, requiring four pressors. She had a rising lactate on broad spectrum antibiotics, and developed a profound lactic acidosis with a lactate peaking at 16. Her family was contact and her sons were able to see her before she expired at 5:30 p.m. on . They requested an autopsy."},"extractive_notes_summ":{"kind":"string","value":"Chronic IVDU & ETOH. Chronic IVDU & ETOH. Chronic IVDU & ETOH. Paracentesis in ED negative for SBP (Pt was given Ceftriaxone 1gm) Action: Lactulose given. Hypotension (not Shock) Assessment: Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60. Action: Pt on lactulose 60ml QID. Action: Pt on lactulose 60ml QID. Action: Pt on lactulose 60ml QID. Action: Pt on lactulose 60ml QID. Noaortic regurgitation is seen. Thiamine/Folate/MVI Hypotension (not Shock) Assessment: Recd pt from ED on Levophed @ 0.18mcg/kg/min. Thiamine/Folate/MVI Hypotension (not Shock) Assessment: Recd pt from ED on Levophed @ 0.18mcg/kg/min. Thiamine/Folate/MVI Hypotension (not Shock) Assessment: Recd pt from ED on Levophed @ 0.18mcg/kg/min. She was noted there to be hypotensive w/ SBP to the 80s, w/ an elevated bili and INR. She was noted there to be hypotensive w/ SBP to the 80s, w/ an elevated bili and INR. She was noted there to be hypotensive w/ SBP to the 80s, w/ an elevated bili and INR. CXR: (my read) hilar fullness w/ mild pulm vascular engorgement, infiltrates in the RML and RUL. - follow UOP and trend creatinine - renally dose meds # Anemia: bleeding likely into intraperitoneal space. Started levophed to limit fluid over-resusication - Rising lactate 4.4 > 5.5. Started levophed to limit fluid over-resusication - Rising lactate 4.4 > 5.5. - Hold diuresis for now while hypotensive - Keep PaO2 >60, try to increase PEEP if needed HYPOTENSION Worse post-intubation. - Hold diuresis for now while hypotensive - Keep PaO2 >60, try to increase PEEP if needed HYPOTENSION Worse post-intubation. Respiratory failure, acute (not ARDS/) Assessment: Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by 15 bpm, and most recent ABG 7.39/37/65. Respiratory failure, acute (not ARDS/) Assessment: Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by 15 bpm, and most recent ABG 7.39/37/65. Action: Pt with MAPs dropping to low 50s at beginning of shift requiring max dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and neo @ 0.5mcg/kg/min. CIRRHOSIS OF LIVER, ALCOHOLIC Stable Tbili, INR up somewhat - On rifaxamin, lactulose - Appreciate hepatology input - Will need FFP prior to procedures RENAL FAILURE Decreased UOP since midnight, with elevated Cr. Chief Complaint: 24 Hour Events: - MELD 27 - Liver consult: stop prednisone, albumin challenge, NGT with TFs, check AFP, GGT, IGG, , hep C viral load - CT chest: volume overload, intraperitoneal hemorrhage likely from paracentesis - Bladder pressure 17 - levophed weaned - had hct drop 35 -> 27.8 -> 26.5. Chief Complaint: 24 Hour Events: - MELD 27 - Liver consult: stop prednisone, albumin challenge, NGT with TFs, check AFP, GGT, IGG, , hep C viral load - CT chest: volume overload, intraperitoneal hemorrhage likely from paracentesis - Bladder pressure 17 - levophed weaned - had hct drop 35 -> 27.8 -> 26.5. Chief Complaint: 24 Hour Events: - MELD 27 - Liver consult: stop prednisone, albumin challenge, NGT with TFs, check AFP, GGT, IGG, , hep C viral load - CT chest: volume overload, intraperitoneal hemorrhage likely from paracentesis - Bladder pressure 17 - levophed weaned - had hct drop 35 -> 27.8 -> 26.5. # Acute hepatic failure: -f/u liver recs -steroids -AFP normal -lactulose and rifaximin # ARF: FeNa < 1%. Pt dysynchronous with vent at start of shift, vent changed to PCV briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06 mg/kg/hr, titrated per train of four for twitches. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. # DISPO: ICU ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 02:32 AM PICC Line - 12:40 PM Arterial Line - 06:29 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Limited ultrasound of the right upper quadrant with diffusely echogenic liver. FINDINGS: Right PICC is malpositioned, coursing cephalad in the right internal jugular vein with tip outside of the field of view. Splenomegaly (Over) 12:27 AM CT ABDOMEN W/CONTRAST Clip # Reason: eval for acute process, clot in portal system. WET READ: EAGg TUE 11:42 PM Very echogenic liver, limited assessment of gallbladder and portal vein. Unchanged markedly hypodense liver, consistent with fatty liver, presumably related to reported clinical history of liver failure. 12:27 AM CT ABDOMEN W/CONTRAST Clip # Reason: eval for acute process, clot in portal system."},"n_notes":{"kind":"number","value":83,"string":"83"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2114-12-29 00:00:00.000","description":"Physician Attending Progress Note","row_id":397775,"text":"Chief Complaint: Acute on chronic hepatic failure\n HPI:\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\n w/respiratory failure and hypotension.\n 24 Hour Events:\n BLOOD CULTURED - At 09:18 AM\n blood cultures drawn from femoral CVL\n SPUTUM CULTURE - At 10:00 AM\n BLOOD CULTURED - At 10:00 AM\n blood cultures drawn from PICC\n URINE CULTURE - At 10:20 AM\n ESOPHOGEAL BALLOON - At 02:30 PM\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,580 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,980 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,040 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Bronchial: )\n Abdominal: Soft, Distended\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.5 g/dL\n 147 K/uL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOTENSION (NOT SHOCK)\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2114-12-29 00:00:00.000","description":"Physician Attending Progress Note","row_id":397781,"text":"Chief Complaint: Acute on chronic hepatic failure\n HPI:\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\n w/respiratory failure and hypotension.\n 24 Hour Events:\n Pan cultured, started vanco/cefepime\n ESOPHOGEAL BALLOON\n PEEP uptitrated\nIncreasing pressor requirement\nStarted on stress dose hydrocortisone\nIncreasing hypoxia requiring paralysis\nVigileo monitor started\nIncreasing lactic acidosis, got 2 amps of bicarb\nRapid influenza negative\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives;\n Vasotec - hypertension;\n Last dose of Antibiotics:\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Levophed\n Propofol\n Cisatricurium\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Other medications:\n Lactulose, Rifaximin, Hydrocortisone\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,580 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,980 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,040 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, MMM\n Cardiovascular: RR, tachy, S1, S2, no RMG\n Extremities/Peripheral Vascular: Warm, palpable radial and DP pulses\n bilat\n Respiratory / Chest: Bronchial at bases bilat\n Abdominal: Soft, Distended, decreased BS\n Skin: NJaundice\n Neurologic: Sedated, paralysed, train of four\n \n Labs / Radiology\n 8.5 g/dL\n 147 K/uL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Cultures\n Blood, urine and sputum NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n Meets ARDS criteria. Etiology of\n infiltrates unclear, differential ARDS/PNA, DAH, cardiogenic edema.\n - Switch back to AC, 4-6cc/kg of IBW TV, will aim to keep PIPs~45\n pending new esophageal balloon numbers\n - Inhalers standing to minimize resistance\n - Consider bronchoscopy to r/o DAH, although tenuous respiratory status\n HYPOTENSION/SHOCK\n Per vigileo, minimal SVV, cardiac output ~,\n unclear if this is sufficient as improved with dopa. Lactate is\n worsening, as is LDH, will re-evaluate for intra-abdominal process.\n Had been favoring a septic/distributive process, although cannot\n exclude a cardiac component.\n - On Neo, vaso, levophed, dopa\n - Follow-up cultures, on broad spectrum abx\n - Consider Swann placement\n - TTE, cycle biomarkers\n - Increase thiamine dose\n - RUQ US w/dopplers\n - Cdiff\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Stable Tbili, INR up somewhat\n - On rifaxamin, lactulose\n - Appreciate hepatology input\n - Will need FFP prior to procedures\nRenal Failure\n Decreased UOP since midnight, with elevated Cr\n - Follow UOP with volume challenge\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin Sc\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Chlorhexidine, HOB to 30 degrees\n Comments:\n Communication: Attempting to contact family to update on her condition\n Code status: Full code\n Disposition : MICu for now\n Total time spent: 30 minutes\n"},{"category":"Physician ","chartdate":"2114-12-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":397484,"text":"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension.\n HPI:\n 24 Hour Events:\n -received 7L crystalloid total and initiated on levophed for blood\n pressure support\n -seen by liver consult in ED\n -received po vitamin K\n -discriminate function was 71 so started on prednisone 40mg daily for\n alcoholic hepatitis\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone\n levaquin\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Protonix\n Folic acid and thiamine\n Lactulose 30mg QID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 97 (92 - 97) bpm\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\n RR: 19 (12 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,973 mL\n PO:\n 200 mL\n TF:\n IVF:\n 773 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,843 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular:RRR,PMI Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: crackles at both bases posteriorly\n Abdominal: Soft, Non-tender\n Extremities: no peripheral edema. Slightly cool to touch.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands. Alert and oriented x3.\n Labs / Radiology\n 11.1 g/dL\n 238 K/uL\n 176 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 99 mEq/L\n 129 mEq/L\n 35.2 %\n 17.7 K/uL\n [image002.jpg]\n From WBC 9.2\n From Cr 0.6 TB 16.3 to 19.8 AST/ALT 195/45 to 103/39\n FeNa 0.4%\n 06:01 AM\n WBC\n 17.7\n Hct\n 35.2\n Plt\n 238\n Cr\n 0.9\n Glucose\n 176\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL lactate 2.2 at midnight serum etoh: negative serum\n acetaminophen negative\n RUQ US: cirrhotic liver, difficult to assess portal vein, ascites noted\n CT abdomen with contrast: no portal vein thrombosis with hypodensities\n in the liver consistent with perfusion defect or mass effect\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n -only potential source at this point is pneumonia\n -titrating down on levophed\n -if off levophed by noon will hold on placing a-line\n -concern for septic shock but no clear source, no evidence of SBP\n -does not appear fluid responsive at this point. If we need to do\n further volume challenge would use 5% albumin\n -will check bladder pressure\n ACUTE LIVER FAILURE\n -will ask liver consult team to make some recommendations\n -followup AFP, lesions on liver can be concerning for hepatocellular\n carcinoma\n -continue prednisone for presumed alcoholic hepatitis\n -trend lactate\n -for elevated INR will continue oral vitamin K 10mg for total of 3 days\n -continue lactulose for encephalopathy\nacute renal failure with low FeNa\n -will ask renal consult to see given potential for hepatorenal syndrome\n vs contrast induced nephropathy\n -will likely need 5% albumin challenge to determine\nhypoxemia now resolved\n -will check CT chest without contrast to evaluate for ovine bronchus\n and possible obstruction\n ICU Care\n Nutrition: npo for now\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM femoral. If not off pressors within\n 24 hours will need to place IJ or subclavian TLC\n Prophylaxis:\n DVT: heparin SQ to be initiated\n Stress ulcer: IV pantoprazole\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code. Will need to clarify with her family.\n Disposition :\n Total time spent:\n"},{"category":"Echo","chartdate":"2114-12-29 00:00:00.000","description":"Report","row_id":72279,"text":"PATIENT/TEST INFORMATION:\nIndication: Shock. Refractory hypotension. Shortness of breath.\nWeight (lb): 233\nBP (mm Hg): 97/61\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 10:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT VENTRICLE: Small LV cavity. Suboptimal technical quality, a focal LV wall\nmotion abnormality cannot be fully excluded. Hyperdynamic LVEF >75%. Moderate\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\nCannot assess regional RV systolic function.\n\nAORTIC VALVE: Aortic valve not well seen. No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left ventricular cavity is unusually small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Left\nventricular systolic function is hyperdynamic (EF>75%). There is a moderate\nresting left ventricular outflow tract obstruction. The right ventricular\ncavity is probably dilated with borderline normal free wall function. The\naortic valve is not well seen. There is no valvular aortic stenosis. The\nincreased transaortic velocity is likely related to high cardiac output. No\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Trivial mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular cavity size may be smaller and left ventricular\nfunction is now hyperdynamic with tachycardia. The right ventricle may not be\ndilated. No definite valvular lesions are identified in the current study but\nviews are suboptimal.\n\n\n"},{"category":"ECG","chartdate":"2114-12-25 00:00:00.000","description":"Report","row_id":170804,"text":"Sinus rhythm. Low precordial lead QRS voltage. Prolonged QTc interval.\nST-T wave abnormalities. Findings are non-specific but cannot exclude possible\ndrug/electrolyte/metabolic effect. Since the previous tracing of \nfurther ST-T wave changes are present.\n\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397754,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. CT chest : volume\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\n pressure ranging 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr\n for + gap and increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397755,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. CT chest : volume\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\n pressure ranging 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr\n for + gap and increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n ------ Protected Section ------\n ~ 0500 pt becoming more hypoxic on 100% 22 PEEP, with sats 87%, ABG\n 7.23/38/67. Pt placed on 25 PEEP, with sats increasing to 95%. BP\n dropped to 70s systolic, and pt was maxed out on vaso, levo, and neo.\n Dopamine gtt was initiated (see Metavision for specifics). Repeat ABG\n 7.14/39/140. 2 amps bicarb given. 500cc NS bolus given, albumin\n ordered- awaiting from pharmacy.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:13 ------\n"},{"category":"Nursing","chartdate":"2114-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":397554,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Rec\nd on levo gtt to keep MAP > 55, UO 30 -60cc/hr, hr nsr 80\ns-90\n Hct 27 at change of shift.\n Action:\n Titrating Levophed gtt to maintain MAPs > 55, stable on 0.06 mcg/kg/min\n Levophed gtt. Repeat Hct sent.\n Response:\n UO improving, Hct stable 28, levophed gtt turned off at 0330.\n Plan:\n Cont. to monitor BP, MAP goal > 55. Currently off levophed gtt.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o abdominal pain,\n oriented x 2, mood labile- calm & cooperative to weepy and agitated.\n Bladder pressure 17 on .\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver team\n following, ivp morphine given frequently for a total of 10mg ivp this\n shift, Reoriented frequently. CIWA q4h, tolerating ice chips and\n popcicles.\n Response:\n no stool, abdominal pain down to 4-5 after narcotics, pt cont. to be\n confused as to time/place, oriented x2. CIWA < 10, no diazepam given\n this shift.\n Plan:\n Cont to monitor MS- cont po lactulose as ordered, reorient as needed,\n iv protonix/iv antibiotics as ordered, pain control. Bladder\n pressures daily. Liver team following.\n ? c/o this pm if stable off levophed gtt.\n"},{"category":"Nursing","chartdate":"2114-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":397649,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: Around 1500, pt c/o difficulty breathing. LS with crackles\n and wheezes and O2 sats decreasing into 80s. Pt given\n albuterol/atrovent nebs and chest xray taken which showed increased\n pulmonary edema. 20mg IV Lasix given for fluid overload with effect\n pending. Sats remaining high 80s/low 90s. BP stable post Lasix. Pt also\n started on PO cipro for UTI but refusing to take.\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs 90s. UOP 40s-50s per hour.\n Action:\n Pt cont OFF levo. Given 50g of 5% albumin today to improve\n intravascular volume and for albumin 2.6 this AM.\n Response:\n BPs remaining >90 with MAPs ranging 60s-70s, systolic pressures\n 90s-120s.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites and c/o \n abdominal pain. Pt alert and oriented x 3 at times but noted to be\n hallucinating at times as well.\n Action:\n Lactulose increased to 60ml PO QID and lactulose enema ordered and\n given. Albumin given for albumin 2.6 this am. Bladder pressure checked-\n 23 today.\n Response:\n Pt cont without stool despite increase in lactulose. Lactulose enema\n with minimal retention. Refused to take lactulose this pm. Pt refusing\n all meds this pm, likely becoming more encephalopathic.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure today. Also will likely\n need NGT if cont to refuse PO meds.\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397472,"text":"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\n study.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\n historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\n Ceftriaxone 1gm) Constant moaning and c/o abd/back pain (although\n extremely inconsistent at times)\n Action:\n Lactulose given. Vitamin K 5mg PO x 1. Morphine 2mg IVP x 2. Frequent\n repositioning and reorientation. Pt extremely forgetful and repetitive.\n Response:\n Unchanged\n Plan:\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\n withdrawal. Thiamine/Folate/MVI\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\n Action:\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\n given. Urine lytes sent.\n Response:\n Awaiting AM lab results (sent @ 0600 post KCL repletion)\n Plan:\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\n cultures. Sputum culture needed if able.\n Full Code\n R femoral TLC\n Social: Would most likely benefit from SW cx. No contact\n with family O/N by this RN.\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397463,"text":"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\n study.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\n historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\n Ceftriaxone 1gm)\n Action:\n Lactulose given. Vitamin K 5mg PO x 1.\n Response:\n Plan:\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\n withdrawal. Thiamine/Folate/MVI\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\n Action:\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\n given. Urine lytes sent.\n Response:\n Plan:\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\n cultures. Sputum culture needed when able.\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397475,"text":"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\n study.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\n historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\n Ceftriaxone 1gm) Constant moaning and c/o abd/back pain (although\n extremely inconsistent at times)\n Action:\n Lactulose given. Vitamin K 5mg PO x 1. Morphine 2mg IVP x 2. Frequent\n repositioning and reorientation. Pt extremely forgetful and repetitive.\n Response:\n Unchanged\n Plan:\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\n withdrawal. Thiamine/Folate/MVI\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\n Action:\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\n given. Urine lytes sent.\n Response:\n Awaiting AM lab results (sent @ 0600 post KCL repletion)\n Plan:\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\n cultures. Sputum culture needed if able.\n Full Code\n R femoral TLC\n Social: Would most likely benefit from SW cx. No contact\n with family O/N by this RN.\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397739,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. CT chest : volume\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\n pressure ranging 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr\n for + gap and increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"},{"category":"Physician ","chartdate":"2114-12-28 00:00:00.000","description":"Physician Attending Progress Note","row_id":397704,"text":"Chief Complaint: Liver failure\n HPI:\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\n failure.\n 24 Hour Events:\n PICC LINE placed\nAntibiotics stopped\n Intubated\n Hypotensive post intubation, increasing pressor requirement,\n increasing O2 requirements\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives\n Vasotec - hypertension\n Last dose of Antibiotics:\n Ciprofloxacin\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Potassium, MVI, folate, thiamine,\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Cool, anasarcic\n Respiratory / Chest: Coarse, bronchial anteriorally\n Abdominal: Soft, Bowel sounds present, slightly distended\n Skin: Icteric, no rashes\n Neurologic: Sedated\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\n Cultures\n Blood and peritoneal fluid NGTD\n CXR\nprogression of diffuse b/l fluffy ASD, no apparent effusions\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n ARDS (Unclear inciting factor\ninfection,\n no witnessed aspiration, no obvious acute pancreatitis) vs volume\n overload.. Plateaus elevated, bilateral infiltrates.\n - Hold diuresis for now while hypotensive\n - Keep PaO2 >60, try to increase PEEP if needed, consider esoph balloon\n placement to optimize given obese abd, wean fio2 as able\n Empiric broad antbx coverage, ruled out for flu. Pan cxs repeated,\n TTE to assess cardiac fx\n HYPOTENSION\n Worse post-intubation. Likely due to sedation and\n PEEP, but cannot exclude worsening infection/sepsis, although no fever\n or elevated WBC. Did have hemo-peritoneum, although Hct stable. Also\n had steroids stopped recently.\n - Broaden antibiotics, add vanco and cefepime\n - TTE, CvO2\n - Pan culture\n - Start stress dose hydrocortisone\n --trend lacate\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Tbili and INR stable\n - Add rifaxamin\n - Continue lactulose\n - stress dose hydrocortisone as above\nAnemia\n Stable yesterday, but given hypotension will trend q6h, space\n out if stable x2\n Renal Failure\n improved UOP, s/p two days of albumin, follow and\n hold on diuresis in light of pressor support\n ICU Care\n Nutrition: Start TFs\n Glycemic Control: RISS\n transition to IV insulin protocol given plan\n to start steroids\n Lines:\n Cleanly placed femoral TLC - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Hob elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU\n Critically ill,\n Total time spent: 30 minutes\n"},{"category":"Physician ","chartdate":"2114-12-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":397479,"text":"Chief Complaint: 49 yo woman with history of hepatitis C, active\n alcohol abuse, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension.\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 02:32 AM\n NASAL SWAB - At 03:00 AM\n MRSA swab\n URINE CULTURE - At 04:04 AM\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 97 (92 - 97) bpm\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\n RR: 19 (12 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,973 mL\n PO:\n 200 mL\n TF:\n IVF:\n 773 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,843 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.1 g/dL\n 238 K/uL\n 176 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 99 mEq/L\n 129 mEq/L\n 35.2 %\n 17.7 K/uL\n [image002.jpg]\n 06:01 AM\n WBC\n 17.7\n Hct\n 35.2\n Plt\n 238\n Cr\n 0.9\n Glucose\n 176\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2114-12-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":397494,"text":"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension.\n HPI:\n 24 Hour Events:\n -received 7L crystalloid total and initiated on levophed for blood\n pressure support\n -seen by liver consult in ED\n -received po vitamin K\n -discriminate function was 71 so started on prednisone 40mg daily for\n alcoholic hepatitis\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone\n levaquin\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Protonix\n Folic acid and thiamine\n Lactulose 30mg QID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 97 (92 - 97) bpm\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\n RR: 19 (12 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,973 mL\n PO:\n 200 mL\n TF:\n IVF:\n 773 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,843 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular:RRR,PMI Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: crackles at both bases posteriorly\n Abdominal: Soft, Non-tender\n Extremities: no peripheral edema. Slightly cool to touch.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands. Alert and oriented x3.\n Labs / Radiology\n 11.1 g/dL\n 238 K/uL\n 176 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 99 mEq/L\n 129 mEq/L\n 35.2 %\n 17.7 K/uL\n [image002.jpg]\n From WBC 9.2\n From Cr 0.6 TB 16.3 to 19.8 AST/ALT 195/45 to 103/39\n FeNa 0.4%\n 06:01 AM\n WBC\n 17.7\n Hct\n 35.2\n Plt\n 238\n Cr\n 0.9\n Glucose\n 176\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL lactate 2.2 at midnight serum etoh: negative serum\n acetaminophen negative\n RUQ US: cirrhotic liver, difficult to assess portal vein, ascites noted\n CT abdomen with contrast: no portal vein thrombosis with hypodensities\n in the liver consistent with perfusion defect or mass effect\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n -only potential source at this point is pneumonia\n -titrating down on levophed\n -if off levophed by noon will hold on placing a-line\n -concern for septic shock but no clear source, no evidence of SBP\n -does not appear fluid responsive at this point. If we need to do\n further volume challenge would use 5% albumin\n -will check bladder pressure\n ACUTE LIVER FAILURE\n -will ask liver consult team to make some recommendations\n -followup AFP, lesions on liver can be concerning for hepatocellular\n carcinoma\n -continue prednisone for presumed alcoholic hepatitis\n -trend lactate\n -for elevated INR will continue oral vitamin K 10mg for total of 3 days\n -continue lactulose for encephalopathy\nacute renal failure with low FeNa\n -will ask renal consult to see given potential for hepatorenal syndrome\n vs contrast induced nephropathy\n -will likely need 5% albumin challenge to determine\nhypoxemia now resolved\n -will check CT chest without contrast to evaluate for ovine bronchus\n and possible obstruction\n ICU Care\n Nutrition: npo for now\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM femoral. If not off pressors within\n 24 hours will need to place IJ or subclavian TLC\n Prophylaxis:\n DVT: heparin SQ to be initiated\n Stress ulcer: IV pantoprazole\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code. Will need to clarify with her family.\n Disposition : MICU\n Total time spent: 60 min\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397719,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\n 15 bpm, and most recent ABG 7.39/37/65.\n Action:\n Multiple vent changes today. Esophageal balloon placed with poor\n measurements pt\ns WOB but PEEP able to be increased to 22. Pt\n placed on triadyne bed.\n Response:\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\n 7.29/41/74\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\n neo @ 0.5mcg/kg/min.\n Response:\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\n Plan:\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\n Wean pressors as tol, would wean vaso off first.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today.\n Action:\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\n recs. Hydrocort added today for increasing bili and coags. Bladder\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\n Liver team following. Liver did not recommend para as they \nt feel\n she has a lg amt of ascites.\n Response:\n Large liquid yellow BM this AM so flexiseal inserted but pt without\n stool since that BM.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397720,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\n 15 bpm, and most recent ABG 7.39/37/65.\n Action:\n Multiple vent changes today. Esophageal balloon placed with poor\n measurements pt\ns WOB but PEEP able to be increased to 22. Pt\n placed on triadyne bed.\n Response:\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\n 7.29/45/74 and sats 88-92%.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\n neo @ 0.5mcg/kg/min. Pt also given 50g 25% albumin to improve\n intravascular volume status. Pt also started on IV Vanc/Cefepime for\n possible sepsis.\n Response:\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\n Plan:\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\n Wean pressors as tol, would wean vaso off first. attempt fluid\n challenge this pm and want vigileo set up.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today.\n Action:\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\n recs. Hydrocort added today for increasing bili and coags. Bladder\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\n Liver team following. Liver did not recommend para as they \nt feel\n she has a lg amt of ascites.\n Response:\n Large liquid yellow BM this AM so flexiseal inserted but pt without\n stool since that BM.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397721,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **EVENTS: Pt started on insulin gtt this AM for anion gap 18 up from\n 12 yesterday AM. Insulin gtt currently infusing @ 11 units/hr with last\n 2 BS 114, 105.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\n 15 bpm, and most recent ABG 7.39/37/65.\n Action:\n Multiple vent changes today. Esophageal balloon placed with poor\n measurements pt\ns WOB but PEEP able to be increased to 22. Pt\n placed on triadyne bed. Suctioned for small amts dark yellow/green thin\n secretions.\n Response:\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\n 7.29/45/74 and sats 88-92%.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\n neo @ 0.5mcg/kg/min. Pt also given 50g 25% albumin to improve\n intravascular volume status. Pt also started on IV Vanc/Cefepime for\n possible sepsis, and blood cx x2 sent from PICC and CVL, urine cx sent,\n sputem cx sent.\n Response:\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\n Plan:\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\n Wean pressors as tol, would wean vaso off first. attempt fluid\n challenge this pm and want vigileo set up. Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today.\n Action:\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\n recs. Hydrocort added today for increasing bili and coags. Bladder\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\n Liver team following. Liver did not recommend para as they \nt feel\n she has a lg amt of ascites.\n Response:\n Large liquid yellow BM this AM so flexiseal inserted but pt without\n stool since that BM.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397459,"text":"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Pt is a poor historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n 2)Hepatic Failure\nThis appears to be acute exacerbation in the setting\n of ongoing alcohol use and abuse. We do not see evidence of portal\n vein thrombosis or intra-peritoneal infection.\n -Steroids based upon discriminant function\n -Will need to send AFP given new densities on CT scan\n -Hepatology to see in the am\n -Lactulose\n 3)Coagulopathy-\n -Vitamin K given\n - be more likely related to poor hepatic function\n 4)EtOH Abuse-\n -Will monitor for withdrawl\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397714,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation. Sxned for bilious looking secretions.\n Response:\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\n vent settings 60% 450/14/5\nplaced on 100% FiO2 and Aline currently\n being placed for ABGs.\n Plan:\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\n ventilation.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mg/hr with SBPs 80s\n Action:\n Pt cont OFF levo for most of shift, then around 0400, pt becoming\n persistently hypotensive with systolics in the 80s, levophed gtt\n initiated, titrating to MAPs > 55.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\n tolerated by BP.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397716,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation. Sxned for bilious looking secretions.\n Response:\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\n vent settings 60% 450/14/5\nplaced on 100% FiO2 and Aline currently\n being placed for ABGs.\n Plan:\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\n ventilation.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mg/hr with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ addition of vasopressin @ 2.4units/hr,\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\n tolerated by BP.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"},{"category":"Respiratory ","chartdate":"2114-12-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":397722,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (1500)\n Comments: Balloon placed measurements not taken Pt actively breathing.\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397737,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. Bladder pressure ranging\n 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr for + gap and\n increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"},{"category":"Nursing","chartdate":"2114-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":397540,"text":"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Continues on levo gtt to keep MAP > 55, UO 30 -60cc/hr, hr nsr\n 80\ns-90\ns. Hct 27 at change of shift.\n Action:\n Titrating Levophed gtt to maintain MAPs > 55, stable on 0.06 mcg/kg/min\n Levophed gtt. Repeat Hct sent.\n Response:\n UO improving, Hct stable 28,\n Plan:\n Levo gtt as ordered to keep MAP > 55, ? a-line insertion this PM,\n frequent labs as ordered\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o # abdominal pain,\n oriented x , calm & cooperative, minimal uo, on levo gtt to maintain\n map > 55\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver consult\n placed, chest ct today, bladder pressure done, iv morphine given x 2 &\n po oxycodone x 1, npo except ice chips, iv albumin given\n Response:\n Bladder pressure 17, no stool, abdominal pain down to #1-2 after\n narcotics, not able to wean levo off, minimal response from iv albumin\n Plan:\n Continue to monitor for sepsis/pancreatitis/GI bleeding, po lactulose\n as ordered, wean levo as able, iv protonix/iv antibiotics as ordered,\n pain controll\n"},{"category":"Nursing","chartdate":"2114-12-27 00:00:00.000","description":"Nursing Progress Note","row_id":397625,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs 90s. UOP 40s-50s per hour.\n Action:\n Pt cont OFF levo. Given 50g of 5% albumin today to improve\n intravascular volume and for albumin 2.6 this AM.\n Response:\n BPs remaining >90 with MAPs ranging 60s-70s, systolic pressures\n 90s-120s.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites and c/o \n abdominal pain. Pt alert and oriented x 3 at times but noted to be\n hallucinating at times as well. Bladder pressure 23 today.\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver team\n following, ivp morphine given frequently for a total of 10mg ivp this\n shift, Reoriented frequently. CIWA q4h, tolerating ice chips and\n popcicles.\n Response:\n no stool, abdominal pain down to 4-5 after narcotics, pt cont. to be\n confused as to time/place, oriented x2. CIWA < 10, no diazepam given\n this shift.\n Plan:\n Cont to monitor MS- cont po lactulose as ordered, reorient as needed,\n iv protonix/iv antibiotics as ordered, pain control. Bladder\n pressures daily. Liver team following.\n"},{"category":"Physician ","chartdate":"2114-12-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":397683,"text":"Chief Complaint:\n 24 Hour Events:\n - D/cd Antibioitcs which were empiric for CAP, but afebrile with normal\n WBC\n - Receive IV Vitamin K x1\n - Started Cipro empirically per liver for mildly positive UA\n - Repeat Hct stable 26.3 < 24.2 < 25.6. Did not give FFP because Hct\n stable (which liver had advised earlier in the day)\n - Worsening hypoxemia around 1600. CXR appeared more volume overloaded.\n Received lasix 20 mg IV x3 with brisk response but continue to be more\n Hypoxic. Intubated around 10 pm with sats in 70s.\n - Hypotensive to SBP 70s-80s post intubation. Started levophed to limit\n fluid over-resusication\n - Rising lactate 4.4 > 5.5. Did not give fluids becuase appears\n overloaded and worsening oxygenation.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsLibrium (Oral) (Chlordiazepoxide\n Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.28 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 98 (94 - 111) bpm\n BP: 71/54(57) {71/40(44) - 141/87(94)} mmHg\n RR: 22 (22 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 327 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 327 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 545 mL\n Urine:\n 2,784 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 98%\n ABG: 7.39/37/65/20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 65\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 94 K/uL\n 8.7 g/dL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n WBC\n 10.6\n 11.0\n Hct\n 27.8\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Imaging: : AP single view of the chest obtained with patient in\n sitting\n semi-upright position is analyzed in direct comparison with the next\n preceding similar study obtained four hours earlier during the same\n day. No significant interval change can be identified. No pneumothorax\n has developed. The scattered bilateral patchy densities are still\n present and there is no evidence of gross pleural effusion as the\n lateral pleural sinuses remain free.\n Microbiology: BCx x 2 NGTD\n Pleural fluid culture NGTD\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG , + 1:20\n -HCV VL < 43\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\n despite BMs w/ lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n -vitamin k 10 mg IV x 1\n -if hct < 21 give FFP for elevated PTT and INR\n # ETOH abuse: thiamine, folate, MVI daily\n - No evidence of withdrawal, will stop CIWA\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n Plan to begin diuresing very gently if Cr stable by .\n -IS for atelectasis\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\n depletion.\n -improved\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2114-12-28 00:00:00.000","description":"Physician Attending Progress Note","row_id":397685,"text":"Chief Complaint:\n HPI:\n 24 Hour Events:\n PICC LINE - START 12:40 PM\n INVASIVE VENTILATION - START 10:18 PM\n ARTERIAL LINE - START 06:29 AM\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOTENSION (NOT SHOCK)\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"},{"category":"Physician ","chartdate":"2114-12-28 00:00:00.000","description":"Physician Attending Progress Note","row_id":397688,"text":"Chief Complaint: Liver failure\n HPI:\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\n failure.\n 24 Hour Events:\n PICC LINE placed\nAntibiotics stopped\n Reintubated\n Hypotensive post intubation, increasing pressor requirement\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives\n Vasotec - hypertension\n Last dose of Antibiotics:\n Ciprofloxacin\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Potassium, MVI, folate, thiamine,\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Cool, anasarcic\n Respiratory / Chest: Coarse, bronchial anteriorally\n Abdominal: Soft, Bowel sounds present, slightly distended\n Skin: Icteric, no rashes\n Neurologic: Sedated\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\n Cultures\n Blood and peritoneal fluid NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n ARDS vs volume overload. Plateaus\n elevated, bilateral infiltrates.\n - Hold diuresis for now while hypotensive\n - Keep PaO2 >60, try to increase PEEP if needed\n HYPOTENSION\n Worse post-intubation. Likely due to sedation and\n PEEP, but cannot exclude worsening infection, although no fever or\n elevated WBC. Did have hemo-peritoneum, although Hct stable. Also had\n steroids stopped recently.\n - Broaden antibiotics, add vanco and cefepime\n - TTE, CvO2\n - Pan culture\n - Start stress dose hydrocortisone\n - q6h\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Tbili and INR stable\n - Add rifaxamin\n - Continue lactulose\n - stress dose hydrocortisone as above\nAnemia\n Stable yesterday, but given hypotension will trend q6h, space\n out if stable x2\n Renal Failure\n improved UOP, s/p two days of albumin\n ICU Care\n Nutrition: Start TFs\n Glycemic Control: RISS\n Lines:\n Cleanly placed femoral TLC - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Hob elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU\n Total time spent: 30 minutes\n"},{"category":"Physician ","chartdate":"2114-12-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":397689,"text":"Chief Complaint:\n 24 Hour Events:\n - D/cd Antibioitcs which were empiric for CAP, but afebrile with normal\n WBC\n - Receive IV Vitamin K x1\n - Started Cipro empirically per liver for mildly positive UA\n - Repeat Hct stable 26.3 < 24.2 < 25.6. Did not give FFP because Hct\n stable (which liver had advised earlier in the day)\n - Worsening hypoxemia around 1600. CXR appeared more volume overloaded.\n Received lasix 20 mg IV x3 with brisk response but continue to be more\n Hypoxic. Intubated around 10 pm with sats in 70s.\n - Hypotensive to SBP 70s-80s post intubation. Started levophed to limit\n fluid over-resusication\n - Rising lactate 4.4 > 5.5. Did not give fluids becuase appears\n overloaded and worsening oxygenation.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsLibrium (Oral) (Chlordiazepoxide\n Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.28 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 98 (94 - 111) bpm\n BP: 71/54(57) {71/40(44) - 141/87(94)} mmHg\n RR: 22 (22 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 327 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 327 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 545 mL\n Urine:\n 2,784 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 98%\n ABG: 7.39/37/65/20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 65\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 94 K/uL\n 8.7 g/dL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n WBC\n 10.6\n 11.0\n Hct\n 27.8\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Imaging: : AP single view of the chest obtained with patient in\n sitting\n semi-upright position is analyzed in direct comparison with the next\n preceding similar study obtained four hours earlier during the same\n day. No significant interval change can be identified. No pneumothorax\n has developed. The scattered bilateral patchy densities are still\n present and there is no evidence of gross pleural effusion as the\n lateral pleural sinuses remain free.\n Microbiology: BCx x 2 NGTD\n Pleural fluid culture NGTD\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Shock: at this point seems to be related to possible infectious\n cause, end stage liver disease, propofol. Would also consider adverse\n reaction to FFP or IV vitamin K. On levo, vaso.\n - MAP goal > 55\n - empiric vanc/zosyn/cipro\n - stress dose steroids\n - follow UOP, pulse pressure variation to assess intravascular volume\n - check ECHO\n - check TSH/FT4\n - wean propofol\n - check lytes, hct, ABG, lactate q6h\n # Respiratory failure/ARDS: Worsening hypoxia on and intubated\n in setting of receiving volume and severe liver disease. Differential\n includes volume overload versus infection versus pulm hemorrhage vs\n TROLI in setting of transfusion though unlikely. Would also consider\n PCP given IVDU history.\n - ARDSnet protocol with low tidal volumes\n - PaO2 > 60, SaO2 > 90\n - empiric antibx\n - r/o flu\n - may consider bronch\n - hold on diuresis for now but will consider pending creatinine trend,\n UOP\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n - restarted steroids with undetectable HCV viral load\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG , + 1:20\n -HCV VL < 43\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose and rifaxamin\n -will obtain OSH previous EGD / if any\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n - follow UOP and trend creatinine\n - renally dose meds\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\n and hct stable.\n -guaiac stools\n -active type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n # ETOH abuse: No evidence of withdrawal\n - thiamine, folate, MVI daily\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition: TF reccs\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2114-12-28 00:00:00.000","description":"Physician Attending Progress Note","row_id":397691,"text":"Chief Complaint: Liver failure\n HPI:\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\n failure.\n 24 Hour Events:\n PICC LINE placed\nAntibiotics stopped\n Reintubated\n Hypotensive post intubation, increasing pressor requirement\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives\n Vasotec - hypertension\n Last dose of Antibiotics:\n Ciprofloxacin\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Potassium, MVI, folate, thiamine,\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Cool, anasarcic\n Respiratory / Chest: Coarse, bronchial anteriorally\n Abdominal: Soft, Bowel sounds present, slightly distended\n Skin: Icteric, no rashes\n Neurologic: Sedated\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\n Cultures\n Blood and peritoneal fluid NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n ARDS vs volume overload. Plateaus\n elevated, bilateral infiltrates.\n - Hold diuresis for now while hypotensive\n - Keep PaO2 >60, try to increase PEEP if needed\n HYPOTENSION\n Worse post-intubation. Likely due to sedation and\n PEEP, but cannot exclude worsening infection, although no fever or\n elevated WBC. Did have hemo-peritoneum, although Hct stable. Also had\n steroids stopped recently.\n - Broaden antibiotics, add vanco and cefepime\n - TTE, CvO2\n - Pan culture\n - Start stress dose hydrocortisone\n - q6h\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Tbili and INR stable\n - Add rifaxamin\n - Continue lactulose\n - stress dose hydrocortisone as above\nAnemia\n Stable yesterday, but given hypotension will trend q6h, space\n out if stable x2\n Renal Failure\n improved UOP, s/p two days of albumin\n ICU Care\n Nutrition: Start TFs\n Glycemic Control: RISS\n transition to IV insulin protocol given plan\n to start steroids\n Lines:\n Cleanly placed femoral TLC - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Hob elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU\n Total time spent: 30 minutes\n"},{"category":"Physician ","chartdate":"2114-12-26 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":397453,"text":"Chief Complaint: Weakness\n Jaundice\n Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient to hospital with complaints of worsening weakness and\n change in urine color now admitted to with concern for evolving\n hepatic failure.\n In the ED here->\n -Pt with MSO4 for pain control\n -CTX given for possible SBP\n -Given hypotension femoral catheter placed and 7 liters fluid given\n -Levophed given for hypotension\n -Paracentesis perfored with 63 WBC seen\n Patient admitted to ICU for further care\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Cirrhosis-Hep C and EtOH\n EtOH abuse-h/o withdrawl seizures\n S/P CCY in past\n DM-II\n Non-contributory\n Occupation: Unk\n Drugs: None noted now\n Tobacco: Continued smoking\n Alcohol: Patient admits to some EtOH ingestion prior to onset of\n abdominal pain\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Psychiatric / Sleep: Daytime somnolence\n Signs or concerns for abuse : No\n Pain: Mild\n Flowsheet Data as of 04:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 92 (92 - 95) bpm\n BP: 90/52(62) {90/52(62) - 115/74(84)} mmHg\n RR: 21 (12 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,257 mL\n PO:\n TF:\n IVF:\n 257 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,167 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Abdominal: Soft, Bowel sounds present, Tender: Diffusely\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\nPatient somnolent\n but arousable.\n Labs / Radiology\n 128\n 31\n 0.6\n 4\n 21\n 102\n 2.8\n 132\n 9\n [image002.jpg]\n Other labs: PT / PTT / INR:23.8/2.3, ALT / AST:45/195, Alk Phos / T\n Bili:91/16.3 (8.4-direct), Amylase / Lipase:/20, Differential-Neuts:78,\n Lactic Acid:3.1\n Fluid analysis / Other labs: TOx-Pos Benzos\n Serum-Negative to Tylenol and EtOH\n Imaging: CXR-Patient with what appears to be right middle lobe opacity.\n U/S--no Cholecystitis seen\n CT--no portal vein thrombosis noted. In segment II of the\n liver--multiple hypodensities noted which were felt to be non-specific\n findings\n Assessment and Plan\n 49 yo female with history of cirrhosis now admitted with worsening\n abdominal discomfort and hyper-bilirubinemia in the setting of recent\n EtOH ingestion. Initial tap of abdominal fluid did not reveal obvious\n SBP as source. This leaves, in the setting of significant hypotension,\n source of initial insult remains to be clearly defined.\n 1) Hypotension- be part of the hepatic failure picture present but\n alternative source of infection (possible urine) is possible with right\n middle lobe opacity but clinical history not suggestive.\n -Ceftriaxone/Levoflox in place\n -9 liters given and will use pressor for now\n -Follow up cultures\n 2)Hepatic Failure\nThis appears to be acute exacerbation in the setting\n of ongoing alcohol use and abuse. We do not see evidence of portal\n vein thrombosis or intra-peritoneal infection.\n -Steroids based upon discriminant function\n -Will need to send AFP given new densities on CT scan\n -Hepatology to see in the am\n -Lactulose\n 3)Coagulopathy-\n -Vitamin K given\n - be more likely related to poor hepatic function\n 4)EtOH Abuse-\n -Will monitor for withdrawl\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments: Discussed with patient but with signfiicant\n confusion\nwould be appropriate to discuss with a social support if\n available.\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"},{"category":"Physician ","chartdate":"2114-12-26 00:00:00.000","description":"Physician Resident Admission Note","row_id":397455,"text":"Chief Complaint: transfer from for liver failure\n HPI:\n 49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \n hospital after presenting with worsening jaundice and fatigue. She was\n noted there to be hypotensive to the low 80s systolic, noted to have an\n elevated bili and INR- she was given 4 Liters IVF and transferred to\n the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\n was given 4 L IVF in hospital, 3 L in the ER at .\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\n sat: 94% on 5L O2 NC.\n Currently the patient complains of generalized abdominal pain, moreso\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\n her abdominal pain beginning.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.16 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Other medications:\n (patient unsure of medications, none on list from hospital)\n patient states she takes insulin.\n Past medical history:\n Family history:\n Social History:\n 1. Hepatitis C.\n 2. Alcoholic hepatitis.\n 3. History of alcohol abuse with withdraw seizures and DTs in the\n past.\n 4. History of hypertension.\n 5. History of chronic pancreatitis.\n 6. Status post cesarean section and ectopic pregnancies in the past.\n 7. History of traumatic wrist laceration in the past status post\n surgical repair with blood transfusions in .\n 8. S/P ccy, s/p oophorectomy\n 9. DM II\n non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: 6 tabs of tylenol 3 days ago, 1 pint of hard liquor on \n however the patient's history is relatively unreliable given\n encephalopathy. She lives w/ friends, smokes and is a current\n abuser of ETOH (daily)- unable to quantify. H/o opiate abuse but no\n opiates x 1 year.\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 94 (94 - 95) bpm\n BP: 115/74(84) {115/74(84) - 115/74(84)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,172 mL\n PO:\n TF:\n IVF:\n 172 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,082 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: serum tylenol negative\n serum etoh negative\n serum opiates negative\n serum benzos +\n Imaging: RUQ ultrasound: (prelim) Very echogenic liver, limited\n assessment of gallbladder and portal vein. Ascites, predominantly in\n the RUQ, but not a good window to mark. Consider ultrasound guided\n paracentesis.\n CXR: (my read) hilar fullness w/ mild pulm vascular engorgement,\n infiltrates in the RML and RUL.\n CT abd / pelvis w/ contrast: . (prelim)\n liver w/ heterogeneous attenuation, shrunken nodular appearance.\n Several areas of hypodensities in segement 2 of the liver could\n represent perfusion defects, dilated bile ducts or could be related to\n underlying mass effect. Anasarca. No evidence of portal vein\n thrombosis. Bibasilar atelectasis.\n Microbiology: BCx x 2 P\n Peritoneal fluid cx P\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis given history and transaminase pattern.\n -paracentesis negative for sbp\n -liver consult\n -liver ultrasound with doppler was a difficult study,\n -discriminate function is 71. Will start steroids x 1 week then taper.\n -will give vitamin K to correct any portion of elevated INR that may be\n nutritional\n -thiamine, folate, MVI daily\n -lactulose- titrate to 3 BMs daily\n -send AFP given risk of HCC and finding on CT abd\n -Send Uhcg\n # Hypotension: no clear cause for hypotension with the exception of\n worsening liver function and possible infectious etiologies including\n pneumonia and possible urinary tract infection.\n -continue levofloxacin / ceftriaxone.\n -keep MAP > 55\n -has rec'd 7 liters IVF and likely fluid replete, appears euvolemic on\n exam\n # Hyponatremia: possibly related to volume overload / liver disease.\n -urine lytes\n # Hypoxia: appears to have R sided opacities which may be pneumonia.\n She has rec'd ceftriaxone. Will add levofloxacin in addition to CTX\n for severe CAP.\n -abx\n -f/u blood cultures\n -sputum culture\n -IS for atelectasis\n # ETOH abuse: h/o w/d seizures in the past.\n -CIWA scale w/ valium.\n # DM: Insulin sliding scale.\n # FEN: NPO for now until MS clears\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nutrition","chartdate":"2114-12-27 00:00:00.000","description":"Clinical Nutrition Note","row_id":397616,"text":"Subjective\n \"Help me!\". Taking oxygen mask off.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 106 kg\n 36.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 173%\n 72.4 kg\n Diagnosis: acute liver failure\n PMHx:\n 1. Hepatitis C.\n 2. Alcoholic hepatitis.\n 3. History of alcohol abuse with withdraw seizures and DTs in the\n past.\n 4. History of hypertension.\n 5. History of chronic pancreatitis.\n 6. Status post cesarean section and ectopic pregnancies in the past.\n 7. History of traumatic wrist laceration in the past status\n postsurgical repair with blood transfusions in .\n 8. S/P ccy, s/p oophorectomy\n 9. DM II\n Food allergies and intolerances: none\n Pertinent medications: Normal saline @ 10ml/hr, Albumin 5%,\n Pantoprazole, RISS, Multi-vitamin, Thiamine, Folic Acid, Lactulose\n Labs:\n Value\n Date\n Glucose\n 182 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 180\n 11:00 AM\n BUN\n 7 mg/dL\n 04:15 AM\n Creatinine\n 1.0 mg/dL\n 04:15 AM\n Sodium\n 134 mEq/L\n 04:15 AM\n Potassium\n 3.4 mEq/L\n 04:15 AM\n Chloride\n 101 mEq/L\n 04:15 AM\n TCO2\n 21 mEq/L\n 04:15 AM\n Albumin\n 2.6 g/dL\n 04:15 AM\n Calcium non-ionized\n 7.8 mg/dL\n 04:15 AM\n Phosphorus\n 3.2 mg/dL\n 04:15 AM\n Magnesium\n 2.6 mg/dL\n 04:15 AM\n ALT\n 34 IU/L\n 04:15 AM\n Alkaline Phosphate\n 82 IU/L\n 04:15 AM\n AST\n 83 IU/L\n 04:15 AM\n Amylase\n 14 IU/L\n 05:20 PM\n Total Bilirubin\n 27.5 mg/dL\n 04:15 AM\n WBC\n 10.6 K/uL\n 04:15 AM\n Hgb\n 8.7 g/dL\n 04:15 AM\n Hematocrit\n 24.2 %\n 12:54 PM\n Current diet order / nutrition support: Diet: regular\n GI: soft/distended, (+) bowel sounds, (+) flatus\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: decreased mental status, liver disease, etoh\n Estimated Nutritional Needs\n Calories: 1600-1810 (22-25 cal/kg)\n Protein: 87-109 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 49 YO female presented with hypotension and worsening jaundice.\n Decreased po\ns and increased alcohol intake recently per chart.\n Consulted for tube feed recommendations and calorie counts. Diet\n advanced today to regular, only had water per co-worker, c/o abdominal\n pain. Would hold off on calorie counts at this time as patient not\n taking po\ns. Would provide temporary nutrition support with tube\n feeding until po\ns improve given likely poor nutritional status PTA.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Encourage\n po\ns as able\n o Will begin calorie counts when po\ns improve\n Multivitamin / Mineral supplement: continue current\n Tube feeding recommendations:\n o Place PPFT given ascites; check placement\n o Begin tube feed: Isosource 1.5 @ 20ml/hr, advance as\n tolerated to goal of 50ml/hr\n Add 15g Beneprotein for total of 1854 calories and 95g\n protein\n o No residual checks with PPFT, monitor abdominal exam, patient\n complaints\n Check chemistry 10 panel daily\n Will follow, page if questions *\n"},{"category":"Respiratory ","chartdate":"2114-12-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":397694,"text":":\n Recruitment Maneuvers Done\n CPAP pressure used: aprv cm H2O\n Duration: 30 sec\n Times per shift:\n Comments: 35/32\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":397592,"text":"Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\n lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Hallucinations: Visual hallucinations this morning. New since\n yesterday. ? Benzo related but also could be encephalopathy.\n - Increase lactulose\n - Hold Benzos for now and see if MS improves\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale but hold benzos for right now\n - D/c thiamine after today\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative.\n INR worsening so will check DIC labs\n -guaiac stools\n -type and screen.\n - IV Vitamin K since did not respond to po vitamin K\n -transfuse for hct < 21, and transfuse w/ Lasix when necessary\n -Q8. hct, DIC labs\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia: Imprved with volume so likely due to intravascular\n depletion prior to admission.\n -improved and will continue to trend lytes daily\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":397593,"text":"Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\n despite BMs w/ lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n -vitamin k 10 mg IV x 1\n -if hct < 25 give FFP for elevated PTT and INR\n # ETOH abuse: thiamine, folate, MVI daily\n - No evidence of withdrawal, will stop CIWA\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\n depletion.\n -improved\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition: calorie count today\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":397594,"text":"Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\n lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Hallucinations: Visual hallucinations this morning. New since\n yesterday. ? Benzo related but also could be encephalopathy.\n - Increase lactulose\n - Hold Benzos for now and see if MS improves\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale but hold benzos for right now\n - D/c thiamine after today\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative.\n INR worsening so will check DIC labs\n -guaiac stools\n -type and screen.\n - IV Vitamin K since did not respond to po vitamin K\n -transfuse for hct < 21, and transfuse w/ Lasix when necessary\n -Q8. hct, DIC labs\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia: Imprved with volume so likely due to intravascular\n depletion prior to admission.\n -improved and will continue to trend lytes daily\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":397595,"text":"Chief Complaint: Liver failure\n HPI:\n Please see admission note for full details. 49F w/HCV and cirrhosis\n admitted with worsening confusion and hepatic insufficiency.\n 24 Hour Events:\n - MELD 27\n - Stopped steroids\n - Chest CT obtained for evaluation of R-sided infiltrates\n - Concern for IP hemorrhage\n - Weaned off pressors\n Allergies:\n Librium - Confusion/Delir\n Erythromycin Base - Hives;\n Vasotec - HTN\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:50 AM\n Pantoprazole (Protonix) - 07:55 AM\n Other medications:\n MVI, folate, thiamine, lactulose, RISS\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 97 (90 - 101) bpm\n BP: 96/64(72) {82/15(40) - 107/69(78)} mmHg\n RR: 24 (15 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 8,915 mL\n 195 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 195 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 431 mL\n Urine:\n 409 mL\n 431 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -235 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Sallow, ill-appearing obese F, laying in bed\n Eyes / Conjunctiva: Scleral icterus\n Head, Ears, Nose, Throat: MMM, sublingual icterus, oropharynx clear\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Warm, diffusely edematous, palpable\n radial, DPs bilat\n Respiratory / Chest: bilateral crackles over the lower half of lung\n fields bilat\n Skin: Sallow, no rashes\n Neurologic: A&Ox2, repeatedly stating that her son is hiding in the\n room\n / Radiology\n 8.7 g/dL\n 127 K/uL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other : PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood cultures and peritoneal fluid cultures\n NGTD\n Chest CT\n Reviewed - Peribronchial edema, thickening, GGOs, trace\n bilateral effusions, ascites, pancreatic calcifiations\n Assessment and Plan\n CIRRHOSIS OF LIVER, ALCOHOLIC\n acutely decompensated\n - Increase lactulose as not stooling\n - Stopped steroids per hepatology\n - Will discuss prognosis given not a transplant candidate with son\n - On thiamine, folate, MVI for chronic EtOH\n HYPOTENSION - ?cirrhotic vs infectious\n - Weaned off pressors yesterday, follow\n - Goal MAP >55\n - Stop antibiotics\nHCT drop\n Appears to have been secondary to intraperitoneal bleed\n after paracentesis\n - Hct checks q8h\n - Transfusion goal >21 or if acute drop concerning for bleed\n - If need to transfuse, consider FFP if acute bleeding\n - IV vitamin K to try and improve coagulopathy\nEtOH Abuse\n - Monitor for withdrawal\nRenal Failure - Poor UOP yesterday with FENA <1, improving now, ATN\n vs hepatorenal vs contrast nephropathy\n - Getting albumin 50gm today\n - If worsens, consider midodrine and/or octreotide\nHypoxia, volume overload\n - On 4L NC\n - Consider gentle diuresis in the next 12-24 hrs pending UOP\n On RISS\n ICU Care\n Nutrition: PO diet\n Glycemic Control: RISS\n Lines: - Plan for PICC, d/c femoral line after\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Will discuss with son today\n status: Full code\n Disposition : MICU for now\n Total time spent: 30 minutes\n"},{"category":"Respiratory ","chartdate":"2114-12-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":397672,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: may need to increase peep as O2 is decreased\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Pt was intubated for impending respiratory failure, hypoxia. New a line\n being placed, abg pending.\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397673,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: At change of shift, pt agitated and in resp. distress,\n increased > Pt given ativan,lasix, with minimal effect, and placed\n on a NRB. Pt with sats 79-80% on NRB, ultimately intubated for resp.\n distress. SBP ranging 80s-90s, persistently hypotensive this AM, and\n levophed gtt initiated, and Aline placed. K 2.6- currently rec\n repletion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\n Action:\n Pt cont OFF levo.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397674,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: At change of shift, pt agitated and in resp. distress,\n increased > Pt given ativan,lasix, with minimal effect, and placed\n on a NRB. Pt with sats 79-80% on NRB, ultimately intubated for resp.\n distress. SBP ranging 80s-90s, persistently hypotensive this AM, and\n levophed gtt initiated, and Aline placed. K 2.6- currently rec\n repletion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation. Sxned for bilious looking secretions.\n Response:\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\n vent settings 60% 450/14/5\nplaced on 100% FiO2 and Aline currently\n being placed for ABGs.\n Plan:\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\n ventilation.\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\n Action:\n Pt cont OFF levo for most of shift, then around 0400, pt becoming\n persistently hypotensive with systolics in the 80s, levophed gtt\n initiated, titrating to MAPs > 55.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\n tolerated by BP.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Attending Progress Note","row_id":397600,"text":"Chief Complaint: Liver failure\n HPI:\n Please see admission note for full details. 49F w/HCV and cirrhosis\n admitted with worsening confusion and hepatic insufficiency.\n 24 Hour Events:\n - MELD 27\n - Stopped steroids\n - Chest CT obtained for evaluation of R-sided infiltrates\n - Concern for IP hemorrhage\n - Weaned off pressors\n Allergies:\n Librium - Confusion/Delir\n Erythromycin Base - Hives;\n Vasotec - HTN\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:50 AM\n Pantoprazole (Protonix) - 07:55 AM\n Other medications:\n MVI, folate, thiamine, lactulose, RISS\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 97 (90 - 101) bpm\n BP: 96/64(72) {82/15(40) - 107/69(78)} mmHg\n RR: 24 (15 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 8,915 mL\n 195 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 195 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 431 mL\n Urine:\n 409 mL\n 431 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -235 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Sallow, ill-appearing obese F, laying in bed\n Eyes / Conjunctiva: Scleral icterus\n Head, Ears, Nose, Throat: MMM, sublingual icterus, oropharynx clear\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Warm, diffusely edematous, palpable\n radial, DPs bilat\n Respiratory / Chest: bilateral crackles over the lower half of lung\n fields bilat\n Skin: Sallow, no rashes\n Neurologic: A&Ox2, repeatedly stating that her son is hiding in the\n room\n / Radiology\n 8.7 g/dL\n 127 K/uL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other : PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood cultures and peritoneal fluid cultures\n NGTD\n Chest CT\n Reviewed - Peribronchial edema, thickening, GGOs, trace\n bilateral effusions, ascites, pancreatic calcifiations\n Assessment and Plan\n CIRRHOSIS OF LIVER, ALCOHOLIC\n acutely decompensated\n - Increase lactulose as not stooling\n - Stopped steroids per hepatology\n - Will discuss prognosis given not a transplant candidate with son\n - On thiamine, folate, MVI for chronic EtOH\n HYPOTENSION - ?cirrhotic vs infectious\n - Weaned off pressors yesterday, follow\n - Goal MAP >55\n - Stop antibiotics\nHCT drop\n Appears to have been secondary to intraperitoneal bleed\n after paracentesis\n - Hct checks q8h\n - Transfusion goal >21 or if acute drop concerning for bleed\n - If need to transfuse, consider FFP if acute bleeding\n - IV vitamin K to try and improve coagulopathy\nEtOH Abuse\n - Monitor for withdrawal\nRenal Failure - Poor UOP yesterday with FENA <1, improving now, ATN\n vs hepatorenal vs contrast nephropathy\n - Getting albumin 50gm today\n - If worsens, consider midodrine and/or octreotide\nHypoxia, volume overload\n - On 4L NC\n - Consider gentle diuresis in the next 12-24 hrs pending UOP\n On RISS\n ICU Care\n Nutrition: PO diet\n Glycemic Control: RISS\n Lines: - Plan for PICC, d/c femoral line after\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Will discuss with son today\n status: Full code\n Disposition : MICU for now\n Total time spent: 30 minutes\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":397606,"text":"Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\n despite BMs w/ lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n -vitamin k 10 mg IV x 1\n -if hct < 21 give FFP for elevated PTT and INR\n # ETOH abuse: thiamine, folate, MVI daily\n - No evidence of withdrawal, will stop CIWA\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n Plan to begin diuresing very gently if Cr stable by .\n -IS for atelectasis\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\n depletion.\n -improved\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition: calorie count today\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Nursing","chartdate":"2114-12-28 00:00:00.000","description":"Nursing Progress Note","row_id":397668,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: Around 1500, pt c/o difficulty breathing. LS with crackles\n and wheezes and O2 sats decreasing into 80s. Pt given\n albuterol/atrovent nebs and chest xray taken which showed increased\n pulmonary edema. 20mg IV Lasix given for fluid overload with effect\n pending. Sats remaining high 80s/low 90s. BP stable post Lasix. Pt also\n started on PO cipro for UTI but refusing to take.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\n Action:\n Pt cont OFF levo.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397802,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett.\n Action:\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. Hypotensive\n Action:\n Pan cx\nd this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397803,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C\n Action:\n Vent changed to PCV\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. Received on four pressors with MAPS ~60. C.O. \n with SVV\n Action:\n On IV Vanco. Pan cx\nd this shift. Started on Flagyl, Zosyn, Micafungin\n this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397804,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30 +25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. Received on four pressors with MAPS ~60. C.O. \n with SVV\n Action:\n On IV Vanco. Pan cx\nd this shift. Started on Flagyl, Zosyn, Micafungin\n this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2114-12-29 00:00:00.000","description":"ICU Event Note","row_id":397830,"text":"TITLE:\n Clinician: Resident\n Patient had progressively worsening shock, on four pressors, with\n severe ARDS requiring high PEEPs and profound lactic acidosis.\n Progressively became more hypotensive, spoke with family (sons)\n multiple times during day. They arrived here at 5 p.m. and she expired\n at 5:30 p.m. in the presence of nursing staff, myself, and a social\n worker. They were aware of the severity of their mother\ns illness and\n we provided support afterward. They also requested an autopsy.\n Total time spent: 15 minutes\n"},{"category":"Respiratory ","chartdate":"2114-12-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":397831,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (1600)\n Comments:\n Pt expired plan for autopsy.\n"},{"category":"Physician ","chartdate":"2114-12-29 00:00:00.000","description":"Physician Attending Progress Note","row_id":397833,"text":"Chief Complaint: Acute respiratory failure\n HPI:\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\n w/respiratory failure and hypotension.\n 24 Hour Events:\n Remains intubated, mechanically ventilated.\n Oxygenation requirement remains high, requiring increased PEEP.\n Remains on multiple vaospressors to maintain adequate MAP.\n Worsening lactic acidosis.\n Rapid influenza negative\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives;\n Vasotec - hypertension;\n Last dose of Antibiotics:\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Levophed\n Propofol\n Cisatricurium\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Other medications:\n Lactulose, Rifaximin, Hydrocortisone\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,580 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,980 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,040 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, MMM\n Cardiovascular: RR, tachy, S1, S2, no RMG\n Extremities/Peripheral Vascular: Warm, palpable radial and DP pulses\n bilat\n Respiratory / Chest: Bronchial at bases bilat\n Abdominal: Soft, Distended, decreased BS\n Skin: NJaundice\n Neurologic: Sedated, paralysed, train of four\n \n Labs / Radiology\n 8.5 g/dL\n 147 K/uL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Cultures\n Blood, urine and sputum NGTD\n Assessment and Plan\n Gravely ill, with persistent respiratory failure, persistent severe\n hypotension, progressive academia and metabolic acidosis.\n RESPIRATORY FAILURE, ACUTE\n Meets ARDS criteria. Etiology of\n infiltrates unclear, differential ARDS/PNA, DAH, cardiogenic edema.\n - Switch back to AC, 4-6cc/kg of IBW TV, will aim to keep PIPs~45\n pending new esophageal balloon numbers\n - Inhalers standing to minimize resistance\n - Consider bronchoscopy to r/o DAH, although tenuous respiratory status\n at this time.\n HYPOTENSION/SHOCK\n Per vigileo, minimal SVV, cardiac output ~,\n unclear if this is sufficient as improved with dopa. Lactate is\n worsening, as is LDH, will re-evaluate for intra-abdominal process.\n Had been favoring a septic/distributive process, although cannot\n exclude a cardiac component. Sepsis sources include SBP, bowel\n ischemia, urinary source, line-related infection, C. diff.\n - On Neo, vasopressin, levophed, dopa\n - Follow-up cultures, on broad spectrum abx\n - Consider Swan-Ganz placement\n - TTE, cycle biomarkers\n - Increase thiamine dose\n - RUQ US w/dopplers\n - Cdiff\n ACIDOSIS\n progressive, lactic acidosis. Concern for evolving sepsis,\n although at risk for bowel ischemia. Doubt thiamine deficiency (as\n received iv thiamine dose). Monitor ABG, lactic acid. HCO3 drip as\n needed to maintain pH >7.20.\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Stable Tbili, INR up somewhat\n - On rifaxamin, lactulose\n - Appreciate hepatology input\n - Will need FFP prior to procedures\n RENAL FAILURE\n Decreased UOP since midnight, with elevated Cr. Poor\n dialysis candidate at this time.\n - Follow UOP with volume challenge\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin Sc\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Chlorhexidine, HOB to 30 degrees\n Comments:\n Communication: Attempting to contact family to update on her condition\n Code status: Full code\n Disposition : ICU\n Total time spent: 45 minutes\n"},{"category":"General","chartdate":"2114-12-29 00:00:00.000","description":"ICU Event Note","row_id":397827,"text":"Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent at start of shift, vent changed to PCV\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\n mg/kg/hr, titrated per train of four for twitches. Temp max 102.1\n po, pan cx\nd this shift. Lactate on the rise throughout shift, multiple\n doses of sodium bicarb given and started on D5W with 3 amps bicarb @\n 150 cc/hr. BP labile throughout the shift with ^ing pressor\n requirements. Albumin given as ordered. Please see metavision for\n multiple abg\ns/vent changes.\n"},{"category":"General","chartdate":"2114-12-29 00:00:00.000","description":"ICU Event Note","row_id":397828,"text":"Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent at start of shift, vent changed to PCV\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\n mg/kg/hr, titrated per train of four. Temp max 102.1 po, pan cx\nd this\n shift. Lactate on the rise throughout shift, multiple doses of sodium\n bicarb given and started on D5W with 3 amps bicarb @ 150 cc/hr. BP\n labile throughout the shift with ^ing pressor requirements. Albumin\n given as ordered. Please see metavision for multiple abg\ns/vent\n changes. Family in to visit in afternoon, emotional support proviced.\n S/W consulted. Pt became drop in HR,drop in BP with family at bedside.\n Dr. spoke with family and CPRNI.Pastor notified and in to pray\n with family at bedside. Fammily has requested an autopsy. Necklaace\n"},{"category":"General","chartdate":"2114-12-29 00:00:00.000","description":"ICU Event Note","row_id":397829,"text":"Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent at start of shift, vent changed to PCV\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\n mg/kg/hr, titrated per train of four. Temp max 102.1 po, pan cx\nd this\n shift. Lactate on the rise and more acidotic throughout shift, multiple\n doses of sodium bicarb given and started on D5W with 3 amps bicarb @\n 150 cc/hr. BP labile throughout the shift with Neo, Levo, &Vasopressin\n maxed, Dopa titrated to 10mcg/kg/min. Albumin given as ordered. Please\n see metavision for multiple abg\ns/vent changes. Sonsx2/girlfriendsx2 in\n to visit in afternoon, emotional support proviced. S/W consulted. Pt\n became hypotensive and bradycardic with family at bedside. Dr. \n spoke with family with plan for no further escalation of care.Pastor\n consulted->to bedside to pray with family. Family has requested an\n autopsy. Necklace with charm and watch sent home with son.\n"},{"category":"General","chartdate":"2114-12-29 00:00:00.000","description":"ICU Event Note","row_id":397836,"text":"Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent, started on parlytics this shift. Temp max\n 102.1, pan cx\nd this shift. Pt with worsening shock, severe ARDS\n requiring PEEP of 25 and profound lactic acidosis. Multiple doses of\n sodium bicarb given and started on D5W with 3 amps bicarb @ 150 cc/hr.\n Please see metavision for multiple abg\ns/vent changes. BP labile\n throughout the shift->Neo, Levo, & Vasopressin maxed, Dopa titrated to\n 10mcg/kg/min. Albumin given as ordered. Abx given as ordered.\n Sonsx2/girlfriendsx2 in to visit in afternoon, updated on status and\n plan of care, emotional support proviced. S/W consulted, at bedside. Pt\n became hypotensive and bradycardic with family at bedside. Dr. \n spoke with family, no further escalation of care, pronounced @ 1730.\n Pastor consulted->to bedside to pray with family. Family has requested\n an autopsy. Necklace with charm and watch sent home with family.\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397807,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Started on lacrilube paralytic.Multiple ABG\ns sent. Fentanyl and\n propofol gtts titrated. Desaturated to 84 after being placed on L side\n for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397808,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Started on lacrilube paralytic.Multiple ABG\ns sent. Fentanyl and\n propofol gtts titrated. Desaturated to 84 after being placed on L side\n for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. A-line dampened, tolerating MAPS >60 per\n NIBP (Dr. aware). C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397809,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Started on lacrilube paralytic.Multiple ABG\ns sent. Fentanyl and\n propofol gtts titrated. Desaturated to 84 after being placed on L side\n for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6 with am labs_. Now\n 12.2-13.7(on the rise). Received on four pressors with MAPS ~60. A-line\n dampened, tolerating MAPS >60 per NIBP (Dr. aware). C.O. \n with SVV\n Action:\n 50 gm Albumin given. NS 1L bolus given. Received total of 150 mEq Na\n bicarb IVP and started on D5W with 3 amps bicarb @ 150 cc/hr. On IV\n Vanco. Pan cx\nd this shift. Started on Flagyl, Zosyn, Micafungin this\n shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397805,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Multiple ABG\ns sent. Fentanyl and propofol gtts titrated. Desaturated\n to 84 after being placed on L side for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397806,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Multiple ABG\ns sent. Fentanyl and propofol gtts titrated. Desaturated\n to 84 after being placed on L side for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":397577,"text":"Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale\n # Anemia:\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia:\n -improved\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: NPO for now until MS clears\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2114-12-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":397776,"text":"TITLE:\n Chief Complaint: 49 yoF w/ a h/o hep C and ETOH related cirrhosis\n presents from hospital with acute hepatic failure.\n 24 Hour Events:\n BLOOD CULTURED - At 09:18 AM\n blood cultures drawn from femoral CVL\n SPUTUM CULTURE - At 10:00 AM\n BLOOD CULTURED - At 10:00 AM\n blood cultures drawn from PICC\n URINE CULTURE - At 10:20 AM\n ESOPHOGEAL BALLOON - At 02:30 PM\n -patient hypotensive requiring max dose levophed and vasopressin, as\n well as intermittent neosynephrine\n -hydrocortisone 50mg IV q6hrs started (serving dual purpose for alcohol\n hepatitis and as stress dose steroids)\n -given hypotension patient pan-cultured and started on broad spectrum\n antibiotics\n -respiratory viral screen negative\n -50g albumin given\n -CVO2 75%\n -Rifaximin started\n -lactulose uptitrated - pt had 1 BM, started dulcolax and senna\n -Esophageal balloon placed, PEEP uptitrated to 22\n -hct relatively stable\n -insulin drip initiated\n -Vigileo initiated, Stroke volume variation 13- 1L fluid challenege, no\n change in BP, over course of night SVV increased to 19. Gave 1L IVF\n and 25g of albumin in 500cc.\n -attempted calling son x 2 overnight given worsening clinical status\n -Additional 500cc bolus NS given and 50g IV albumin ordered\n -ABG 7.14 / 39 / 140 on AC 400 x 30- breathing at a rate of 35 and w/\n tidal volumes of 500. RR increased to 36, and pt breathing at 40 after\n this. PaO2 140, PEEP 25, FiO2 100%. 2 amps of bicarb given.\n -patient dysynchronous w/ the ventilator despite 70 of propofol and\n 150mcg of fentanyl. Unresponsive. Peak pressures increasing to low\n 40s (previously mid / low 30s) and unable to control PCO2 / normalize\n pH- decision made to paralyze.\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Cisatracurium - 07:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,588 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,988 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,051 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 147 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Shock: at this point seems to be related to possible infectious\n cause, end stage liver disease, propofol. Would also consider adverse\n reaction to FFP or IV vitamin K. On levo, vaso.\n - MAP goal > 55\n - empiric vanc/zosyn/cipro\n - stress dose steroids\n - follow UOP, pulse pressure variation to assess intravascular volume\n - check ECHO\n - check TSH/FT4\n - wean propofol\n - check lytes, hct, ABG, lactate q6h\n # Respiratory failure/ARDS: Worsening hypoxia on and intubated\n in setting of receiving volume and severe liver disease. Differential\n includes volume overload versus infection versus pulm hemorrhage vs\n TROLI in setting of transfusion though unlikely. Would also consider\n PCP given IVDU history.\n - ARDSnet protocol with low tidal volumes\n - PaO2 > 60, SaO2 > 90\n - empiric antibx\n - r/o flu\n - may consider bronch\n - hold on diuresis for now but will consider pending creatinine trend,\n UOP\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n - restarted steroids with undetectable HCV viral load\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG , + 1:20\n -HCV VL < 43\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose and rifaxamin\n -will obtain OSH previous EGD / if any\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n - follow UOP and trend creatinine\n - renally dose meds\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\n and hct stable.\n -guaiac stools\n -active type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n # ETOH abuse: No evidence of withdrawal\n - thiamine, folate, MVI daily\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2114-12-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":397780,"text":"TITLE:\n Chief Complaint: 49 yoF w/ a h/o hep C and ETOH related cirrhosis\n presents from hospital with acute hepatic failure.\n 24 Hour Events:\n BLOOD CULTURED - At 09:18 AM\n blood cultures drawn from femoral CVL\n SPUTUM CULTURE - At 10:00 AM\n BLOOD CULTURED - At 10:00 AM\n blood cultures drawn from PICC\n URINE CULTURE - At 10:20 AM\n ESOPHOGEAL BALLOON - At 02:30 PM\n -patient hypotensive requiring max dose levophed and vasopressin, as\n well as intermittent neosynephrine\n -hydrocortisone 50mg IV q6hrs started (serving dual purpose for alcohol\n hepatitis and as stress dose steroids)\n -given hypotension patient pan-cultured and started on broad spectrum\n antibiotics\n -respiratory viral screen negative\n -50g albumin given\n -CVO2 75%\n -Rifaximin started\n -lactulose uptitrated - pt had 1 BM, started dulcolax and senna\n -Esophageal balloon placed, PEEP uptitrated to 22\n -hct relatively stable\n -insulin drip initiated\n -Vigileo initiated, Stroke volume variation 13- 1L fluid challenege, no\n change in BP, over course of night SVV increased to 19. Gave 1L IVF\n and 25g of albumin in 500cc.\n -attempted calling son x 2 overnight given worsening clinical status\n -Additional 500cc bolus NS given and 50g IV albumin ordered\n -ABG 7.14 / 39 / 140 on AC 400 x 30- breathing at a rate of 35 and w/\n tidal volumes of 500. RR increased to 36, and pt breathing at 40 after\n this. PaO2 140, PEEP 25, FiO2 100%. 2 amps of bicarb given.\n -patient dysynchronous w/ the ventilator despite 70 of propofol and\n 150mcg of fentanyl. Unresponsive. Peak pressures increasing to low\n 40s (previously mid / low 30s) and unable to control PCO2 / normalize\n pH- decision made to paralyze.\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Cisatracurium - 07:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,588 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,988 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,051 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n GEN: intubated sedated., unresponsive\n HEENT: PERRL, minimally reactive\n CARD: RRR, HSM at the LLSB\n PULM: CTAB ant\n ABD: soft, obese, NT\n EXT: WWP, no c/c/e\n NEURO: sedated, unresponsive, paralyzed, pupils minimally reactive to\n light. Train of 4: .\n Labs / Radiology\n 147 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Shock: sepsis versus hepatic failure.\n - MAP goal > 55\n - empiric vanc/zosyn/cipro\n - stress dose steroids\n - follow UOP, pulse pressure variation to assess intravascular volume\n - possible swan ganz catheter plcmt today to further evaluate\n hemodynamics, especially given good BP and Cardiac index response to\n dopamine\n - check ECHO\n - wean fentanyl\n - q6hrs lactate\n -send c diff\n # Respiratory failure/ARDS: intubated related to ARDS.\n -ECHO\n -possible swan plcmt\n -ARDSnet ventilation\n -attempt to wean FiO2\n .\n # Acute hepatic failure:\n -f/u liver recs\n -steroids\n -AFP normal\n -lactulose and rifaximin\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n - follow UOP and trend creatinine\n - renally dose meds\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\n and hct stable.\n -guaiac stools\n -active type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n # ETOH abuse: No evidence of withdrawal\n - thiamine, folate, MVI daily\n # DM: Insulin sliding scale.\n # FEN: when GI output decreasing can start tube feeds.\n # PPX: PPI, INR elevated- hct stable so will restart sc heparin\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2114-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":397800,"text":"49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2114-12-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":397748,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 61.2\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Green / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C 400x30/+25/1.0\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\n efforts, High flow demand\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: appears dysynchronous\n Comments: Pt overbreathing vent with high flow demand, rate increased\n in an effort to match; desat necessitating increased Fi02/peep up to\n 25; unable to tol recruitment d/t dysynchrony\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: Unable to measure esophageal pressures d/t\n dysynchrony; RSBI held d/t peep/Fi02\n"},{"category":"Physician ","chartdate":"2114-12-26 00:00:00.000","description":"Physician Resident Admission Note","row_id":397448,"text":"Chief Complaint: transfer from for liver failure\n HPI:\n 49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \n hospital after presenting with worsening jaundice and fatigue. She was\n noted there to be hypotensive to the low 80s systolic, noted to have an\n elevated bili and INR- she was given 4 Liters IVF and transferred to\n the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\n was given 4 L IVF in hospital, 3 L in the ER at .\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\n sat: 94% on 5L O2 NC.\n Currently the patient complains of generalized abdominal pain, moreso\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\n her abdominal pain beginning.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.16 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Other medications:\n (patient unsure of medications, none on list from hospital)\n patient states she takes insulin.\n Past medical history:\n Family history:\n Social History:\n 1. Hepatitis C.\n 2. Alcoholic hepatitis.\n 3. History of alcohol abuse with withdraw seizures and DTs in the\n past.\n 4. History of hypertension.\n 5. History of chronic pancreatitis.\n 6. Status post cesarean section and ectopic pregnancies in the past.\n 7. History of traumatic wrist laceration in the past status post\n surgical repair with blood transfusions in .\n 8. S/P ccy, s/p oophorectomy\n 9. DM II\n non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: 6 tabs of tylenol 3 days ago, 1 pint of hard liquor on \n however the patient's history is relatively unreliable given\n encephalopathy. She lives w/ friends, smokes and is a current\n abuser of ETOH (daily)- unable to quantify. H/o opiate abuse but no\n opiates x 1 year.\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 94 (94 - 95) bpm\n BP: 115/74(84) {115/74(84) - 115/74(84)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,172 mL\n PO:\n TF:\n IVF:\n 172 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,082 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n Vitals - T: BP: HR: RR: 02 sat:\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: serum tylenol negative\n serum etoh negative\n serum opiates negative\n serum benzos +\n Imaging: RUQ ultrasound: (prelim) Very echogenic liver, limited\n assessment of gallbladder and portal vein. Ascites, predominantly in\n the RUQ, but not a good window to mark. Consider ultrasound guided\n paracentesis.\n CXR: (my read) hilar fullness w/ mild pulm vascular engorgement,\n infiltrates in the RML and RUL.\n CT abd / pelvis w/ contrast: . (prelim)\n liver w/ heterogeneous attenuation, shrunken nodular appearance.\n Several areas of hypodensities in segement 2 of the liver could\n represent perfusion defects, dilated bile ducts or could be related to\n underlying mass effect. Anasarca. No evidence of portal vein\n thrombosis. Bibasilar atelectasis.\n Microbiology: BCx x 2 P\n Peritoneal fluid cx P\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis given history and transaminase pattern.\n -paracentesis negative for sbp\n -liver consult\n -liver ultrasound with doppler was a difficult study,\n -discriminate function is 172. Will start steroids x 1 week then\n taper.\n -will give vitamin K to correct any portion of elevated INR that may be\n nutritional\n -thiamine, folate, MVI daily\n -lactulose- titrate to 3 BMs daily\n -send AFP given risk of HCC and finding on CT abd\n -Send Uhcg\n # Hypotension: no clear cause for hypotension with the exception of\n worsening liver function and possible infectious etiologies including\n pneumonia and possible urinary tract infection.\n -continue levofloxacin / ceftriaxone.\n -keep MAP > 55\n -has rec'd 7 liters IVF and likely fluid replete, appears euvolemic on\n exam\n # Hyponatremia: possibly related to volume overload / liver disease.\n -urine lytes\n # Hypoxia: appears to have R sided opacities which may be pneumonia.\n She has rec'd ceftriaxone. Will add levofloxacin in addition to CTX\n for severe CAP.\n -abx\n -f/u blood cultures\n -sputum culture\n -IS for atelectasis\n # ETOH abuse: h/o w/d seizures in the past.\n -CIWA scale w/ valium.\n # DM: Insulin sliding scale.\n # FEN: NPO for now until MS clears\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397449,"text":"49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \n hospital after presenting with worsening jaundice and fatigue. She was\n noted there to be hypotensive to the low 80s systolic, noted to have an\n elevated bili and INR- she was given 4 Liters IVF and transferred to\n the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\n was given 4 L IVF in hospital, 3 L in the ER at .\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\n sat: 94% on 5L O2 NC.\n Currently the patient complains of generalized abdominal pain, moreso\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\n her abdominal pain beginning.\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397445,"text":"Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397450,"text":"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Pt is a poor historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2114-12-26 00:00:00.000","description":"Nursing Progress Note","row_id":397517,"text":"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Continues on levo gtt to keep MAP > 55, low uo < 30 cc/hr, hr nsr\n 80\ns-90\n Action:\n Levo gtt weaned down to 0.03 mic/kg/min but not able to keep map> 55 on\n that dose so gtt titrated back up, 5% albumim 500 cc\n x 2 today, labs\n sent as ordered\n Response:\n Not able to wean levo off, minimal improvement in uo & bp after albumin\n Plan:\n Levo gtt as ordered to keep MAP > 55, ? a-line insertion this PM,\n frequent labs as ordered\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o # abdominal pain,\n oriented x , calm & cooperative, minimal uo, on levo gtt to maintain\n map > 55\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver consult\n placed, chest ct today, bladder pressure done, iv morphine given x 2 &\n po oxycodone x 1, npo except ice chips, iv albumin given\n Response:\n Bladder pressure 17, no stool, abdominal pain down to #1-2 after\n narcotics, not able to wean levo off, minimal response from iv albumin\n Plan:\n Continue to monitor for sepsis/pancreatitis/GI bleeding, po lactulose\n as ordered, wean levo as able, iv protonix/iv antibiotics as ordered,\n pain controll\n"},{"category":"Physician ","chartdate":"2114-12-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":397582,"text":"Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\n lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen.\n -transfuse for hct < 25, transfuse w/ Lasix when necessary\n -p.m. hct\n -if hct < 25 give FFP for elevated PTT and INR\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia:\n -improved\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"},{"category":"Radiology","chartdate":"2114-12-27 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1114503,"text":" 11:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Plesea read for right basilic PICC, 46cm. Thanks! #\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with need for PICC line for access.\n REASON FOR THIS EXAMINATION:\n Plesea read for right basilic PICC, 46cm. Thanks! #\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: Radiograph .\n\n INDICATION: PICC placement.\n\n FINDINGS: Right PICC is malpositioned, coursing cephalad in the right\n internal jugular vein with tip outside of the field of view. This finding was\n communicated by phone with the IV nurse, .\n\n Cardiac silhouette is mildly enlarged and there is persistent widening of the\n right mediastinal contour, corresponding to prominent mediastinal fat and\n vascular distention on the recent CT of one day earlier.\n\n Interstitial edema has worsened in the interval, and there are also increasing\n scattered patchy opacities in the right mid and lower lung. These are\n nonspecific but could potentially represent an early developing\n bronchopneumonia in the appropriate clinical setting. Opacities in the left\n base have improved and a small left effusion has decreased in size.\n\n\n"},{"category":"Radiology","chartdate":"2114-12-26 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1114296,"text":" 10:33 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for pna\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with liver failure, ?pna.\n REASON FOR THIS EXAMINATION:\n assess for pna\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST WITHOUT CONTRAST, \n\n INDICATION: Liver failure, and concern for pneumonia.\n\n COMPARISON: Abdominal CT, , 00:27 hours.\n\n TECHNIQUE: Volumetric CT of the chest was performed without contrast per\n departmental protocol, including multiplanar reformatted images.\n\n CT CHEST: Heart size is upper limits of normal. There are three-vessel\n coronary artery calcifications. There is no pericardial effusion. Thoracic\n aorta is normal in caliber and contour throughout. There are mild\n atherosclerotic calcifications in the arch and descending thoracic aorta.\n\n Central airways are patent to the subsegmental level. There are scattered\n mediastinal small lymph nodes, none meeting specific CT criteria for\n pathologic enlargement. Thyroid gland is normal.\n\n Evaluation of the lung parenchyma shows no focal airspace consolidation.\n However, there is mild diffuse thickening of the interlobular septa, and\n irregular areas of linear airspace opacity in the bilateral lower lobes.\n There are small bilateral pleural effusions, and mild dependent bibasilar\n atelectasis. Note is also made of mild biapical pleural/parenchymal scarring.\n\n This study is not specifically tailored for subdiaphragmatic evaluation.\n Within the visualized upper abdomen, note is made of moderate ascites around\n the liver and spleen. However, in contrast to recent abdominal CT of less\n than 12 hours prior, the ascitic fluid is now high in density, worrisome for\n development of intraperitoneal hemorrhage. Diffusely hypodense liver, most\n consistent with fatty liver or changes related to clinically reported liver\n failure, is unchanged. Geographic areas of slightly different hepatic density\n probably reflect differing degrees of steatosis.\n\n Calcifications within the pancreas consistent with chronic pancreatitis, and\n cholecystectomy clips are unchanged.\n\n OSSEOUS STRUCTURES: There is no osseous lesion suspicious for malignancy.\n\n IMPRESSION:\n\n (Over)\n\n 10:33 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for pna\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No evidence of lobar/bacterial pneumonia. Findings most consistent with\n volume overload, probably with superimposed areas of linear and dependent\n atelectasis. A concurrent atypical pneumonia is difficult to exclude.\n\n 2. Slight increase in ascites, which is now hyperdense, most consistent with\n hemorrhage. Findings are very concerning for new intraperitoneal hemorrhage,\n particularly if there has been a recent procedure such as paracentesis.\n\n 3. Unchanged markedly hypodense liver, consistent with fatty liver,\n presumably related to reported clinical history of liver failure.\n\n Findings discussed via telephone with Dr. at 11:30 on .\n\n\n\n"},{"category":"Radiology","chartdate":"2114-12-27 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1114551,"text":" 4:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: SOB\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with liver cirrhosis\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 49-year-old female patient with liver cirrhosis, shortness of\n breath. Followup examination.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position is analyzed in direct comparison with the next preceding\n similar study obtained four hours earlier during the same day. No significant\n interval change can be identified. No pneumothorax has developed. The\n scattered bilateral patchy densities are still present and there is no\n evidence of gross pleural effusion as the lateral pleural sinuses remain free.\n\n IMPRESSION: No significant interval change during last four hours examination\n interval.\n\n\n"},{"category":"Radiology","chartdate":"2114-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1114713,"text":" 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 49-year-old woman with respiratory failure and tube placement.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The tip of the endotracheal tube is 8 cm above the carina, could be advanced 1\n to 2 cm for optimal placement. The ETT tube has been pulled back since the\n previous study. The nasogastric tube and side port are well below the\n gastroesophageal junction. There has been mild improvement of the airspace\n opacities since the previous study. However, they remain diffuse. There is a\n right-sided PICC line with the distal lead tip at the distal SVC.\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2114-12-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1114598,"text":" 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alcohol/hep c cirrhosis s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post intubation, cirrhosis, evaluate for change.\n\n CHEST:The bilateral densities are now somewhat more confluent than on the\n prior film of six hours ago and is noticeably worse than the prior film of ten\n hours before.\n\n The position of the various lines and tubes is satisfactory. A nasogastric\n tube has been placed and the tip lies within the stomach.\n\n IMPRESSION: Worsening lung densities.\n\n"},{"category":"Radiology","chartdate":"2114-12-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1114578,"text":" 10:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: intubated\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with intubated\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Liver cirrhosis, SOB.\n\n CHEST: An endotracheal tube has been placed with the tip at the thoracic\n inlet. There has been a subtle increase in the bilateral densities since\n prior scan of four hours previous.\n\n IMPRESSION: Endotracheal tube placed. Slight increase in density.\n\n\n"},{"category":"Radiology","chartdate":"2114-12-27 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1114516,"text":" 12:20 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: pic repositioned. check tip now\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n pic repositioned. check tip now\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST, \n\n INDICATION: New PICC.\n\n FINDINGS: Comparison is made to 11:42 hours. Since\n previous exam, right PICC has been repositioned, now with tip pointing\n inferiorly, at roughly the position of the superior cavoatrial junction. Lung\n volumes are extremely low, limiting evaluation of cardiomediastinal contours,\n which are probably unchanged. Interstitial pulmonary edema appears slightly\n worse.\n\n\n"},{"category":"Radiology","chartdate":"2114-12-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1114242,"text":" 12:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with acute liver failure. Evaluate for acute\n process.\n\n COMPARISON: CT and chest radiograph of .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Evaluation is limited by low lung volumes.\n Within this limitation, there is right retrocardiac and peripheral mid-lung\n opacity that may represent atelectasis, but underlying infection is not\n excluded. There is no pneumothorax. The heart size is normal. Widened\n mediastinum is most likely a combination of tortuous aorta, low lung volumes\n and mild overload. Pulmonary vasculature is slightly engorged.\n\n"},{"category":"Radiology","chartdate":"2114-12-26 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1114244,"text":" 12:27 AM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: eval for acute process, clot in portal system. Please do CT\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with abd pain, acute liver failure\n REASON FOR THIS EXAMINATION:\n eval for acute process, clot in portal system. Please do CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EAGg WED 1:53 AM\n Portal vein patent. Cirrhotic liver with moderate ascites. Atelectatis at b/l\n lung bases, underlying infection not excluded. Wedge deformity of an upper\n lumbar vertebra (??L2), new since , but uncertain chronicity.\n WET READ VERSION #1 EAGg WED 1:48 AM\n Portal vein patent. Cirrhotic liver with moderate ascites.\n WET READ VERSION #2 EAGg WED 1:51 AM\n Portal vein patent. Cirrhotic liver with moderate ascites. Wedge deformity of\n an upper lumbar vertebra (??L2), new since , but uncertain chronicity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with abdominal pain and acute liver failure.\n Evaluate portal vein.\n\n COMPARISON: CT abdomen and CT chest .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen after\n administration of 130 cc IV Optiray contrast. Coronal and sagittal reformats\n were displayed.\n\n CT ABDOMEN WITH IV CONTRAST: There is extensive bibasilar atelectasis in the\n lungs with trace pleural effusion bilaterally. Underlying infection is not\n excluded. Coronary artery calcifications are noted, but the heart is\n otherwise unremarkable.\n\n The liver demonstrates low and heterogeneous attenuation with shrunken nodular\n contour. Several areas of hypodensity are noted within segment II of the\n liver and may represent perfusion abnormality, focal hepatitis, or dilated\n bile ducts, but underlying mass lesion is not excluded in context of\n cirrhosis. There is enlargement of the caudate lobe with exaggerated\n hypoattenuation consistent with severe fatty infiltration, particularly at the\n inferior of the caudate. There is a 4-mm newly apparent round hypodensity in\n segment VII of the liver (2:27), which is incompletely evaluated but may\n represent a cyst. There is no extrahepatic biliary ductal dilatation.\n\n The main portal vein and major branches are patent without filling defect.\n Gastric and splenic varices are noted.\n\n There is moderate diffuse ascites and anasarca.\n\n The patient is status post cholecystectomy. The pancreas demonstrates diffuse\n calcification, as before, consistent with chronic pancreatitis. Splenomegaly\n (Over)\n\n 12:27 AM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: eval for acute process, clot in portal system. Please do CT\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is less apparent than on concurrent ultrasound, measuring up to 12 cm. The\n bilateral adrenal glands are unremarkable. The kidneys enhance and excrete\n contrast symmetrically, without evidence of hydronephrosis or hydroureter.\n There are small nonspecific portacaval and periaortic lymph nodes not meeting\n CT criteria for pathologic enlargement. No mesenteric lymphadenopathy meeting\n CT criteria for pathologic enlargement is noted. The stomach and\n intra-abdominal loops of bowel are unremarkable. There is an\n ascites-containing ventral abdominal wall hernia. There is no free air in the\n abdomen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n There is a wedge deformity of the L2 vertebral body, likely chronic in nature\n but new since . There is atherosclerotic calcification of the abdominal\n aorta.\n\n IMPRESSION:\n\n 1. No evidence of portal vein thrombosis.\n\n 2. Cirrhotic liver with stigmata of liver disease. New segmental regions of\n hypodensity in segment II of the liver which may represent perfusion\n abnormality, focal hepatitis or dilated intrahepatic ducts, but underlying\n mass lesion is not excluded. Further assessment could be performed by MRI once\n the patient is able to cooperate with breathhold instructions.\n\n 3. Moderate ascites and anasarca.\n\n 4. Bibasilar atelectasis, underlying infection is not excluded.\n\n"},{"category":"Radiology","chartdate":"2114-12-25 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1114235,"text":" 10:25 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for acute process/thrombus. Also please mark for parac\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure\n REASON FOR THIS EXAMINATION:\n eval for acute process/thrombus. Also please mark for paracentesis.\n ______________________________________________________________________________\n WET READ: EAGg TUE 11:42 PM\n Very echogenic liver, limited assessment of gallbladder and portal vein.\n Ascites, predominantly in the RUQ, but not a good window to mark. Consider\n ultrasound guided paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with acute liver failure. Evaluate for acute\n process or thrombus. Mark for paracentesis.\n\n COMPARISON: Ultrasound of and CT, .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic and\n shrunken. No focal hepatic lesion is identified on this limited exam. The\n gallbladder is not identified. The main portal vein could not be assessed.\n Visualized portion of the pancreas is unremarkable. The spleen appears mildly\n enlarged measuring approximately 13 cm. There is a small-to-moderate amount of\n ascites, predominantly in the right upper quadrant but there is no suitable\n site to mark for paracentesis.\n\n IMPRESSION:\n\n 1. Limited ultrasound of the right upper quadrant with diffusely echogenic\n liver. Slightly shrunken morphology suggests more advanced forms of liver\n disease such as fibrosis or cirrhosis.\n\n 2. Gallbladder and main portal vein not visualized.\n\n 3. Small-to-moderate amount of ascites, predominantly in the right upper\n quadrant but there is no suitable window to mark.\n\n 4. Splenomegaly.\n\n Findings were discussed with Dr. at 11:40 p.m. on .\n\n"},{"category":"Radiology","chartdate":"2114-12-29 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1114758,"text":" 11:21 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate for portal vein thrombosis or budd chiari w/\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alk hep now w/ worsening pressor requirement and rising\n lactate\n REASON FOR THIS EXAMINATION:\n please evaluate for portal vein thrombosis or budd chiari w/ doppler\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SAT 2:55 PM\n Non-diagnostic study due to technical limitations. Hepatic steatosis is\n _____.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rising lactate, evaluate for portal vein thrombosis or Budd-Chiari\n syndrome.\n\n COMPARISON: .\n\n FINDINGS: This is a non-diagnostic study. Due to the patient's body habitus\n and intubated state, diagnostic Doppler studies could not be obtained. Fatty\n infiltration of the liver is again noted in visualized regions of the liver\n parenchyma.\n\n IMPRESSION: Non-diagnostic study due to technical limitations.\n\n\n"},{"category":"Radiology","chartdate":"2114-12-29 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1114759,"text":", D. MED MICU-7 11:21 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate for portal vein thrombosis or budd chiari w/\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alk hep now w/ worsening pressor requirement and rising\n lactate\n REASON FOR THIS EXAMINATION:\n please evaluate for portal vein thrombosis or budd chiari w/ doppler\n ______________________________________________________________________________\n PFI REPORT\n Non-diagnostic study due to technical limitations. Hepatic steatosis is\n _____.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397775,\n \"text\": \"Chief Complaint: Acute on chronic hepatic failure\\n HPI:\\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\\n w/respiratory failure and hypotension.\\n 24 Hour Events:\\n BLOOD CULTURED - At 09:18 AM\\n blood cultures drawn from femoral CVL\\n SPUTUM CULTURE - At 10:00 AM\\n BLOOD CULTURED - At 10:00 AM\\n blood cultures drawn from PICC\\n URINE CULTURE - At 10:20 AM\\n ESOPHOGEAL BALLOON - At 02:30 PM\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin - 10:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\\n Cefipime - 01:15 PM\\n Vancomycin - 10:53 PM\\n Infusions:\\n Vasopressin - 2.4 units/hour\\n Fentanyl (Concentrate) - 150 mcg/hour\\n Dopamine - 3 mcg/Kg/min\\n Phenylephrine - 4 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 122 (85 - 126) bpm\\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\\n RR: 48 (20 - 48) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 67 Inch\\n Bladder pressure: 15 (14 - 16) mmHg\\n Mixed Venous O2% Sat: 75 - 75\\n Total In:\\n 4,777 mL\\n 3,580 mL\\n PO:\\n TF:\\n IVF:\\n 4,117 mL\\n 2,980 mL\\n Blood products:\\n 200 mL\\n 500 mL\\n Total out:\\n 1,058 mL\\n 540 mL\\n Urine:\\n 818 mL\\n 20 mL\\n NG:\\n 240 mL\\n 120 mL\\n Stool:\\n 400 mL\\n Drains:\\n Balance:\\n 3,719 mL\\n 3,040 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: PCV+\\n Vt (Set): 420 (400 - 420) mL\\n Vt (Spontaneous): 350 (330 - 350) mL\\n PS : 10 cmH2O\\n RR (Set): 36\\n RR (Spontaneous): 7\\n PEEP: 25 cmH2O\\n FiO2: 85%\\n RSBI Deferred: PEEP > 10\\n PIP: 43 cmH2O\\n Plateau: 40 cmH2O\\n SpO2: 96%\\n ABG: 7.18/42/153/15/-12\\n Ve: 12.4 L/min\\n PaO2 / FiO2: 180\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Bronchial: )\\n Abdominal: Soft, Distended\\n Skin: Not assessed, Jaundice\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\\n Paralyzed, Tone: Not assessed\\n Labs / Radiology\\n 8.5 g/dL\\n 147 K/uL\\n 102 mg/dL\\n 0.9 mg/dL\\n 15 mEq/L\\n 4.7 mEq/L\\n 8 mg/dL\\n 100 mEq/L\\n 135 mEq/L\\n 26.1 %\\n 19.2 K/uL\\n [image002.jpg]\\n 11:15 AM\\n 01:26 PM\\n 03:18 PM\\n 05:33 PM\\n 05:41 PM\\n 01:50 AM\\n 03:57 AM\\n 04:07 AM\\n 05:30 AM\\n 06:35 AM\\n WBC\\n 19.2\\n Hct\\n 25.6\\n 26.1\\n Plt\\n 147\\n Cr\\n 0.9\\n TCO2\\n 21\\n 21\\n 21\\n 23\\n 19\\n 17\\n 14\\n 16\\n Glucose\\n 102\\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n HYPOTENSION (NOT SHOCK)\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397781,\n \"text\": \"Chief Complaint: Acute on chronic hepatic failure\\n HPI:\\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\\n w/respiratory failure and hypotension.\\n 24 Hour Events:\\n Pan cultured, started vanco/cefepime\\n ESOPHOGEAL BALLOON\\n PEEP uptitrated\\nIncreasing pressor requirement\\nStarted on stress dose hydrocortisone\\nIncreasing hypoxia requiring paralysis\\nVigileo monitor started\\nIncreasing lactic acidosis, got 2 amps of bicarb\\nRapid influenza negative\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin - Hives;\\n Vasotec - hypertension;\\n Last dose of Antibiotics:\\n Cefipime - 01:15 PM\\n Vancomycin - 10:53 PM\\n Infusions:\\n Vasopressin - 2.4 units/hour\\n Fentanyl (Concentrate) - 150 mcg/hour\\n Dopamine - 3 mcg/Kg/min\\n Phenylephrine - 4 mcg/Kg/min\\n Levophed\\n Propofol\\n Cisatricurium\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\\n Other medications:\\n Lactulose, Rifaximin, Hydrocortisone\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 122 (85 - 126) bpm\\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\\n RR: 48 (20 - 48) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 67 Inch\\n Bladder pressure: 15 (14 - 16) mmHg\\n Mixed Venous O2% Sat: 75 - 75\\n Total In:\\n 4,777 mL\\n 3,580 mL\\n PO:\\n TF:\\n IVF:\\n 4,117 mL\\n 2,980 mL\\n Blood products:\\n 200 mL\\n 500 mL\\n Total out:\\n 1,058 mL\\n 540 mL\\n Urine:\\n 818 mL\\n 20 mL\\n NG:\\n 240 mL\\n 120 mL\\n Stool:\\n 400 mL\\n Drains:\\n Balance:\\n 3,719 mL\\n 3,040 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: PCV+\\n Vt (Set): 420 (400 - 420) mL\\n Vt (Spontaneous): 350 (330 - 350) mL\\n PS : 10 cmH2O\\n RR (Set): 36\\n RR (Spontaneous): 7\\n PEEP: 25 cmH2O\\n FiO2: 85%\\n RSBI Deferred: PEEP > 10\\n PIP: 43 cmH2O\\n Plateau: 40 cmH2O\\n SpO2: 96%\\n ABG: 7.18/42/153/15/-12\\n Ve: 12.4 L/min\\n PaO2 / FiO2: 180\\n Physical Examination\\n General Appearance: Overweight / Obese, intubated, sedated\\n Eyes / Conjunctiva: PERRL, icteric sclera\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, MMM\\n Cardiovascular: RR, tachy, S1, S2, no RMG\\n Extremities/Peripheral Vascular: Warm, palpable radial and DP pulses\\n bilat\\n Respiratory / Chest: Bronchial at bases bilat\\n Abdominal: Soft, Distended, decreased BS\\n Skin: NJaundice\\n Neurologic: Sedated, paralysed, train of four\\n \\n Labs / Radiology\\n 8.5 g/dL\\n 147 K/uL\\n 102 mg/dL\\n 0.9 mg/dL\\n 15 mEq/L\\n 4.7 mEq/L\\n 8 mg/dL\\n 100 mEq/L\\n 135 mEq/L\\n 26.1 %\\n 19.2 K/uL\\n [image002.jpg]\\n 11:15 AM\\n 01:26 PM\\n 03:18 PM\\n 05:33 PM\\n 05:41 PM\\n 01:50 AM\\n 03:57 AM\\n 04:07 AM\\n 05:30 AM\\n 06:35 AM\\n WBC\\n 19.2\\n Hct\\n 25.6\\n 26.1\\n Plt\\n 147\\n Cr\\n 0.9\\n TCO2\\n 21\\n 21\\n 21\\n 23\\n 19\\n 17\\n 14\\n 16\\n Glucose\\n 102\\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\\n Cultures\\n Blood, urine and sputum NGTD\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE\\n Meets ARDS criteria. Etiology of\\n infiltrates unclear, differential ARDS/PNA, DAH, cardiogenic edema.\\n - Switch back to AC, 4-6cc/kg of IBW TV, will aim to keep PIPs~45\\n pending new esophageal balloon numbers\\n - Inhalers standing to minimize resistance\\n - Consider bronchoscopy to r/o DAH, although tenuous respiratory status\\n HYPOTENSION/SHOCK\\n Per vigileo, minimal SVV, cardiac output ~,\\n unclear if this is sufficient as improved with dopa. Lactate is\\n worsening, as is LDH, will re-evaluate for intra-abdominal process.\\n Had been favoring a septic/distributive process, although cannot\\n exclude a cardiac component.\\n - On Neo, vaso, levophed, dopa\\n - Follow-up cultures, on broad spectrum abx\\n - Consider Swann placement\\n - TTE, cycle biomarkers\\n - Increase thiamine dose\\n - RUQ US w/dopplers\\n - Cdiff\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n Stable Tbili, INR up somewhat\\n - On rifaxamin, lactulose\\n - Appreciate hepatology input\\n - Will need FFP prior to procedures\\nRenal Failure\\n Decreased UOP since midnight, with elevated Cr\\n - Follow UOP with volume challenge\\n ICU Care\\n Nutrition: NPO\\n Glycemic Control: Insulin Sc\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: P-boots\\n Stress ulcer: PPI\\n VAP: Chlorhexidine, HOB to 30 degrees\\n Comments:\\n Communication: Attempting to contact family to update on her condition\\n Code status: Full code\\n Disposition : MICu for now\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397484,\n \"text\": \"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\\n seizures, chronic pancreatitis transferred from Hospital\\n with hepatic failure and hypotension.\\n HPI:\\n 24 Hour Events:\\n -received 7L crystalloid total and initiated on levophed for blood\\n pressure support\\n -seen by liver consult in ED\\n -received po vitamin K\\n -discriminate function was 71 so started on prednisone 40mg daily for\\n alcoholic hepatitis\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone\\n levaquin\\n Infusions:\\n Norepinephrine - 0.06 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:00 AM\\n Other medications:\\n Protonix\\n Folic acid and thiamine\\n Lactulose 30mg QID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 97 (92 - 97) bpm\\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\\n RR: 19 (12 - 23) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 6,973 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 773 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 130 mL\\n Urine:\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 6,843 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///19/\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular:RRR,PMI Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: crackles at both bases posteriorly\\n Abdominal: Soft, Non-tender\\n Extremities: no peripheral edema. Slightly cool to touch.\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands. Alert and oriented x3.\\n Labs / Radiology\\n 11.1 g/dL\\n 238 K/uL\\n 176 mg/dL\\n 0.9 mg/dL\\n 19 mEq/L\\n 4.2 mEq/L\\n 5 mg/dL\\n 99 mEq/L\\n 129 mEq/L\\n 35.2 %\\n 17.7 K/uL\\n [image002.jpg]\\n From WBC 9.2\\n From Cr 0.6 TB 16.3 to 19.8 AST/ALT 195/45 to 103/39\\n FeNa 0.4%\\n 06:01 AM\\n WBC\\n 17.7\\n Hct\\n 35.2\\n Plt\\n 238\\n Cr\\n 0.9\\n Glucose\\n 176\\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\\n PO4:3.6 mg/dL lactate 2.2 at midnight serum etoh: negative serum\\n acetaminophen negative\\n RUQ US: cirrhotic liver, difficult to assess portal vein, ascites noted\\n CT abdomen with contrast: no portal vein thrombosis with hypodensities\\n in the liver consistent with perfusion defect or mass effect\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK)\\n -only potential source at this point is pneumonia\\n -titrating down on levophed\\n -if off levophed by noon will hold on placing a-line\\n -concern for septic shock but no clear source, no evidence of SBP\\n -does not appear fluid responsive at this point. If we need to do\\n further volume challenge would use 5% albumin\\n -will check bladder pressure\\n ACUTE LIVER FAILURE\\n -will ask liver consult team to make some recommendations\\n -followup AFP, lesions on liver can be concerning for hepatocellular\\n carcinoma\\n -continue prednisone for presumed alcoholic hepatitis\\n -trend lactate\\n -for elevated INR will continue oral vitamin K 10mg for total of 3 days\\n -continue lactulose for encephalopathy\\nacute renal failure with low FeNa\\n -will ask renal consult to see given potential for hepatorenal syndrome\\n vs contrast induced nephropathy\\n -will likely need 5% albumin challenge to determine\\nhypoxemia now resolved\\n -will check CT chest without contrast to evaluate for ovine bronchus\\n and possible obstruction\\n ICU Care\\n Nutrition: npo for now\\n Glycemic Control: RISS\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM femoral. If not off pressors within\\n 24 hours will need to place IJ or subclavian TLC\\n Prophylaxis:\\n DVT: heparin SQ to be initiated\\n Stress ulcer: IV pantoprazole\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Will need to clarify with her family.\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 72279,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Shock. Refractory hypotension. Shortness of breath.\\nWeight (lb): 233\\nBP (mm Hg): 97/61\\nHR (bpm): 115\\nStatus: Inpatient\\nDate/Time: at 10:20\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the report of the prior study (images not\\navailable) of .\\n\\n\\nLEFT VENTRICLE: Small LV cavity. Suboptimal technical quality, a focal LV wall\\nmotion abnormality cannot be fully excluded. Hyperdynamic LVEF >75%. Moderate\\nresting LVOT gradient.\\n\\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\\nCannot assess regional RV systolic function.\\n\\nAORTIC VALVE: Aortic valve not well seen. No valvular AS. The increased\\ntransaortic velocity is related to high cardiac output. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\\n\\nConclusions:\\nThe left ventricular cavity is unusually small. Due to suboptimal technical\\nquality, a focal wall motion abnormality cannot be fully excluded. Left\\nventricular systolic function is hyperdynamic (EF>75%). There is a moderate\\nresting left ventricular outflow tract obstruction. The right ventricular\\ncavity is probably dilated with borderline normal free wall function. The\\naortic valve is not well seen. There is no valvular aortic stenosis. The\\nincreased transaortic velocity is likely related to high cardiac output. No\\naortic regurgitation is seen. The mitral valve leaflets are structurally\\nnormal. Trivial mitral regurgitation is seen. There is mild pulmonary artery\\nsystolic hypertension. There is a trivial/physiologic pericardial effusion.\\n\\nCompared with the report of the prior study (images unavailable for review) of\\n, left ventricular cavity size may be smaller and left ventricular\\nfunction is now hyperdynamic with tachycardia. The right ventricle may not be\\ndilated. No definite valvular lesions are identified in the current study but\\nviews are suboptimal.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 170804,\n \"text\": \"Sinus rhythm. Low precordial lead QRS voltage. Prolonged QTc interval.\\nST-T wave abnormalities. Findings are non-specific but cannot exclude possible\\ndrug/electrolyte/metabolic effect. Since the previous tracing of \\nfurther ST-T wave changes are present.\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397754,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\\n 7.29/45/74. Rec\\nd on fentanyl and propofol gtts. On triadyne bed.\\n Action:\\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\\n for small amts dark yellow/green thin secretions.\\n Response:\\n Pt not over breathing vent, although sats remained 85%- so FiO2\\n increased to 100%, pt now sating 91%. Rotation currently turned off on\\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\\n 5-15cc/hr.\\n Action:\\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\\n vasopressin. Rec\\nd a total of 2L NS and 25% albumin for low\\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\\n Response:\\n Cont. on triple pressors to maintain MAPs > 55. Currently not\\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\\n SVV ranging .\\n Plan:\\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\\n possible sepsis related hypotension. F/U culture results.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today. CT chest : volume\\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\\n pressure ranging 15-16 this shift. Rec\\nd on insulin gtt at 11 units/hr\\n for + gap and increasing FSBS.\\n Action:\\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\\n low BS and thought gap r/t liver fail. And increasing lactate. On\\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\\n Bladder pressure checked Q6. Liver team following.\\n Response:\\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\\n 15-16. Cont. to monitor FSBS.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397755,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\\n 7.29/45/74. Rec\\nd on fentanyl and propofol gtts. On triadyne bed.\\n Action:\\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\\n for small amts dark yellow/green thin secretions.\\n Response:\\n Pt not over breathing vent, although sats remained 85%- so FiO2\\n increased to 100%, pt now sating 91%. Rotation currently turned off on\\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\\n 5-15cc/hr.\\n Action:\\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\\n vasopressin. Rec\\nd a total of 2L NS and 25% albumin for low\\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\\n Response:\\n Cont. on triple pressors to maintain MAPs > 55. Currently not\\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\\n SVV ranging .\\n Plan:\\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\\n possible sepsis related hypotension. F/U culture results.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today. CT chest : volume\\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\\n pressure ranging 15-16 this shift. Rec\\nd on insulin gtt at 11 units/hr\\n for + gap and increasing FSBS.\\n Action:\\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\\n low BS and thought gap r/t liver fail. And increasing lactate. On\\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\\n Bladder pressure checked Q6. Liver team following.\\n Response:\\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\\n 15-16. Cont. to monitor FSBS.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n ------ Protected Section ------\\n ~ 0500 pt becoming more hypoxic on 100% 22 PEEP, with sats 87%, ABG\\n 7.23/38/67. Pt placed on 25 PEEP, with sats increasing to 95%. BP\\n dropped to 70s systolic, and pt was maxed out on vaso, levo, and neo.\\n Dopamine gtt was initiated (see Metavision for specifics). Repeat ABG\\n 7.14/39/140. 2 amps bicarb given. 500cc NS bolus given, albumin\\n ordered- awaiting from pharmacy.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 06:13 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397554,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension\\n Hypotension (not Shock)\\n Assessment:\\n Rec\\nd on levo gtt to keep MAP > 55, UO 30 -60cc/hr, hr nsr 80\\ns-90\\n Hct 27 at change of shift.\\n Action:\\n Titrating Levophed gtt to maintain MAPs > 55, stable on 0.06 mcg/kg/min\\n Levophed gtt. Repeat Hct sent.\\n Response:\\n UO improving, Hct stable 28, levophed gtt turned off at 0330.\\n Plan:\\n Cont. to monitor BP, MAP goal > 55. Currently off levophed gtt.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o abdominal pain,\\n oriented x 2, mood labile- calm & cooperative to weepy and agitated.\\n Bladder pressure 17 on .\\n Action:\\n Frequent labs sent as ordered, po lactulose as ordered, liver team\\n following, ivp morphine given frequently for a total of 10mg ivp this\\n shift, Reoriented frequently. CIWA q4h, tolerating ice chips and\\n popcicles.\\n Response:\\n no stool, abdominal pain down to 4-5 after narcotics, pt cont. to be\\n confused as to time/place, oriented x2. CIWA < 10, no diazepam given\\n this shift.\\n Plan:\\n Cont to monitor MS- cont po lactulose as ordered, reorient as needed,\\n iv protonix/iv antibiotics as ordered, pain control. Bladder\\n pressures daily. Liver team following.\\n ? c/o this pm if stable off levophed gtt.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397649,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n **Events: Around 1500, pt c/o difficulty breathing. LS with crackles\\n and wheezes and O2 sats decreasing into 80s. Pt given\\n albuterol/atrovent nebs and chest xray taken which showed increased\\n pulmonary edema. 20mg IV Lasix given for fluid overload with effect\\n pending. Sats remaining high 80s/low 90s. BP stable post Lasix. Pt also\\n started on PO cipro for UTI but refusing to take.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt OFF levo gtt. BPs 90s. UOP 40s-50s per hour.\\n Action:\\n Pt cont OFF levo. Given 50g of 5% albumin today to improve\\n intravascular volume and for albumin 2.6 this AM.\\n Response:\\n BPs remaining >90 with MAPs ranging 60s-70s, systolic pressures\\n 90s-120s.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites and c/o \\n abdominal pain. Pt alert and oriented x 3 at times but noted to be\\n hallucinating at times as well.\\n Action:\\n Lactulose increased to 60ml PO QID and lactulose enema ordered and\\n given. Albumin given for albumin 2.6 this am. Bladder pressure checked-\\n 23 today.\\n Response:\\n Pt cont without stool despite increase in lactulose. Lactulose enema\\n with minimal retention. Refused to take lactulose this pm. Pt refusing\\n all meds this pm, likely becoming more encephalopathic.\\n Plan:\\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\\n therapeutic para for increased bladder pressure today. Also will likely\\n need NGT if cont to refuse PO meds.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397472,\n \"text\": \"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \\n Hospital after worsening abd pain, jaundice and fatigue. She was noted\\n there to be hypotensive w/ SBP to the 80\\ns, w/ an elevated bili and\\n INR. She was given 4L IVF and transferred to the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\\n (for concern of SBP) A right femoral line was placed. Pt placed on\\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\\n study.\\n Currently the patient complains of generalized abdominal pain, more so\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\\n historian overall.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\\n Ceftriaxone 1gm) Constant moaning and c/o abd/back pain (although\\n extremely inconsistent at times)\\n Action:\\n Lactulose given. Vitamin K 5mg PO x 1. Morphine 2mg IVP x 2. Frequent\\n repositioning and reorientation. Pt extremely forgetful and repetitive.\\n Response:\\n Unchanged\\n Plan:\\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\\n withdrawal. Thiamine/Folate/MVI\\n Hypotension (not Shock)\\n Assessment:\\n Rec\\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\\n Action:\\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\\n given. Urine lytes sent.\\n Response:\\n Awaiting AM lab results (sent @ 0600 post KCL repletion)\\n Plan:\\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\\n cultures. Sputum culture needed if able.\\n Full Code\\n R femoral TLC\\n Social: Would most likely benefit from SW cx. No contact\\n with family O/N by this RN.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397463,\n \"text\": \"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \\n Hospital after worsening abd pain, jaundice and fatigue. She was noted\\n there to be hypotensive w/ SBP to the 80\\ns, w/ an elevated bili and\\n INR. She was given 4L IVF and transferred to the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\\n (for concern of SBP) A right femoral line was placed. Pt placed on\\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\\n study.\\n Currently the patient complains of generalized abdominal pain, more so\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\\n historian overall.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\\n Ceftriaxone 1gm)\\n Action:\\n Lactulose given. Vitamin K 5mg PO x 1.\\n Response:\\n Plan:\\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\\n withdrawal. Thiamine/Folate/MVI\\n Hypotension (not Shock)\\n Assessment:\\n Rec\\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\\n Action:\\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\\n given. Urine lytes sent.\\n Response:\\n Plan:\\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\\n cultures. Sputum culture needed when able.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397475,\n \"text\": \"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \\n Hospital after worsening abd pain, jaundice and fatigue. She was noted\\n there to be hypotensive w/ SBP to the 80\\ns, w/ an elevated bili and\\n INR. She was given 4L IVF and transferred to the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\\n (for concern of SBP) A right femoral line was placed. Pt placed on\\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\\n study.\\n Currently the patient complains of generalized abdominal pain, more so\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\\n historian overall.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\\n Ceftriaxone 1gm) Constant moaning and c/o abd/back pain (although\\n extremely inconsistent at times)\\n Action:\\n Lactulose given. Vitamin K 5mg PO x 1. Morphine 2mg IVP x 2. Frequent\\n repositioning and reorientation. Pt extremely forgetful and repetitive.\\n Response:\\n Unchanged\\n Plan:\\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\\n withdrawal. Thiamine/Folate/MVI\\n Hypotension (not Shock)\\n Assessment:\\n Rec\\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\\n Action:\\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\\n given. Urine lytes sent.\\n Response:\\n Awaiting AM lab results (sent @ 0600 post KCL repletion)\\n Plan:\\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\\n cultures. Sputum culture needed if able.\\n Full Code\\n R femoral TLC\\n Social: Would most likely benefit from SW cx. No contact\\n with family O/N by this RN.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397739,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\\n 7.29/45/74. Rec\\nd on fentanyl and propofol gtts. On triadyne bed.\\n Action:\\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\\n for small amts dark yellow/green thin secretions.\\n Response:\\n Pt not over breathing vent, although sats remained 85%- so FiO2\\n increased to 100%, pt now sating 91%. Rotation currently turned off on\\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\\n 5-15cc/hr.\\n Action:\\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\\n vasopressin. Rec\\nd a total of 2L NS and 25% albumin for low\\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\\n Response:\\n Cont. on triple pressors to maintain MAPs > 55. Currently not\\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\\n SVV ranging .\\n Plan:\\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\\n possible sepsis related hypotension. F/U culture results.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today. CT chest : volume\\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\\n pressure ranging 15-16 this shift. Rec\\nd on insulin gtt at 11 units/hr\\n for + gap and increasing FSBS.\\n Action:\\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\\n low BS and thought gap r/t liver fail. And increasing lactate. On\\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\\n Bladder pressure checked Q6. Liver team following.\\n Response:\\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\\n 15-16. Cont. to monitor FSBS.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397704,\n \"text\": \"Chief Complaint: Liver failure\\n HPI:\\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\\n failure.\\n 24 Hour Events:\\n PICC LINE placed\\nAntibiotics stopped\\n Intubated\\n Hypotensive post intubation, increasing pressor requirement,\\n increasing O2 requirements\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin - Hives\\n Vasotec - hypertension\\n Last dose of Antibiotics:\\n Ciprofloxacin\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Norepinephrine - 0.32 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:55 AM\\n Lorazepam (Ativan) - 07:00 PM\\n Morphine Sulfate - 08:15 PM\\n Furosemide (Lasix) - 10:00 PM\\n Other medications:\\n Potassium, MVI, folate, thiamine,\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 92 (92 - 111) bpm\\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\\n RR: 29 (22 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 23 (23 - 23) mmHg\\n Total In:\\n 1,666 mL\\n 365 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 426 mL\\n 365 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 2,784 mL\\n 575 mL\\n Urine:\\n 2,784 mL\\n 575 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,118 mL\\n -210 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 100%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 29 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 95%\\n ABG: 7.41/35/98./20/-1\\n Ve: 15.1 L/min\\n PaO2 / FiO2: 98\\n Physical Examination\\n General Appearance: Overweight / Obese, intubated, sedated\\n Eyes / Conjunctiva: PERRL, icteric sclera\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: RRR, S1, S2\\n Extremities/Peripheral Vascular: Cool, anasarcic\\n Respiratory / Chest: Coarse, bronchial anteriorally\\n Abdominal: Soft, Bowel sounds present, slightly distended\\n Skin: Icteric, no rashes\\n Neurologic: Sedated\\n Labs / Radiology\\n 8.7 g/dL\\n 94 K/uL\\n 156 mg/dL\\n 1.0 mg/dL\\n 20 mEq/L\\n 2.6 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 139 mEq/L\\n 26.0 %\\n 11.0 K/uL\\n [image002.jpg]\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n 12:54 PM\\n 07:33 PM\\n 08:25 PM\\n 12:54 AM\\n 03:57 AM\\n 06:31 AM\\n 07:26 AM\\n WBC\\n 10.6\\n 11.0\\n Hct\\n 26.5\\n 28.0\\n 26.3\\n 24.2\\n 25.6\\n 26.0\\n Plt\\n 127\\n 94\\n Cr\\n 1.0\\n 1.0\\n TCO2\\n 22\\n 24\\n 23\\n 23\\n Glucose\\n 182\\n 156\\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\\n Cultures\\n Blood and peritoneal fluid NGTD\\n CXR\\nprogression of diffuse b/l fluffy ASD, no apparent effusions\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE\\n ARDS (Unclear inciting factor\\ninfection,\\n no witnessed aspiration, no obvious acute pancreatitis) vs volume\\n overload.. Plateaus elevated, bilateral infiltrates.\\n - Hold diuresis for now while hypotensive\\n - Keep PaO2 >60, try to increase PEEP if needed, consider esoph balloon\\n placement to optimize given obese abd, wean fio2 as able\\n Empiric broad antbx coverage, ruled out for flu. Pan cxs repeated,\\n TTE to assess cardiac fx\\n HYPOTENSION\\n Worse post-intubation. Likely due to sedation and\\n PEEP, but cannot exclude worsening infection/sepsis, although no fever\\n or elevated WBC. Did have hemo-peritoneum, although Hct stable. Also\\n had steroids stopped recently.\\n - Broaden antibiotics, add vanco and cefepime\\n - TTE, CvO2\\n - Pan culture\\n - Start stress dose hydrocortisone\\n --trend lacate\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n Tbili and INR stable\\n - Add rifaxamin\\n - Continue lactulose\\n - stress dose hydrocortisone as above\\nAnemia\\n Stable yesterday, but given hypotension will trend q6h, space\\n out if stable x2\\n Renal Failure\\n improved UOP, s/p two days of albumin, follow and\\n hold on diuresis in light of pressor support\\n ICU Care\\n Nutrition: Start TFs\\n Glycemic Control: RISS\\n transition to IV insulin protocol given plan\\n to start steroids\\n Lines:\\n Cleanly placed femoral TLC - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: P-boots\\n Stress ulcer: PPI\\n VAP: Hob elevated, chlorhexidine\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : MICU\\n Critically ill,\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397479,\n \"text\": \"Chief Complaint: 49 yo woman with history of hepatitis C, active\\n alcohol abuse, chronic pancreatitis transferred from Hospital\\n with hepatic failure and hypotension.\\n HPI:\\n 24 Hour Events:\\n MULTI LUMEN - START 02:32 AM\\n NASAL SWAB - At 03:00 AM\\n MRSA swab\\n URINE CULTURE - At 04:04 AM\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.06 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 97 (92 - 97) bpm\\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\\n RR: 19 (12 - 23) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 6,973 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 773 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 130 mL\\n Urine:\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 6,843 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///19/\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular: (PMI Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 11.1 g/dL\\n 238 K/uL\\n 176 mg/dL\\n 0.9 mg/dL\\n 19 mEq/L\\n 4.2 mEq/L\\n 5 mg/dL\\n 99 mEq/L\\n 129 mEq/L\\n 35.2 %\\n 17.7 K/uL\\n [image002.jpg]\\n 06:01 AM\\n WBC\\n 17.7\\n Hct\\n 35.2\\n Plt\\n 238\\n Cr\\n 0.9\\n Glucose\\n 176\\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\\n PO4:3.6 mg/dL\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK)\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397494,\n \"text\": \"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\\n seizures, chronic pancreatitis transferred from Hospital\\n with hepatic failure and hypotension.\\n HPI:\\n 24 Hour Events:\\n -received 7L crystalloid total and initiated on levophed for blood\\n pressure support\\n -seen by liver consult in ED\\n -received po vitamin K\\n -discriminate function was 71 so started on prednisone 40mg daily for\\n alcoholic hepatitis\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone\\n levaquin\\n Infusions:\\n Norepinephrine - 0.06 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 06:00 AM\\n Other medications:\\n Protonix\\n Folic acid and thiamine\\n Lactulose 30mg QID\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:41 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 97 (92 - 97) bpm\\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\\n RR: 19 (12 - 23) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 6,973 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 773 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 130 mL\\n Urine:\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 6,843 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///19/\\n Physical Examination\\n General Appearance: Well nourished\\n Eyes / Conjunctiva: PERRL\\n Cardiovascular:RRR,PMI Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: crackles at both bases posteriorly\\n Abdominal: Soft, Non-tender\\n Extremities: no peripheral edema. Slightly cool to touch.\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands. Alert and oriented x3.\\n Labs / Radiology\\n 11.1 g/dL\\n 238 K/uL\\n 176 mg/dL\\n 0.9 mg/dL\\n 19 mEq/L\\n 4.2 mEq/L\\n 5 mg/dL\\n 99 mEq/L\\n 129 mEq/L\\n 35.2 %\\n 17.7 K/uL\\n [image002.jpg]\\n From WBC 9.2\\n From Cr 0.6 TB 16.3 to 19.8 AST/ALT 195/45 to 103/39\\n FeNa 0.4%\\n 06:01 AM\\n WBC\\n 17.7\\n Hct\\n 35.2\\n Plt\\n 238\\n Cr\\n 0.9\\n Glucose\\n 176\\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\\n PO4:3.6 mg/dL lactate 2.2 at midnight serum etoh: negative serum\\n acetaminophen negative\\n RUQ US: cirrhotic liver, difficult to assess portal vein, ascites noted\\n CT abdomen with contrast: no portal vein thrombosis with hypodensities\\n in the liver consistent with perfusion defect or mass effect\\n Assessment and Plan\\n HYPOTENSION (NOT SHOCK)\\n -only potential source at this point is pneumonia\\n -titrating down on levophed\\n -if off levophed by noon will hold on placing a-line\\n -concern for septic shock but no clear source, no evidence of SBP\\n -does not appear fluid responsive at this point. If we need to do\\n further volume challenge would use 5% albumin\\n -will check bladder pressure\\n ACUTE LIVER FAILURE\\n -will ask liver consult team to make some recommendations\\n -followup AFP, lesions on liver can be concerning for hepatocellular\\n carcinoma\\n -continue prednisone for presumed alcoholic hepatitis\\n -trend lactate\\n -for elevated INR will continue oral vitamin K 10mg for total of 3 days\\n -continue lactulose for encephalopathy\\nacute renal failure with low FeNa\\n -will ask renal consult to see given potential for hepatorenal syndrome\\n vs contrast induced nephropathy\\n -will likely need 5% albumin challenge to determine\\nhypoxemia now resolved\\n -will check CT chest without contrast to evaluate for ovine bronchus\\n and possible obstruction\\n ICU Care\\n Nutrition: npo for now\\n Glycemic Control: RISS\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM femoral. If not off pressors within\\n 24 hours will need to place IJ or subclavian TLC\\n Prophylaxis:\\n DVT: heparin SQ to be initiated\\n Stress ulcer: IV pantoprazole\\n VAP: NA\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Will need to clarify with her family.\\n Disposition : MICU\\n Total time spent: 60 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397719,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\\n 15 bpm, and most recent ABG 7.39/37/65.\\n Action:\\n Multiple vent changes today. Esophageal balloon placed with poor\\n measurements pt\\ns WOB but PEEP able to be increased to 22. Pt\\n placed on triadyne bed.\\n Response:\\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\\n 7.29/41/74\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\\n Action:\\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\\n neo @ 0.5mcg/kg/min.\\n Response:\\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\\n Plan:\\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\\n Wean pressors as tol, would wean vaso off first.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today.\\n Action:\\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\\n recs. Hydrocort added today for increasing bili and coags. Bladder\\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\\n Liver team following. Liver did not recommend para as they \\nt feel\\n she has a lg amt of ascites.\\n Response:\\n Large liquid yellow BM this AM so flexiseal inserted but pt without\\n stool since that BM.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397720,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\\n 15 bpm, and most recent ABG 7.39/37/65.\\n Action:\\n Multiple vent changes today. Esophageal balloon placed with poor\\n measurements pt\\ns WOB but PEEP able to be increased to 22. Pt\\n placed on triadyne bed.\\n Response:\\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\\n 7.29/45/74 and sats 88-92%.\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\\n Action:\\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\\n neo @ 0.5mcg/kg/min. Pt also given 50g 25% albumin to improve\\n intravascular volume status. Pt also started on IV Vanc/Cefepime for\\n possible sepsis.\\n Response:\\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\\n Plan:\\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\\n Wean pressors as tol, would wean vaso off first. attempt fluid\\n challenge this pm and want vigileo set up.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today.\\n Action:\\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\\n recs. Hydrocort added today for increasing bili and coags. Bladder\\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\\n Liver team following. Liver did not recommend para as they \\nt feel\\n she has a lg amt of ascites.\\n Response:\\n Large liquid yellow BM this AM so flexiseal inserted but pt without\\n stool since that BM.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397721,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n **EVENTS: Pt started on insulin gtt this AM for anion gap 18 up from\\n 12 yesterday AM. Insulin gtt currently infusing @ 11 units/hr with last\\n 2 BS 114, 105.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\\n 15 bpm, and most recent ABG 7.39/37/65.\\n Action:\\n Multiple vent changes today. Esophageal balloon placed with poor\\n measurements pt\\ns WOB but PEEP able to be increased to 22. Pt\\n placed on triadyne bed. Suctioned for small amts dark yellow/green thin\\n secretions.\\n Response:\\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\\n 7.29/45/74 and sats 88-92%.\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\\n Action:\\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\\n neo @ 0.5mcg/kg/min. Pt also given 50g 25% albumin to improve\\n intravascular volume status. Pt also started on IV Vanc/Cefepime for\\n possible sepsis, and blood cx x2 sent from PICC and CVL, urine cx sent,\\n sputem cx sent.\\n Response:\\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\\n Plan:\\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\\n Wean pressors as tol, would wean vaso off first. attempt fluid\\n challenge this pm and want vigileo set up. Cont current IV abx for\\n possible sepsis related hypotension. F/U culture results.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today.\\n Action:\\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\\n recs. Hydrocort added today for increasing bili and coags. Bladder\\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\\n Liver team following. Liver did not recommend para as they \\nt feel\\n she has a lg amt of ascites.\\n Response:\\n Large liquid yellow BM this AM so flexiseal inserted but pt without\\n stool since that BM.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397459,\n \"text\": \"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \\n Hospital after worsening abd pain, jaundice and fatigue. She was noted\\n there to be hypotensive w/ SBP to the 80\\ns, w/ an elevated bili and\\n INR. She was given 4L IVF and transferred to the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\\n (for concern of SBP) A right femoral line was placed. Pt placed on\\n Levophed & given 3L IVF.\\n Currently the patient complains of generalized abdominal pain, more so\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\\n her abdominal pain beginning. Pt is a poor historian overall.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n 2)Hepatic Failure\\nThis appears to be acute exacerbation in the setting\\n of ongoing alcohol use and abuse. We do not see evidence of portal\\n vein thrombosis or intra-peritoneal infection.\\n -Steroids based upon discriminant function\\n -Will need to send AFP given new densities on CT scan\\n -Hepatology to see in the am\\n -Lactulose\\n 3)Coagulopathy-\\n -Vitamin K given\\n - be more likely related to poor hepatic function\\n 4)EtOH Abuse-\\n -Will monitor for withdrawl\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397714,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt agitated, yelling out, increased noted at change of shift, pt\\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\\n t/o. RR 30s.\\n Action:\\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\\n aide in , Pt eventually intubated, placed on propofol gtt for\\n sedation. Sxned for bilious looking secretions.\\n Response:\\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\\n vent settings 60% 450/14/5\\nplaced on 100% FiO2 and Aline currently\\n being placed for ABGs.\\n Plan:\\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\\n ventilation.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.3mg/hr with SBPs 80s\\n Action:\\n Pt cont OFF levo for most of shift, then around 0400, pt becoming\\n persistently hypotensive with systolics in the 80s, levophed gtt\\n initiated, titrating to MAPs > 55.\\n Response:\\n BP maintained at goal MAP > 55.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\\n tolerated by BP.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites. Rec\\nd pt agitated,\\n yelling out, hallucinating, difficult to reorient. Oriented only to\\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\\n .\\n Action:\\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\\n dose lactulose.\\n Response:\\n Pt cont with only small smears of liquid stool despite increase in\\n lactulose.\\n Plan:\\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\\n therapeutic para for increased bladder pressure.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397716,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt agitated, yelling out, increased noted at change of shift, pt\\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\\n t/o. RR 30s.\\n Action:\\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\\n aide in , Pt eventually intubated, placed on propofol gtt for\\n sedation. Sxned for bilious looking secretions.\\n Response:\\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\\n vent settings 60% 450/14/5\\nplaced on 100% FiO2 and Aline currently\\n being placed for ABGs.\\n Plan:\\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\\n ventilation.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.3mg/hr with SBPs 80s, MAPs 55-60.\\n Action:\\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\\n dose levo @ addition of vasopressin @ 2.4units/hr,\\n Response:\\n BP maintained at goal MAP > 55.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\\n tolerated by BP.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites. Rec\\nd pt agitated,\\n yelling out, hallucinating, difficult to reorient. Oriented only to\\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\\n .\\n Action:\\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\\n dose lactulose.\\n Response:\\n Pt cont with only small smears of liquid stool despite increase in\\n lactulose.\\n Plan:\\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\\n therapeutic para for increased bladder pressure.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 397722,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 30 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Green / Thin\\n Sputum source/amount: Suctioned / Moderate\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Hemodynimic instability\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Pleural pressure measurement (1500)\\n Comments: Balloon placed measurements not taken Pt actively breathing.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397737,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\\n 7.29/45/74. Rec\\nd on fentanyl and propofol gtts. On triadyne bed.\\n Action:\\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\\n for small amts dark yellow/green thin secretions.\\n Response:\\n Pt not over breathing vent, although sats remained 85%- so FiO2\\n increased to 100%, pt now sating 91%. Rotation currently turned off on\\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\\n Plan:\\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\\n tolerate PaO2s >65 and O2 sats >86%.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\\n 5-15cc/hr.\\n Action:\\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\\n vasopressin. Rec\\nd a total of 2L NS and 25% albumin for low\\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\\n Response:\\n Cont. on triple pressors to maintain MAPs > 55. Currently not\\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\\n SVV ranging .\\n Plan:\\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\\n possible sepsis related hypotension. F/U culture results.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\\n slightly elevated and tbili up to 27.7 today. Bladder pressure ranging\\n 15-16 this shift. Rec\\nd on insulin gtt at 11 units/hr for + gap and\\n increasing FSBS.\\n Action:\\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\\n low BS and thought gap r/t liver fail. And increasing lactate. On\\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\\n Bladder pressure checked Q6. Liver team following.\\n Response:\\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\\n 15-16. Cont. to monitor FSBS.\\n Plan:\\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\\n rifaximin/lactulose and hydrocort. F/U liver team recs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397540,\n \"text\": \"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\\n seizures, chronic pancreatitis transferred from Hospital\\n with hepatic failure and hypotension\\n Hypotension (not Shock)\\n Assessment:\\n Continues on levo gtt to keep MAP > 55, UO 30 -60cc/hr, hr nsr\\n 80\\ns-90\\ns. Hct 27 at change of shift.\\n Action:\\n Titrating Levophed gtt to maintain MAPs > 55, stable on 0.06 mcg/kg/min\\n Levophed gtt. Repeat Hct sent.\\n Response:\\n UO improving, Hct stable 28,\\n Plan:\\n Levo gtt as ordered to keep MAP > 55, ? a-line insertion this PM,\\n frequent labs as ordered\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o # abdominal pain,\\n oriented x , calm & cooperative, minimal uo, on levo gtt to maintain\\n map > 55\\n Action:\\n Frequent labs sent as ordered, po lactulose as ordered, liver consult\\n placed, chest ct today, bladder pressure done, iv morphine given x 2 &\\n po oxycodone x 1, npo except ice chips, iv albumin given\\n Response:\\n Bladder pressure 17, no stool, abdominal pain down to #1-2 after\\n narcotics, not able to wean levo off, minimal response from iv albumin\\n Plan:\\n Continue to monitor for sepsis/pancreatitis/GI bleeding, po lactulose\\n as ordered, wean levo as able, iv protonix/iv antibiotics as ordered,\\n pain controll\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397625,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension\\n Hypotension (not Shock)\\n Assessment:\\n Received pt OFF levo gtt. BPs 90s. UOP 40s-50s per hour.\\n Action:\\n Pt cont OFF levo. Given 50g of 5% albumin today to improve\\n intravascular volume and for albumin 2.6 this AM.\\n Response:\\n BPs remaining >90 with MAPs ranging 60s-70s, systolic pressures\\n 90s-120s.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites and c/o \\n abdominal pain. Pt alert and oriented x 3 at times but noted to be\\n hallucinating at times as well. Bladder pressure 23 today.\\n Action:\\n Frequent labs sent as ordered, po lactulose as ordered, liver team\\n following, ivp morphine given frequently for a total of 10mg ivp this\\n shift, Reoriented frequently. CIWA q4h, tolerating ice chips and\\n popcicles.\\n Response:\\n no stool, abdominal pain down to 4-5 after narcotics, pt cont. to be\\n confused as to time/place, oriented x2. CIWA < 10, no diazepam given\\n this shift.\\n Plan:\\n Cont to monitor MS- cont po lactulose as ordered, reorient as needed,\\n iv protonix/iv antibiotics as ordered, pain control. Bladder\\n pressures daily. Liver team following.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397683,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - D/cd Antibioitcs which were empiric for CAP, but afebrile with normal\\n WBC\\n - Receive IV Vitamin K x1\\n - Started Cipro empirically per liver for mildly positive UA\\n - Repeat Hct stable 26.3 < 24.2 < 25.6. Did not give FFP because Hct\\n stable (which liver had advised earlier in the day)\\n - Worsening hypoxemia around 1600. CXR appeared more volume overloaded.\\n Received lasix 20 mg IV x3 with brisk response but continue to be more\\n Hypoxic. Intubated around 10 pm with sats in 70s.\\n - Hypotensive to SBP 70s-80s post intubation. Started levophed to limit\\n fluid over-resusication\\n - Rising lactate 4.4 > 5.5. Did not give fluids becuase appears\\n overloaded and worsening oxygenation.\\n History obtained from Medical records\\n Allergies:\\n History obtained from Medical recordsLibrium (Oral) (Chlordiazepoxide\\n Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin - 10:00 AM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Norepinephrine - 0.28 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:55 AM\\n Lorazepam (Ativan) - 07:00 PM\\n Morphine Sulfate - 08:15 PM\\n Furosemide (Lasix) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 98 (94 - 111) bpm\\n BP: 71/54(57) {71/40(44) - 141/87(94)} mmHg\\n RR: 22 (22 - 34) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 23 (23 - 23) mmHg\\n Total In:\\n 1,666 mL\\n 327 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 426 mL\\n 327 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 2,784 mL\\n 545 mL\\n Urine:\\n 2,784 mL\\n 545 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,118 mL\\n -216 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 100%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 29 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 98%\\n ABG: 7.39/37/65/20/-1\\n Ve: 15.1 L/min\\n PaO2 / FiO2: 65\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 94 K/uL\\n 8.7 g/dL\\n 156 mg/dL\\n 1.0 mg/dL\\n 20 mEq/L\\n 2.6 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 139 mEq/L\\n 26.0 %\\n 11.0 K/uL\\n [image002.jpg]\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n 12:54 PM\\n 07:33 PM\\n 08:25 PM\\n 12:54 AM\\n 03:57 AM\\n 06:31 AM\\n WBC\\n 10.6\\n 11.0\\n Hct\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n 24.2\\n 25.6\\n 26.0\\n Plt\\n 127\\n 94\\n Cr\\n 1.0\\n 1.0\\n 1.0\\n TCO2\\n 22\\n 24\\n 23\\n Glucose\\n 182\\n 156\\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\\n Imaging: : AP single view of the chest obtained with patient in\\n sitting\\n semi-upright position is analyzed in direct comparison with the next\\n preceding similar study obtained four hours earlier during the same\\n day. No significant interval change can be identified. No pneumothorax\\n has developed. The scattered bilateral patchy densities are still\\n present and there is no evidence of gross pleural effusion as the\\n lateral pleural sinuses remain free.\\n Microbiology: BCx x 2 NGTD\\n Pleural fluid culture NGTD\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis. New hallucinations this morning.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG , + 1:20\\n -HCV VL < 43\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\\n despite BMs w/ lactulose will start rifaximin\\n -will obtain OSH previous EGD / if any\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\\n negative.\\n -guaiac stools\\n -type and screen\\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\\n necessary\\n -p.m. hct\\n -vitamin k 10 mg IV x 1\\n -if hct < 21 give FFP for elevated PTT and INR\\n # ETOH abuse: thiamine, folate, MVI daily\\n - No evidence of withdrawal, will stop CIWA\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, hepatorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n Plan to begin diuresing very gently if Cr stable by .\\n -IS for atelectasis\\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\\n depletion.\\n -improved\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397685,\n \"text\": \"Chief Complaint:\\n HPI:\\n 24 Hour Events:\\n PICC LINE - START 12:40 PM\\n INVASIVE VENTILATION - START 10:18 PM\\n ARTERIAL LINE - START 06:29 AM\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin - 10:00 AM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Norepinephrine - 0.32 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:55 AM\\n Lorazepam (Ativan) - 07:00 PM\\n Morphine Sulfate - 08:15 PM\\n Furosemide (Lasix) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 92 (92 - 111) bpm\\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\\n RR: 29 (22 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 23 (23 - 23) mmHg\\n Total In:\\n 1,666 mL\\n 365 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 426 mL\\n 365 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 2,784 mL\\n 575 mL\\n Urine:\\n 2,784 mL\\n 575 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,118 mL\\n -210 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 100%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 29 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 95%\\n ABG: 7.41/35/98./20/-1\\n Ve: 15.1 L/min\\n PaO2 / FiO2: 98\\n Physical Examination\\n General Appearance: Overweight / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n )\\n Abdominal: Soft, Bowel sounds present\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 8.7 g/dL\\n 94 K/uL\\n 156 mg/dL\\n 1.0 mg/dL\\n 20 mEq/L\\n 2.6 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 139 mEq/L\\n 26.0 %\\n 11.0 K/uL\\n [image002.jpg]\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n 12:54 PM\\n 07:33 PM\\n 08:25 PM\\n 12:54 AM\\n 03:57 AM\\n 06:31 AM\\n 07:26 AM\\n WBC\\n 10.6\\n 11.0\\n Hct\\n 26.5\\n 28.0\\n 26.3\\n 24.2\\n 25.6\\n 26.0\\n Plt\\n 127\\n 94\\n Cr\\n 1.0\\n 1.0\\n TCO2\\n 22\\n 24\\n 23\\n 23\\n Glucose\\n 182\\n 156\\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n HYPOTENSION (NOT SHOCK)\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397688,\n \"text\": \"Chief Complaint: Liver failure\\n HPI:\\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\\n failure.\\n 24 Hour Events:\\n PICC LINE placed\\nAntibiotics stopped\\n Reintubated\\n Hypotensive post intubation, increasing pressor requirement\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin - Hives\\n Vasotec - hypertension\\n Last dose of Antibiotics:\\n Ciprofloxacin\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Norepinephrine - 0.32 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:55 AM\\n Lorazepam (Ativan) - 07:00 PM\\n Morphine Sulfate - 08:15 PM\\n Furosemide (Lasix) - 10:00 PM\\n Other medications:\\n Potassium, MVI, folate, thiamine,\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 92 (92 - 111) bpm\\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\\n RR: 29 (22 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 23 (23 - 23) mmHg\\n Total In:\\n 1,666 mL\\n 365 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 426 mL\\n 365 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 2,784 mL\\n 575 mL\\n Urine:\\n 2,784 mL\\n 575 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,118 mL\\n -210 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 100%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 29 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 95%\\n ABG: 7.41/35/98./20/-1\\n Ve: 15.1 L/min\\n PaO2 / FiO2: 98\\n Physical Examination\\n General Appearance: Overweight / Obese, intubated, sedated\\n Eyes / Conjunctiva: PERRL, icteric sclera\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: RRR, S1, S2\\n Extremities/Peripheral Vascular: Cool, anasarcic\\n Respiratory / Chest: Coarse, bronchial anteriorally\\n Abdominal: Soft, Bowel sounds present, slightly distended\\n Skin: Icteric, no rashes\\n Neurologic: Sedated\\n Labs / Radiology\\n 8.7 g/dL\\n 94 K/uL\\n 156 mg/dL\\n 1.0 mg/dL\\n 20 mEq/L\\n 2.6 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 139 mEq/L\\n 26.0 %\\n 11.0 K/uL\\n [image002.jpg]\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n 12:54 PM\\n 07:33 PM\\n 08:25 PM\\n 12:54 AM\\n 03:57 AM\\n 06:31 AM\\n 07:26 AM\\n WBC\\n 10.6\\n 11.0\\n Hct\\n 26.5\\n 28.0\\n 26.3\\n 24.2\\n 25.6\\n 26.0\\n Plt\\n 127\\n 94\\n Cr\\n 1.0\\n 1.0\\n TCO2\\n 22\\n 24\\n 23\\n 23\\n Glucose\\n 182\\n 156\\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\\n Cultures\\n Blood and peritoneal fluid NGTD\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE\\n ARDS vs volume overload. Plateaus\\n elevated, bilateral infiltrates.\\n - Hold diuresis for now while hypotensive\\n - Keep PaO2 >60, try to increase PEEP if needed\\n HYPOTENSION\\n Worse post-intubation. Likely due to sedation and\\n PEEP, but cannot exclude worsening infection, although no fever or\\n elevated WBC. Did have hemo-peritoneum, although Hct stable. Also had\\n steroids stopped recently.\\n - Broaden antibiotics, add vanco and cefepime\\n - TTE, CvO2\\n - Pan culture\\n - Start stress dose hydrocortisone\\n - q6h\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n Tbili and INR stable\\n - Add rifaxamin\\n - Continue lactulose\\n - stress dose hydrocortisone as above\\nAnemia\\n Stable yesterday, but given hypotension will trend q6h, space\\n out if stable x2\\n Renal Failure\\n improved UOP, s/p two days of albumin\\n ICU Care\\n Nutrition: Start TFs\\n Glycemic Control: RISS\\n Lines:\\n Cleanly placed femoral TLC - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: P-boots\\n Stress ulcer: PPI\\n VAP: Hob elevated, chlorhexidine\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : MICU\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397689,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - D/cd Antibioitcs which were empiric for CAP, but afebrile with normal\\n WBC\\n - Receive IV Vitamin K x1\\n - Started Cipro empirically per liver for mildly positive UA\\n - Repeat Hct stable 26.3 < 24.2 < 25.6. Did not give FFP because Hct\\n stable (which liver had advised earlier in the day)\\n - Worsening hypoxemia around 1600. CXR appeared more volume overloaded.\\n Received lasix 20 mg IV x3 with brisk response but continue to be more\\n Hypoxic. Intubated around 10 pm with sats in 70s.\\n - Hypotensive to SBP 70s-80s post intubation. Started levophed to limit\\n fluid over-resusication\\n - Rising lactate 4.4 > 5.5. Did not give fluids becuase appears\\n overloaded and worsening oxygenation.\\n History obtained from Medical records\\n Allergies:\\n History obtained from Medical recordsLibrium (Oral) (Chlordiazepoxide\\n Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin - 10:00 AM\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Norepinephrine - 0.28 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:55 AM\\n Lorazepam (Ativan) - 07:00 PM\\n Morphine Sulfate - 08:15 PM\\n Furosemide (Lasix) - 10:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:32 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 98 (94 - 111) bpm\\n BP: 71/54(57) {71/40(44) - 141/87(94)} mmHg\\n RR: 22 (22 - 34) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 23 (23 - 23) mmHg\\n Total In:\\n 1,666 mL\\n 327 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 426 mL\\n 327 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 2,784 mL\\n 545 mL\\n Urine:\\n 2,784 mL\\n 545 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,118 mL\\n -216 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 100%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 29 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 98%\\n ABG: 7.39/37/65/20/-1\\n Ve: 15.1 L/min\\n PaO2 / FiO2: 65\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 94 K/uL\\n 8.7 g/dL\\n 156 mg/dL\\n 1.0 mg/dL\\n 20 mEq/L\\n 2.6 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 139 mEq/L\\n 26.0 %\\n 11.0 K/uL\\n [image002.jpg]\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n 12:54 PM\\n 07:33 PM\\n 08:25 PM\\n 12:54 AM\\n 03:57 AM\\n 06:31 AM\\n WBC\\n 10.6\\n 11.0\\n Hct\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n 24.2\\n 25.6\\n 26.0\\n Plt\\n 127\\n 94\\n Cr\\n 1.0\\n 1.0\\n 1.0\\n TCO2\\n 22\\n 24\\n 23\\n Glucose\\n 182\\n 156\\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\\n Imaging: : AP single view of the chest obtained with patient in\\n sitting\\n semi-upright position is analyzed in direct comparison with the next\\n preceding similar study obtained four hours earlier during the same\\n day. No significant interval change can be identified. No pneumothorax\\n has developed. The scattered bilateral patchy densities are still\\n present and there is no evidence of gross pleural effusion as the\\n lateral pleural sinuses remain free.\\n Microbiology: BCx x 2 NGTD\\n Pleural fluid culture NGTD\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Shock: at this point seems to be related to possible infectious\\n cause, end stage liver disease, propofol. Would also consider adverse\\n reaction to FFP or IV vitamin K. On levo, vaso.\\n - MAP goal > 55\\n - empiric vanc/zosyn/cipro\\n - stress dose steroids\\n - follow UOP, pulse pressure variation to assess intravascular volume\\n - check ECHO\\n - check TSH/FT4\\n - wean propofol\\n - check lytes, hct, ABG, lactate q6h\\n # Respiratory failure/ARDS: Worsening hypoxia on and intubated\\n in setting of receiving volume and severe liver disease. Differential\\n includes volume overload versus infection versus pulm hemorrhage vs\\n TROLI in setting of transfusion though unlikely. Would also consider\\n PCP given IVDU history.\\n - ARDSnet protocol with low tidal volumes\\n - PaO2 > 60, SaO2 > 90\\n - empiric antibx\\n - r/o flu\\n - may consider bronch\\n - hold on diuresis for now but will consider pending creatinine trend,\\n UOP\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis. New hallucinations this morning.\\n - restarted steroids with undetectable HCV viral load\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG , + 1:20\\n -HCV VL < 43\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose and rifaxamin\\n -will obtain OSH previous EGD / if any\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, hepatorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n - follow UOP and trend creatinine\\n - renally dose meds\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\\n and hct stable.\\n -guaiac stools\\n -active type and screen\\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\\n necessary\\n -p.m. hct\\n # ETOH abuse: No evidence of withdrawal\\n - thiamine, folate, MVI daily\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition: TF reccs\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397691,\n \"text\": \"Chief Complaint: Liver failure\\n HPI:\\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\\n failure.\\n 24 Hour Events:\\n PICC LINE placed\\nAntibiotics stopped\\n Reintubated\\n Hypotensive post intubation, increasing pressor requirement\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin - Hives\\n Vasotec - hypertension\\n Last dose of Antibiotics:\\n Ciprofloxacin\\n Infusions:\\n Fentanyl (Concentrate) - 100 mcg/hour\\n Norepinephrine - 0.32 mcg/Kg/min\\n Propofol - 20 mcg/Kg/min\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:55 AM\\n Lorazepam (Ativan) - 07:00 PM\\n Morphine Sulfate - 08:15 PM\\n Furosemide (Lasix) - 10:00 PM\\n Other medications:\\n Potassium, MVI, folate, thiamine,\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 92 (92 - 111) bpm\\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\\n RR: 29 (22 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 23 (23 - 23) mmHg\\n Total In:\\n 1,666 mL\\n 365 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 426 mL\\n 365 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 2,784 mL\\n 575 mL\\n Urine:\\n 2,784 mL\\n 575 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,118 mL\\n -210 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 450 (450 - 450) mL\\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 10 cmH2O\\n FiO2: 100%\\n RSBI Deferred: FiO2 > 60%\\n PIP: 29 cmH2O\\n Plateau: 28 cmH2O\\n SpO2: 95%\\n ABG: 7.41/35/98./20/-1\\n Ve: 15.1 L/min\\n PaO2 / FiO2: 98\\n Physical Examination\\n General Appearance: Overweight / Obese, intubated, sedated\\n Eyes / Conjunctiva: PERRL, icteric sclera\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\\n Cardiovascular: RRR, S1, S2\\n Extremities/Peripheral Vascular: Cool, anasarcic\\n Respiratory / Chest: Coarse, bronchial anteriorally\\n Abdominal: Soft, Bowel sounds present, slightly distended\\n Skin: Icteric, no rashes\\n Neurologic: Sedated\\n Labs / Radiology\\n 8.7 g/dL\\n 94 K/uL\\n 156 mg/dL\\n 1.0 mg/dL\\n 20 mEq/L\\n 2.6 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 139 mEq/L\\n 26.0 %\\n 11.0 K/uL\\n [image002.jpg]\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n 12:54 PM\\n 07:33 PM\\n 08:25 PM\\n 12:54 AM\\n 03:57 AM\\n 06:31 AM\\n 07:26 AM\\n WBC\\n 10.6\\n 11.0\\n Hct\\n 26.5\\n 28.0\\n 26.3\\n 24.2\\n 25.6\\n 26.0\\n Plt\\n 127\\n 94\\n Cr\\n 1.0\\n 1.0\\n TCO2\\n 22\\n 24\\n 23\\n 23\\n Glucose\\n 182\\n 156\\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\\n Cultures\\n Blood and peritoneal fluid NGTD\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE\\n ARDS vs volume overload. Plateaus\\n elevated, bilateral infiltrates.\\n - Hold diuresis for now while hypotensive\\n - Keep PaO2 >60, try to increase PEEP if needed\\n HYPOTENSION\\n Worse post-intubation. Likely due to sedation and\\n PEEP, but cannot exclude worsening infection, although no fever or\\n elevated WBC. Did have hemo-peritoneum, although Hct stable. Also had\\n steroids stopped recently.\\n - Broaden antibiotics, add vanco and cefepime\\n - TTE, CvO2\\n - Pan culture\\n - Start stress dose hydrocortisone\\n - q6h\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n Tbili and INR stable\\n - Add rifaxamin\\n - Continue lactulose\\n - stress dose hydrocortisone as above\\nAnemia\\n Stable yesterday, but given hypotension will trend q6h, space\\n out if stable x2\\n Renal Failure\\n improved UOP, s/p two days of albumin\\n ICU Care\\n Nutrition: Start TFs\\n Glycemic Control: RISS\\n transition to IV insulin protocol given plan\\n to start steroids\\n Lines:\\n Cleanly placed femoral TLC - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: P-boots\\n Stress ulcer: PPI\\n VAP: Hob elevated, chlorhexidine\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition : MICU\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 397453,\n \"text\": \"Chief Complaint: Weakness\\n Jaundice\\n Hypotension\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n Patient to hospital with complaints of worsening weakness and\\n change in urine color now admitted to with concern for evolving\\n hepatic failure.\\n In the ED here->\\n -Pt with MSO4 for pain control\\n -CTX given for possible SBP\\n -Given hypotension femoral catheter placed and 7 liters fluid given\\n -Levophed given for hypotension\\n -Paracentesis perfored with 63 WBC seen\\n Patient admitted to ICU for further care\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.14 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 03:30 AM\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Cirrhosis-Hep C and EtOH\\n EtOH abuse-h/o withdrawl seizures\\n S/P CCY in past\\n DM-II\\n Non-contributory\\n Occupation: Unk\\n Drugs: None noted now\\n Tobacco: Continued smoking\\n Alcohol: Patient admits to some EtOH ingestion prior to onset of\\n abdominal pain\\n Other:\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever\\n Nutritional Support: NPO\\n Gastrointestinal: Abdominal pain\\n Genitourinary: Foley\\n Psychiatric / Sleep: Daytime somnolence\\n Signs or concerns for abuse : No\\n Pain: Mild\\n Flowsheet Data as of 04:32 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n HR: 92 (92 - 95) bpm\\n BP: 90/52(62) {90/52(62) - 115/74(84)} mmHg\\n RR: 21 (12 - 22) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 6,257 mL\\n PO:\\n TF:\\n IVF:\\n 257 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 90 mL\\n Urine:\\n 60 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 6,167 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 93%\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Abdominal: Soft, Bowel sounds present, Tender: Diffusely\\n Musculoskeletal: Unable to stand\\n Skin: Not assessed\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\nPatient somnolent\\n but arousable.\\n Labs / Radiology\\n 128\\n 31\\n 0.6\\n 4\\n 21\\n 102\\n 2.8\\n 132\\n 9\\n [image002.jpg]\\n Other labs: PT / PTT / INR:23.8/2.3, ALT / AST:45/195, Alk Phos / T\\n Bili:91/16.3 (8.4-direct), Amylase / Lipase:/20, Differential-Neuts:78,\\n Lactic Acid:3.1\\n Fluid analysis / Other labs: TOx-Pos Benzos\\n Serum-Negative to Tylenol and EtOH\\n Imaging: CXR-Patient with what appears to be right middle lobe opacity.\\n U/S--no Cholecystitis seen\\n CT--no portal vein thrombosis noted. In segment II of the\\n liver--multiple hypodensities noted which were felt to be non-specific\\n findings\\n Assessment and Plan\\n 49 yo female with history of cirrhosis now admitted with worsening\\n abdominal discomfort and hyper-bilirubinemia in the setting of recent\\n EtOH ingestion. Initial tap of abdominal fluid did not reveal obvious\\n SBP as source. This leaves, in the setting of significant hypotension,\\n source of initial insult remains to be clearly defined.\\n 1) Hypotension- be part of the hepatic failure picture present but\\n alternative source of infection (possible urine) is possible with right\\n middle lobe opacity but clinical history not suggestive.\\n -Ceftriaxone/Levoflox in place\\n -9 liters given and will use pressor for now\\n -Follow up cultures\\n 2)Hepatic Failure\\nThis appears to be acute exacerbation in the setting\\n of ongoing alcohol use and abuse. We do not see evidence of portal\\n vein thrombosis or intra-peritoneal infection.\\n -Steroids based upon discriminant function\\n -Will need to send AFP given new densities on CT scan\\n -Hepatology to see in the am\\n -Lactulose\\n 3)Coagulopathy-\\n -Vitamin K given\\n - be more likely related to poor hepatic function\\n 4)EtOH Abuse-\\n -Will monitor for withdrawl\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Comments:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: Comments: Discussed with patient but with signfiicant\\n confusion\\nwould be appropriate to discuss with a social support if\\n available.\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 397455,\n \"text\": \"Chief Complaint: transfer from for liver failure\\n HPI:\\n 49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \\n hospital after presenting with worsening jaundice and fatigue. She was\\n noted there to be hypotensive to the low 80s systolic, noted to have an\\n elevated bili and INR- she was given 4 Liters IVF and transferred to\\n the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\\n was given 4 L IVF in hospital, 3 L in the ER at .\\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\\n sat: 94% on 5L O2 NC.\\n Currently the patient complains of generalized abdominal pain, moreso\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\\n her abdominal pain beginning.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.16 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 03:30 AM\\n Other medications:\\n (patient unsure of medications, none on list from hospital)\\n patient states she takes insulin.\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Hepatitis C.\\n 2. Alcoholic hepatitis.\\n 3. History of alcohol abuse with withdraw seizures and DTs in the\\n past.\\n 4. History of hypertension.\\n 5. History of chronic pancreatitis.\\n 6. Status post cesarean section and ectopic pregnancies in the past.\\n 7. History of traumatic wrist laceration in the past status post\\n surgical repair with blood transfusions in .\\n 8. S/P ccy, s/p oophorectomy\\n 9. DM II\\n non contributory\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: 6 tabs of tylenol 3 days ago, 1 pint of hard liquor on \\n however the patient's history is relatively unreliable given\\n encephalopathy. She lives w/ friends, smokes and is a current\\n abuser of ETOH (daily)- unable to quantify. H/o opiate abuse but no\\n opiates x 1 year.\\n Review of systems:\\n Flowsheet Data as of 03:54 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n HR: 94 (94 - 95) bpm\\n BP: 115/74(84) {115/74(84) - 115/74(84)} mmHg\\n RR: 22 (12 - 22) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 6,172 mL\\n PO:\\n TF:\\n IVF:\\n 172 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 90 mL\\n Urine:\\n 60 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 6,082 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: serum tylenol negative\\n serum etoh negative\\n serum opiates negative\\n serum benzos +\\n Imaging: RUQ ultrasound: (prelim) Very echogenic liver, limited\\n assessment of gallbladder and portal vein. Ascites, predominantly in\\n the RUQ, but not a good window to mark. Consider ultrasound guided\\n paracentesis.\\n CXR: (my read) hilar fullness w/ mild pulm vascular engorgement,\\n infiltrates in the RML and RUL.\\n CT abd / pelvis w/ contrast: . (prelim)\\n liver w/ heterogeneous attenuation, shrunken nodular appearance.\\n Several areas of hypodensities in segement 2 of the liver could\\n represent perfusion defects, dilated bile ducts or could be related to\\n underlying mass effect. Anasarca. No evidence of portal vein\\n thrombosis. Bibasilar atelectasis.\\n Microbiology: BCx x 2 P\\n Peritoneal fluid cx P\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis given history and transaminase pattern.\\n -paracentesis negative for sbp\\n -liver consult\\n -liver ultrasound with doppler was a difficult study,\\n -discriminate function is 71. Will start steroids x 1 week then taper.\\n -will give vitamin K to correct any portion of elevated INR that may be\\n nutritional\\n -thiamine, folate, MVI daily\\n -lactulose- titrate to 3 BMs daily\\n -send AFP given risk of HCC and finding on CT abd\\n -Send Uhcg\\n # Hypotension: no clear cause for hypotension with the exception of\\n worsening liver function and possible infectious etiologies including\\n pneumonia and possible urinary tract infection.\\n -continue levofloxacin / ceftriaxone.\\n -keep MAP > 55\\n -has rec'd 7 liters IVF and likely fluid replete, appears euvolemic on\\n exam\\n # Hyponatremia: possibly related to volume overload / liver disease.\\n -urine lytes\\n # Hypoxia: appears to have R sided opacities which may be pneumonia.\\n She has rec'd ceftriaxone. Will add levofloxacin in addition to CTX\\n for severe CAP.\\n -abx\\n -f/u blood cultures\\n -sputum culture\\n -IS for atelectasis\\n # ETOH abuse: h/o w/d seizures in the past.\\n -CIWA scale w/ valium.\\n # DM: Insulin sliding scale.\\n # FEN: NPO for now until MS clears\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT:\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 397616,\n \"text\": \"Subjective\\n \\\"Help me!\\\". Taking oxygen mask off.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 170 cm\\n 106 kg\\n 36.5\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 61.2 kg\\n 173%\\n 72.4 kg\\n Diagnosis: acute liver failure\\n PMHx:\\n 1. Hepatitis C.\\n 2. Alcoholic hepatitis.\\n 3. History of alcohol abuse with withdraw seizures and DTs in the\\n past.\\n 4. History of hypertension.\\n 5. History of chronic pancreatitis.\\n 6. Status post cesarean section and ectopic pregnancies in the past.\\n 7. History of traumatic wrist laceration in the past status\\n postsurgical repair with blood transfusions in .\\n 8. S/P ccy, s/p oophorectomy\\n 9. DM II\\n Food allergies and intolerances: none\\n Pertinent medications: Normal saline @ 10ml/hr, Albumin 5%,\\n Pantoprazole, RISS, Multi-vitamin, Thiamine, Folic Acid, Lactulose\\n Labs:\\n Value\\n Date\\n Glucose\\n 182 mg/dL\\n 04:15 AM\\n Glucose Finger Stick\\n 180\\n 11:00 AM\\n BUN\\n 7 mg/dL\\n 04:15 AM\\n Creatinine\\n 1.0 mg/dL\\n 04:15 AM\\n Sodium\\n 134 mEq/L\\n 04:15 AM\\n Potassium\\n 3.4 mEq/L\\n 04:15 AM\\n Chloride\\n 101 mEq/L\\n 04:15 AM\\n TCO2\\n 21 mEq/L\\n 04:15 AM\\n Albumin\\n 2.6 g/dL\\n 04:15 AM\\n Calcium non-ionized\\n 7.8 mg/dL\\n 04:15 AM\\n Phosphorus\\n 3.2 mg/dL\\n 04:15 AM\\n Magnesium\\n 2.6 mg/dL\\n 04:15 AM\\n ALT\\n 34 IU/L\\n 04:15 AM\\n Alkaline Phosphate\\n 82 IU/L\\n 04:15 AM\\n AST\\n 83 IU/L\\n 04:15 AM\\n Amylase\\n 14 IU/L\\n 05:20 PM\\n Total Bilirubin\\n 27.5 mg/dL\\n 04:15 AM\\n WBC\\n 10.6 K/uL\\n 04:15 AM\\n Hgb\\n 8.7 g/dL\\n 04:15 AM\\n Hematocrit\\n 24.2 %\\n 12:54 PM\\n Current diet order / nutrition support: Diet: regular\\n GI: soft/distended, (+) bowel sounds, (+) flatus\\n Assessment of Nutritional Status\\n Obese, At risk for malnutrition\\n Patient at risk due to: decreased mental status, liver disease, etoh\\n Estimated Nutritional Needs\\n Calories: 1600-1810 (22-25 cal/kg)\\n Protein: 87-109 (1.2-1.5 g/kg)\\n Fluid: per team\\n Calculations based on: Adjusted weight\\n Estimation of previous intake: likely inadequate\\n Estimation of current intake: Inadequate\\n Specifics:\\n 49 YO female presented with hypotension and worsening jaundice.\\n Decreased po\\ns and increased alcohol intake recently per chart.\\n Consulted for tube feed recommendations and calorie counts. Diet\\n advanced today to regular, only had water per co-worker, c/o abdominal\\n pain. Would hold off on calorie counts at this time as patient not\\n taking po\\ns. Would provide temporary nutrition support with tube\\n feeding until po\\ns improve given likely poor nutritional status PTA.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Current diet / nutrition support is appropriate: Encourage\\n po\\ns as able\\n o Will begin calorie counts when po\\ns improve\\n Multivitamin / Mineral supplement: continue current\\n Tube feeding recommendations:\\n o Place PPFT given ascites; check placement\\n o Begin tube feed: Isosource 1.5 @ 20ml/hr, advance as\\n tolerated to goal of 50ml/hr\\n Add 15g Beneprotein for total of 1854 calories and 95g\\n protein\\n o No residual checks with PPFT, monitor abdominal exam, patient\\n complaints\\n Check chemistry 10 panel daily\\n Will follow, page if questions *\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 397694,\n \"text\": \":\\n Recruitment Maneuvers Done\\n CPAP pressure used: aprv cm H2O\\n Duration: 30 sec\\n Times per shift:\\n Comments: 35/32\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397592,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - MELD 27\\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\\n check AFP, GGT, IGG, , hep C viral load\\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\\n paracentesis\\n - Bladder pressure 17\\n - levophed weaned\\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\\n - Son takes care of for the past 6 months or so\\n given worsening mental status. He noticed that she was drinking 1\\n liter of vodka per day. He forced her to stop and then after that she\\n was drinking 3-4 beers per day. She had a male friend that would\\n provide her with klonopin 2mg pills (5 pills at a time). She was only\\n drinking beer and taking klonopin but not eating any other food or\\n leaving her bed. The son then left for two days after getting into a\\n fight with his mother's male friend for one day and then his mother's\\n friend stated that she was becoming more jaundice and was brought to\\n the hospital.\\n -per son the only medication is metformin\\n -per son she is currently full code but will come in for a meeting w/\\n the medical team tomorrow . He also requests if she improves that\\n she has a prolonged 3 month inpt stay somewhere to prevent her from\\n drinking ETOH.\\n -SW consult ordered- son would like to talk to SW when he comes in\\n tomorrow.\\n - friend is \\\"\\\" and we should not provide him w/ any medical\\n information. If comes to see him we should have security search\\n him for substances prior to his visit.\\n History obtained from Patient, Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 04:26 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 93 (90 - 101) bpm\\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\\n RR: 21 (15 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 17 (17 - 17) mmHg\\n Total In:\\n 8,915 mL\\n 165 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 165 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 330 mL\\n Urine:\\n 409 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -165 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n 127 K/uL\\n 8.7 g/dL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood culture x 2 Pending\\n Peritoneal fluid pending (GS negative)\\n HCV viral load pending\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG, P\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\\n lactulose will start rifaximin\\n -will obtain OSH previous EGD / if any\\n # Hallucinations: Visual hallucinations this morning. New since\\n yesterday. ? Benzo related but also could be encephalopathy.\\n - Increase lactulose\\n - Hold Benzos for now and see if MS improves\\n # ETOH abuse: thiamine, folate, MVI daily\\n -CIWA scale but hold benzos for right now\\n - D/c thiamine after today\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative.\\n INR worsening so will check DIC labs\\n -guaiac stools\\n -type and screen.\\n - IV Vitamin K since did not respond to po vitamin K\\n -transfuse for hct < 21, and transfuse w/ Lasix when necessary\\n -Q8. hct, DIC labs\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, heptorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hyponatremia: Imprved with volume so likely due to intravascular\\n depletion prior to admission.\\n -improved and will continue to trend lytes daily\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n -IS for atelectasis\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397593,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - MELD 27\\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\\n check AFP, GGT, IGG, , hep C viral load\\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\\n paracentesis\\n - Bladder pressure 17\\n - levophed weaned\\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\\n - Son takes care of for the past 6 months or so\\n given worsening mental status. He noticed that she was drinking 1\\n liter of vodka per day. He forced her to stop and then after that she\\n was drinking 3-4 beers per day. She had a male friend that would\\n provide her with klonopin 2mg pills (5 pills at a time). She was only\\n drinking beer and taking klonopin but not eating any other food or\\n leaving her bed. The son then left for two days after getting into a\\n fight with his mother's male friend for one day and then his mother's\\n friend stated that she was becoming more jaundice and was brought to\\n the hospital.\\n -per son the only medication is metformin\\n -per son she is currently full code but will come in for a meeting w/\\n the medical team tomorrow . He also requests if she improves that\\n she has a prolonged 3 month inpt stay somewhere to prevent her from\\n drinking ETOH.\\n -SW consult ordered- son would like to talk to SW when he comes in\\n tomorrow.\\n - friend is \\\"\\\" and we should not provide him w/ any medical\\n information. If comes to see him we should have security search\\n him for substances prior to his visit.\\n History obtained from Patient, Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 04:26 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 93 (90 - 101) bpm\\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\\n RR: 21 (15 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 17 (17 - 17) mmHg\\n Total In:\\n 8,915 mL\\n 165 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 165 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 330 mL\\n Urine:\\n 409 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -165 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n 127 K/uL\\n 8.7 g/dL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood culture x 2 Pending\\n Peritoneal fluid pending (GS negative)\\n HCV viral load pending\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis. New hallucinations this morning.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG, P\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\\n despite BMs w/ lactulose will start rifaximin\\n -will obtain OSH previous EGD / if any\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\\n negative.\\n -guaiac stools\\n -type and screen\\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\\n necessary\\n -p.m. hct\\n -vitamin k 10 mg IV x 1\\n -if hct < 25 give FFP for elevated PTT and INR\\n # ETOH abuse: thiamine, folate, MVI daily\\n - No evidence of withdrawal, will stop CIWA\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, hepatorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n -IS for atelectasis\\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\\n depletion.\\n -improved\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition: calorie count today\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397594,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - MELD 27\\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\\n check AFP, GGT, IGG, , hep C viral load\\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\\n paracentesis\\n - Bladder pressure 17\\n - levophed weaned\\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\\n - Son takes care of for the past 6 months or so\\n given worsening mental status. He noticed that she was drinking 1\\n liter of vodka per day. He forced her to stop and then after that she\\n was drinking 3-4 beers per day. She had a male friend that would\\n provide her with klonopin 2mg pills (5 pills at a time). She was only\\n drinking beer and taking klonopin but not eating any other food or\\n leaving her bed. The son then left for two days after getting into a\\n fight with his mother's male friend for one day and then his mother's\\n friend stated that she was becoming more jaundice and was brought to\\n the hospital.\\n -per son the only medication is metformin\\n -per son she is currently full code but will come in for a meeting w/\\n the medical team tomorrow . He also requests if she improves that\\n she has a prolonged 3 month inpt stay somewhere to prevent her from\\n drinking ETOH.\\n -SW consult ordered- son would like to talk to SW when he comes in\\n tomorrow.\\n - friend is \\\"\\\" and we should not provide him w/ any medical\\n information. If comes to see him we should have security search\\n him for substances prior to his visit.\\n History obtained from Patient, Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 04:26 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 93 (90 - 101) bpm\\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\\n RR: 21 (15 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 17 (17 - 17) mmHg\\n Total In:\\n 8,915 mL\\n 165 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 165 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 330 mL\\n Urine:\\n 409 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -165 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n 127 K/uL\\n 8.7 g/dL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood culture x 2 Pending\\n Peritoneal fluid pending (GS negative)\\n HCV viral load pending\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG, P\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\\n lactulose will start rifaximin\\n -will obtain OSH previous EGD / if any\\n # Hallucinations: Visual hallucinations this morning. New since\\n yesterday. ? Benzo related but also could be encephalopathy.\\n - Increase lactulose\\n - Hold Benzos for now and see if MS improves\\n # ETOH abuse: thiamine, folate, MVI daily\\n -CIWA scale but hold benzos for right now\\n - D/c thiamine after today\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative.\\n INR worsening so will check DIC labs\\n -guaiac stools\\n -type and screen.\\n - IV Vitamin K since did not respond to po vitamin K\\n -transfuse for hct < 21, and transfuse w/ Lasix when necessary\\n -Q8. hct, DIC labs\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, heptorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hyponatremia: Imprved with volume so likely due to intravascular\\n depletion prior to admission.\\n -improved and will continue to trend lytes daily\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n -IS for atelectasis\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397595,\n \"text\": \"Chief Complaint: Liver failure\\n HPI:\\n Please see admission note for full details. 49F w/HCV and cirrhosis\\n admitted with worsening confusion and hepatic insufficiency.\\n 24 Hour Events:\\n - MELD 27\\n - Stopped steroids\\n - Chest CT obtained for evaluation of R-sided infiltrates\\n - Concern for IP hemorrhage\\n - Weaned off pressors\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin Base - Hives;\\n Vasotec - HTN\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 07:50 AM\\n Pantoprazole (Protonix) - 07:55 AM\\n Other medications:\\n MVI, folate, thiamine, lactulose, RISS\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 97 (90 - 101) bpm\\n BP: 96/64(72) {82/15(40) - 107/69(78)} mmHg\\n RR: 24 (15 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 8,915 mL\\n 195 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 195 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 431 mL\\n Urine:\\n 409 mL\\n 431 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -235 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Sallow, ill-appearing obese F, laying in bed\\n Eyes / Conjunctiva: Scleral icterus\\n Head, Ears, Nose, Throat: MMM, sublingual icterus, oropharynx clear\\n Cardiovascular: RRR, S1, S2\\n Extremities/Peripheral Vascular: Warm, diffusely edematous, palpable\\n radial, DPs bilat\\n Respiratory / Chest: bilateral crackles over the lower half of lung\\n fields bilat\\n Skin: Sallow, no rashes\\n Neurologic: A&Ox2, repeatedly stating that her son is hiding in the\\n room\\n / Radiology\\n 8.7 g/dL\\n 127 K/uL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other : PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood cultures and peritoneal fluid cultures\\n NGTD\\n Chest CT\\n Reviewed - Peribronchial edema, thickening, GGOs, trace\\n bilateral effusions, ascites, pancreatic calcifiations\\n Assessment and Plan\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n acutely decompensated\\n - Increase lactulose as not stooling\\n - Stopped steroids per hepatology\\n - Will discuss prognosis given not a transplant candidate with son\\n - On thiamine, folate, MVI for chronic EtOH\\n HYPOTENSION - ?cirrhotic vs infectious\\n - Weaned off pressors yesterday, follow\\n - Goal MAP >55\\n - Stop antibiotics\\nHCT drop\\n Appears to have been secondary to intraperitoneal bleed\\n after paracentesis\\n - Hct checks q8h\\n - Transfusion goal >21 or if acute drop concerning for bleed\\n - If need to transfuse, consider FFP if acute bleeding\\n - IV vitamin K to try and improve coagulopathy\\nEtOH Abuse\\n - Monitor for withdrawal\\nRenal Failure - Poor UOP yesterday with FENA <1, improving now, ATN\\n vs hepatorenal vs contrast nephropathy\\n - Getting albumin 50gm today\\n - If worsens, consider midodrine and/or octreotide\\nHypoxia, volume overload\\n - On 4L NC\\n - Consider gentle diuresis in the next 12-24 hrs pending UOP\\n On RISS\\n ICU Care\\n Nutrition: PO diet\\n Glycemic Control: RISS\\n Lines: - Plan for PICC, d/c femoral line after\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: SCDs\\n Stress ulcer: PPI\\n VAP: N/A\\n Comments:\\n Communication: Will discuss with son today\\n status: Full code\\n Disposition : MICU for now\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 397672,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Crackles\\n LUL Lung Sounds: Crackles\\n LLL Lung Sounds: Crackles\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\n Visual assessment of breathing pattern: Normal quiet breathing,\\n Frequent desaturation episodes\\n Assessment of breathing comfort:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\\n tolerated; Comments: may need to increase peep as O2 is decreased\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Pt was intubated for impending respiratory failure, hypoxia. New a line\\n being placed, abg pending.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397673,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n **Events: At change of shift, pt agitated and in resp. distress,\\n increased > Pt given ativan,lasix, with minimal effect, and placed\\n on a NRB. Pt with sats 79-80% on NRB, ultimately intubated for resp.\\n distress. SBP ranging 80s-90s, persistently hypotensive this AM, and\\n levophed gtt initiated, and Aline placed. K 2.6- currently rec\\n repletion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt agitated, yelling out, increased noted at change of shift, pt\\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\\n t/o. RR 30s.\\n Action:\\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\\n aide in , Pt eventually intubated, placed on propofol gtt for\\n sedation.\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\\n Action:\\n Pt cont OFF levo.\\n Response:\\n BP maintained at goal MAP > 55.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites. Rec\\nd pt agitated,\\n yelling out, hallucinating, difficult to reorient. Oriented only to\\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\\n .\\n Action:\\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\\n dose lactulose.\\n Response:\\n Pt cont with only small smears of liquid stool despite increase in\\n lactulose.\\n Plan:\\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\\n therapeutic para for increased bladder pressure.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397674,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n **Events: At change of shift, pt agitated and in resp. distress,\\n increased > Pt given ativan,lasix, with minimal effect, and placed\\n on a NRB. Pt with sats 79-80% on NRB, ultimately intubated for resp.\\n distress. SBP ranging 80s-90s, persistently hypotensive this AM, and\\n levophed gtt initiated, and Aline placed. K 2.6- currently rec\\n repletion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt agitated, yelling out, increased noted at change of shift, pt\\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\\n t/o. RR 30s.\\n Action:\\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\\n aide in , Pt eventually intubated, placed on propofol gtt for\\n sedation. Sxned for bilious looking secretions.\\n Response:\\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\\n vent settings 60% 450/14/5\\nplaced on 100% FiO2 and Aline currently\\n being placed for ABGs.\\n Plan:\\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\\n ventilation.\\n Hypotension (not Shock)\\n Assessment:\\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\\n Action:\\n Pt cont OFF levo for most of shift, then around 0400, pt becoming\\n persistently hypotensive with systolics in the 80s, levophed gtt\\n initiated, titrating to MAPs > 55.\\n Response:\\n BP maintained at goal MAP > 55.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\\n tolerated by BP.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites. Rec\\nd pt agitated,\\n yelling out, hallucinating, difficult to reorient. Oriented only to\\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\\n .\\n Action:\\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\\n dose lactulose.\\n Response:\\n Pt cont with only small smears of liquid stool despite increase in\\n lactulose.\\n Plan:\\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\\n therapeutic para for increased bladder pressure.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397600,\n \"text\": \"Chief Complaint: Liver failure\\n HPI:\\n Please see admission note for full details. 49F w/HCV and cirrhosis\\n admitted with worsening confusion and hepatic insufficiency.\\n 24 Hour Events:\\n - MELD 27\\n - Stopped steroids\\n - Chest CT obtained for evaluation of R-sided infiltrates\\n - Concern for IP hemorrhage\\n - Weaned off pressors\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin Base - Hives;\\n Vasotec - HTN\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 07:50 AM\\n Pantoprazole (Protonix) - 07:55 AM\\n Other medications:\\n MVI, folate, thiamine, lactulose, RISS\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 09:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 97 (90 - 101) bpm\\n BP: 96/64(72) {82/15(40) - 107/69(78)} mmHg\\n RR: 24 (15 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 8,915 mL\\n 195 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 195 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 431 mL\\n Urine:\\n 409 mL\\n 431 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -235 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Sallow, ill-appearing obese F, laying in bed\\n Eyes / Conjunctiva: Scleral icterus\\n Head, Ears, Nose, Throat: MMM, sublingual icterus, oropharynx clear\\n Cardiovascular: RRR, S1, S2\\n Extremities/Peripheral Vascular: Warm, diffusely edematous, palpable\\n radial, DPs bilat\\n Respiratory / Chest: bilateral crackles over the lower half of lung\\n fields bilat\\n Skin: Sallow, no rashes\\n Neurologic: A&Ox2, repeatedly stating that her son is hiding in the\\n room\\n / Radiology\\n 8.7 g/dL\\n 127 K/uL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other : PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood cultures and peritoneal fluid cultures\\n NGTD\\n Chest CT\\n Reviewed - Peribronchial edema, thickening, GGOs, trace\\n bilateral effusions, ascites, pancreatic calcifiations\\n Assessment and Plan\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n acutely decompensated\\n - Increase lactulose as not stooling\\n - Stopped steroids per hepatology\\n - Will discuss prognosis given not a transplant candidate with son\\n - On thiamine, folate, MVI for chronic EtOH\\n HYPOTENSION - ?cirrhotic vs infectious\\n - Weaned off pressors yesterday, follow\\n - Goal MAP >55\\n - Stop antibiotics\\nHCT drop\\n Appears to have been secondary to intraperitoneal bleed\\n after paracentesis\\n - Hct checks q8h\\n - Transfusion goal >21 or if acute drop concerning for bleed\\n - If need to transfuse, consider FFP if acute bleeding\\n - IV vitamin K to try and improve coagulopathy\\nEtOH Abuse\\n - Monitor for withdrawal\\nRenal Failure - Poor UOP yesterday with FENA <1, improving now, ATN\\n vs hepatorenal vs contrast nephropathy\\n - Getting albumin 50gm today\\n - If worsens, consider midodrine and/or octreotide\\nHypoxia, volume overload\\n - On 4L NC\\n - Consider gentle diuresis in the next 12-24 hrs pending UOP\\n On RISS\\n ICU Care\\n Nutrition: PO diet\\n Glycemic Control: RISS\\n Lines: - Plan for PICC, d/c femoral line after\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: SCDs\\n Stress ulcer: PPI\\n VAP: N/A\\n Comments:\\n Communication: Will discuss with son today\\n status: Full code\\n Disposition : MICU for now\\n Total time spent: 30 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397606,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - MELD 27\\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\\n check AFP, GGT, IGG, , hep C viral load\\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\\n paracentesis\\n - Bladder pressure 17\\n - levophed weaned\\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\\n - Son takes care of for the past 6 months or so\\n given worsening mental status. He noticed that she was drinking 1\\n liter of vodka per day. He forced her to stop and then after that she\\n was drinking 3-4 beers per day. She had a male friend that would\\n provide her with klonopin 2mg pills (5 pills at a time). She was only\\n drinking beer and taking klonopin but not eating any other food or\\n leaving her bed. The son then left for two days after getting into a\\n fight with his mother's male friend for one day and then his mother's\\n friend stated that she was becoming more jaundice and was brought to\\n the hospital.\\n -per son the only medication is metformin\\n -per son she is currently full code but will come in for a meeting w/\\n the medical team tomorrow . He also requests if she improves that\\n she has a prolonged 3 month inpt stay somewhere to prevent her from\\n drinking ETOH.\\n -SW consult ordered- son would like to talk to SW when he comes in\\n tomorrow.\\n - friend is \\\"\\\" and we should not provide him w/ any medical\\n information. If comes to see him we should have security search\\n him for substances prior to his visit.\\n History obtained from Patient, Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 04:26 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 93 (90 - 101) bpm\\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\\n RR: 21 (15 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 17 (17 - 17) mmHg\\n Total In:\\n 8,915 mL\\n 165 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 165 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 330 mL\\n Urine:\\n 409 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -165 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n 127 K/uL\\n 8.7 g/dL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood culture x 2 Pending\\n Peritoneal fluid pending (GS negative)\\n HCV viral load pending\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis. New hallucinations this morning.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG, P\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\\n despite BMs w/ lactulose will start rifaximin\\n -will obtain OSH previous EGD / if any\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\\n negative.\\n -guaiac stools\\n -type and screen\\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\\n necessary\\n -p.m. hct\\n -vitamin k 10 mg IV x 1\\n -if hct < 21 give FFP for elevated PTT and INR\\n # ETOH abuse: thiamine, folate, MVI daily\\n - No evidence of withdrawal, will stop CIWA\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, hepatorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n Plan to begin diuresing very gently if Cr stable by .\\n -IS for atelectasis\\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\\n depletion.\\n -improved\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition: calorie count today\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397668,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n **Events: Around 1500, pt c/o difficulty breathing. LS with crackles\\n and wheezes and O2 sats decreasing into 80s. Pt given\\n albuterol/atrovent nebs and chest xray taken which showed increased\\n pulmonary edema. 20mg IV Lasix given for fluid overload with effect\\n pending. Sats remaining high 80s/low 90s. BP stable post Lasix. Pt also\\n started on PO cipro for UTI but refusing to take.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt agitated, yelling out, increased noted at change of shift, pt\\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\\n t/o. RR 30s.\\n Action:\\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\\n aide in , Pt eventually\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\\n Action:\\n Pt cont OFF levo.\\n Response:\\n BP maintained at goal MAP > 55.\\n Plan:\\n Cont to monitor BPs. Maintain goal MAP > 55.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft/distended with ascites. Rec\\nd pt agitated,\\n yelling out, hallucinating, difficult to reorient. Oriented only to\\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\\n .\\n Action:\\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\\n dose lactulose.\\n Response:\\n Pt cont with only small smears of liquid stool despite increase in\\n lactulose.\\n Plan:\\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\\n therapeutic para for increased bladder pressure.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397802,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett.\\n Action:\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. Hypotensive\\n Action:\\n Pan cx\\nd this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397803,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C\\n Action:\\n Vent changed to PCV\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. Received on four pressors with MAPS ~60. C.O. \\n with SVV\\n Action:\\n On IV Vanco. Pan cx\\nd this shift. Started on Flagyl, Zosyn, Micafungin\\n this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397804,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C 85x400x30 +25. Fentanyl gtt @ 150 mcg/hr and\\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\\n Action:\\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\\n 0.06 mcg/kg/min.\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. Received on four pressors with MAPS ~60. C.O. \\n with SVV\\n Action:\\n On IV Vanco. Pan cx\\nd this shift. Started on Flagyl, Zosyn, Micafungin\\n this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 397830,\n \"text\": \"TITLE:\\n Clinician: Resident\\n Patient had progressively worsening shock, on four pressors, with\\n severe ARDS requiring high PEEPs and profound lactic acidosis.\\n Progressively became more hypotensive, spoke with family (sons)\\n multiple times during day. They arrived here at 5 p.m. and she expired\\n at 5:30 p.m. in the presence of nursing staff, myself, and a social\\n worker. They were aware of the severity of their mother\\ns illness and\\n we provided support afterward. They also requested an autopsy.\\n Total time spent: 15 minutes\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 397831,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 3\\n Ideal body weight: 61.2 None\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 30 cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Bronchial\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Crackles\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern:\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Bedside Procedures:\\n Pleural pressure measurement (1600)\\n Comments:\\n Pt expired plan for autopsy.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 397833,\n \"text\": \"Chief Complaint: Acute respiratory failure\\n HPI:\\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\\n w/respiratory failure and hypotension.\\n 24 Hour Events:\\n Remains intubated, mechanically ventilated.\\n Oxygenation requirement remains high, requiring increased PEEP.\\n Remains on multiple vaospressors to maintain adequate MAP.\\n Worsening lactic acidosis.\\n Rapid influenza negative\\n Allergies:\\n Librium - Confusion/Delir\\n Erythromycin - Hives;\\n Vasotec - hypertension;\\n Last dose of Antibiotics:\\n Cefipime - 01:15 PM\\n Vancomycin - 10:53 PM\\n Infusions:\\n Vasopressin - 2.4 units/hour\\n Fentanyl (Concentrate) - 150 mcg/hour\\n Dopamine - 3 mcg/Kg/min\\n Phenylephrine - 4 mcg/Kg/min\\n Levophed\\n Propofol\\n Cisatricurium\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\\n Other medications:\\n Lactulose, Rifaximin, Hydrocortisone\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 122 (85 - 126) bpm\\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\\n RR: 48 (20 - 48) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 67 Inch\\n Bladder pressure: 15 (14 - 16) mmHg\\n Mixed Venous O2% Sat: 75 - 75\\n Total In:\\n 4,777 mL\\n 3,580 mL\\n PO:\\n TF:\\n IVF:\\n 4,117 mL\\n 2,980 mL\\n Blood products:\\n 200 mL\\n 500 mL\\n Total out:\\n 1,058 mL\\n 540 mL\\n Urine:\\n 818 mL\\n 20 mL\\n NG:\\n 240 mL\\n 120 mL\\n Stool:\\n 400 mL\\n Drains:\\n Balance:\\n 3,719 mL\\n 3,040 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: PCV+\\n Vt (Set): 420 (400 - 420) mL\\n Vt (Spontaneous): 350 (330 - 350) mL\\n PS : 10 cmH2O\\n RR (Set): 36\\n RR (Spontaneous): 7\\n PEEP: 25 cmH2O\\n FiO2: 85%\\n RSBI Deferred: PEEP > 10\\n PIP: 43 cmH2O\\n Plateau: 40 cmH2O\\n SpO2: 96%\\n ABG: 7.18/42/153/15/-12\\n Ve: 12.4 L/min\\n PaO2 / FiO2: 180\\n Physical Examination\\n General Appearance: Overweight / Obese, intubated, sedated\\n Eyes / Conjunctiva: PERRL, icteric sclera\\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, MMM\\n Cardiovascular: RR, tachy, S1, S2, no RMG\\n Extremities/Peripheral Vascular: Warm, palpable radial and DP pulses\\n bilat\\n Respiratory / Chest: Bronchial at bases bilat\\n Abdominal: Soft, Distended, decreased BS\\n Skin: NJaundice\\n Neurologic: Sedated, paralysed, train of four\\n \\n Labs / Radiology\\n 8.5 g/dL\\n 147 K/uL\\n 102 mg/dL\\n 0.9 mg/dL\\n 15 mEq/L\\n 4.7 mEq/L\\n 8 mg/dL\\n 100 mEq/L\\n 135 mEq/L\\n 26.1 %\\n 19.2 K/uL\\n [image002.jpg]\\n 11:15 AM\\n 01:26 PM\\n 03:18 PM\\n 05:33 PM\\n 05:41 PM\\n 01:50 AM\\n 03:57 AM\\n 04:07 AM\\n 05:30 AM\\n 06:35 AM\\n WBC\\n 19.2\\n Hct\\n 25.6\\n 26.1\\n Plt\\n 147\\n Cr\\n 0.9\\n TCO2\\n 21\\n 21\\n 21\\n 23\\n 19\\n 17\\n 14\\n 16\\n Glucose\\n 102\\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\\n Cultures\\n Blood, urine and sputum NGTD\\n Assessment and Plan\\n Gravely ill, with persistent respiratory failure, persistent severe\\n hypotension, progressive academia and metabolic acidosis.\\n RESPIRATORY FAILURE, ACUTE\\n Meets ARDS criteria. Etiology of\\n infiltrates unclear, differential ARDS/PNA, DAH, cardiogenic edema.\\n - Switch back to AC, 4-6cc/kg of IBW TV, will aim to keep PIPs~45\\n pending new esophageal balloon numbers\\n - Inhalers standing to minimize resistance\\n - Consider bronchoscopy to r/o DAH, although tenuous respiratory status\\n at this time.\\n HYPOTENSION/SHOCK\\n Per vigileo, minimal SVV, cardiac output ~,\\n unclear if this is sufficient as improved with dopa. Lactate is\\n worsening, as is LDH, will re-evaluate for intra-abdominal process.\\n Had been favoring a septic/distributive process, although cannot\\n exclude a cardiac component. Sepsis sources include SBP, bowel\\n ischemia, urinary source, line-related infection, C. diff.\\n - On Neo, vasopressin, levophed, dopa\\n - Follow-up cultures, on broad spectrum abx\\n - Consider Swan-Ganz placement\\n - TTE, cycle biomarkers\\n - Increase thiamine dose\\n - RUQ US w/dopplers\\n - Cdiff\\n ACIDOSIS\\n progressive, lactic acidosis. Concern for evolving sepsis,\\n although at risk for bowel ischemia. Doubt thiamine deficiency (as\\n received iv thiamine dose). Monitor ABG, lactic acid. HCO3 drip as\\n needed to maintain pH >7.20.\\n CIRRHOSIS OF LIVER, ALCOHOLIC\\n Stable Tbili, INR up somewhat\\n - On rifaxamin, lactulose\\n - Appreciate hepatology input\\n - Will need FFP prior to procedures\\n RENAL FAILURE\\n Decreased UOP since midnight, with elevated Cr. Poor\\n dialysis candidate at this time.\\n - Follow UOP with volume challenge\\n ICU Care\\n Nutrition: NPO\\n Glycemic Control: Insulin Sc\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT: P-boots\\n Stress ulcer: PPI\\n VAP: Chlorhexidine, HOB to 30 degrees\\n Comments:\\n Communication: Attempting to contact family to update on her condition\\n Code status: Full code\\n Disposition : ICU\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 397827,\n \"text\": \"Clinician: Nurse\\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Pt dysynchronous with vent at start of shift, vent changed to PCV\\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\\n mg/kg/hr, titrated per train of four for twitches. Temp max 102.1\\n po, pan cx\\nd this shift. Lactate on the rise throughout shift, multiple\\n doses of sodium bicarb given and started on D5W with 3 amps bicarb @\\n 150 cc/hr. BP labile throughout the shift with ^ing pressor\\n requirements. Albumin given as ordered. Please see metavision for\\n multiple abg\\ns/vent changes.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 397828,\n \"text\": \"Clinician: Nurse\\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Pt dysynchronous with vent at start of shift, vent changed to PCV\\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\\n mg/kg/hr, titrated per train of four. Temp max 102.1 po, pan cx\\nd this\\n shift. Lactate on the rise throughout shift, multiple doses of sodium\\n bicarb given and started on D5W with 3 amps bicarb @ 150 cc/hr. BP\\n labile throughout the shift with ^ing pressor requirements. Albumin\\n given as ordered. Please see metavision for multiple abg\\ns/vent\\n changes. Family in to visit in afternoon, emotional support proviced.\\n S/W consulted. Pt became drop in HR,drop in BP with family at bedside.\\n Dr. spoke with family and CPRNI.Pastor notified and in to pray\\n with family at bedside. Fammily has requested an autopsy. Necklaace\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 397829,\n \"text\": \"Clinician: Nurse\\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Pt dysynchronous with vent at start of shift, vent changed to PCV\\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\\n mg/kg/hr, titrated per train of four. Temp max 102.1 po, pan cx\\nd this\\n shift. Lactate on the rise and more acidotic throughout shift, multiple\\n doses of sodium bicarb given and started on D5W with 3 amps bicarb @\\n 150 cc/hr. BP labile throughout the shift with Neo, Levo, &Vasopressin\\n maxed, Dopa titrated to 10mcg/kg/min. Albumin given as ordered. Please\\n see metavision for multiple abg\\ns/vent changes. Sonsx2/girlfriendsx2 in\\n to visit in afternoon, emotional support proviced. S/W consulted. Pt\\n became hypotensive and bradycardic with family at bedside. Dr. \\n spoke with family with plan for no further escalation of care.Pastor\\n consulted->to bedside to pray with family. Family has requested an\\n autopsy. Necklace with charm and watch sent home with son.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 397836,\n \"text\": \"Clinician: Nurse\\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Pt dysynchronous with vent, started on parlytics this shift. Temp max\\n 102.1, pan cx\\nd this shift. Pt with worsening shock, severe ARDS\\n requiring PEEP of 25 and profound lactic acidosis. Multiple doses of\\n sodium bicarb given and started on D5W with 3 amps bicarb @ 150 cc/hr.\\n Please see metavision for multiple abg\\ns/vent changes. BP labile\\n throughout the shift->Neo, Levo, & Vasopressin maxed, Dopa titrated to\\n 10mcg/kg/min. Albumin given as ordered. Abx given as ordered.\\n Sonsx2/girlfriendsx2 in to visit in afternoon, updated on status and\\n plan of care, emotional support proviced. S/W consulted, at bedside. Pt\\n became hypotensive and bradycardic with family at bedside. Dr. \\n spoke with family, no further escalation of care, pronounced @ 1730.\\n Pastor consulted->to bedside to pray with family. Family has requested\\n an autopsy. Necklace with charm and watch sent home with family.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397807,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\\n Action:\\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\\n Started on lacrilube paralytic.Multiple ABG\\ns sent. Fentanyl and\\n propofol gtts titrated. Desaturated to 84 after being placed on L side\\n for Abd U/S.\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\\n(on the rise). Received on\\n four pressors with MAPS ~60. C.O. with SVV\\n Action:\\n 50 gm Albumin given. On IV Vanco. Pan cx\\nd this shift. Started on\\n Flagyl, Zosyn, Micafungin this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397808,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\\n Action:\\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\\n Started on lacrilube paralytic.Multiple ABG\\ns sent. Fentanyl and\\n propofol gtts titrated. Desaturated to 84 after being placed on L side\\n for Abd U/S.\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\\n(on the rise). Received on\\n four pressors with MAPS ~60. A-line dampened, tolerating MAPS >60 per\\n NIBP (Dr. aware). C.O. with SVV\\n Action:\\n 50 gm Albumin given. On IV Vanco. Pan cx\\nd this shift. Started on\\n Flagyl, Zosyn, Micafungin this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397809,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\\n Action:\\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\\n Started on lacrilube paralytic.Multiple ABG\\ns sent. Fentanyl and\\n propofol gtts titrated. Desaturated to 84 after being placed on L side\\n for Abd U/S.\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. WBC= 192. Lactate 9.6 with am labs_. Now\\n 12.2-13.7(on the rise). Received on four pressors with MAPS ~60. A-line\\n dampened, tolerating MAPS >60 per NIBP (Dr. aware). C.O. \\n with SVV\\n Action:\\n 50 gm Albumin given. NS 1L bolus given. Received total of 150 mEq Na\\n bicarb IVP and started on D5W with 3 amps bicarb @ 150 cc/hr. On IV\\n Vanco. Pan cx\\nd this shift. Started on Flagyl, Zosyn, Micafungin this\\n shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397805,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\\n Action:\\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\\n Multiple ABG\\ns sent. Fentanyl and propofol gtts titrated. Desaturated\\n to 84 after being placed on L side for Abd U/S.\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\\n(on the rise). Received on\\n four pressors with MAPS ~60. C.O. with SVV\\n Action:\\n 50 gm Albumin given. On IV Vanco. Pan cx\\nd this shift. Started on\\n Flagyl, Zosyn, Micafungin this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397806,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\\n Action:\\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\\n Multiple ABG\\ns sent. Fentanyl and propofol gtts titrated. Desaturated\\n to 84 after being placed on L side for Abd U/S.\\n Response:\\n Plan:\\n Shock, other\\n Assessment:\\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\\n(on the rise). Received on\\n four pressors with MAPS ~60. C.O. with SVV\\n Action:\\n 50 gm Albumin given. On IV Vanco. Pan cx\\nd this shift. Started on\\n Flagyl, Zosyn, Micafungin this shift.\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n TF\\ns off ^ residuals. Abd soft and distended, hypo BS noted.\\n Flexiseal draining loose golden colored stool. ~500\\ns residuals noted.\\n Action:\\n Held all po meds ^ residuals.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397577,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - MELD 27\\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\\n check AFP, GGT, IGG, , hep C viral load\\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\\n paracentesis\\n - Bladder pressure 17\\n - levophed weaned\\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\\n - Son takes care of for the past 6 months or so\\n given worsening mental status. He noticed that she was drinking 1\\n liter of vodka per day. He forced her to stop and then after that she\\n was drinking 3-4 beers per day. She had a male friend that would\\n provide her with klonopin 2mg pills (5 pills at a time). She was only\\n drinking beer and taking klonopin but not eating any other food or\\n leaving her bed. The son then left for two days after getting into a\\n fight with his mother's male friend for one day and then his mother's\\n friend stated that she was becoming more jaundice and was brought to\\n the hospital.\\n -per son the only medication is metformin\\n -per son she is currently full code but will come in for a meeting w/\\n the medical team tomorrow . He also requests if she improves that\\n she has a prolonged 3 month inpt stay somewhere to prevent her from\\n drinking ETOH.\\n -SW consult ordered- son would like to talk to SW when he comes in\\n tomorrow.\\n - friend is \\\"\\\" and we should not provide him w/ any medical\\n information. If comes to see him we should have security search\\n him for substances prior to his visit.\\n History obtained from Patient, Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 04:26 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 93 (90 - 101) bpm\\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\\n RR: 21 (15 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 17 (17 - 17) mmHg\\n Total In:\\n 8,915 mL\\n 165 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 165 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 330 mL\\n Urine:\\n 409 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -165 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n 127 K/uL\\n 8.7 g/dL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood culture x 2 Pending\\n Peritoneal fluid pending (GS negative)\\n HCV viral load pending\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily\\n # ETOH abuse: thiamine, folate, MVI daily\\n -CIWA scale\\n # Anemia:\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, heptorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hyponatremia:\\n -improved\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n -IS for atelectasis\\n # DM: Insulin sliding scale.\\n # FEN: NPO for now until MS clears\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397776,\n \"text\": \"TITLE:\\n Chief Complaint: 49 yoF w/ a h/o hep C and ETOH related cirrhosis\\n presents from hospital with acute hepatic failure.\\n 24 Hour Events:\\n BLOOD CULTURED - At 09:18 AM\\n blood cultures drawn from femoral CVL\\n SPUTUM CULTURE - At 10:00 AM\\n BLOOD CULTURED - At 10:00 AM\\n blood cultures drawn from PICC\\n URINE CULTURE - At 10:20 AM\\n ESOPHOGEAL BALLOON - At 02:30 PM\\n -patient hypotensive requiring max dose levophed and vasopressin, as\\n well as intermittent neosynephrine\\n -hydrocortisone 50mg IV q6hrs started (serving dual purpose for alcohol\\n hepatitis and as stress dose steroids)\\n -given hypotension patient pan-cultured and started on broad spectrum\\n antibiotics\\n -respiratory viral screen negative\\n -50g albumin given\\n -CVO2 75%\\n -Rifaximin started\\n -lactulose uptitrated - pt had 1 BM, started dulcolax and senna\\n -Esophageal balloon placed, PEEP uptitrated to 22\\n -hct relatively stable\\n -insulin drip initiated\\n -Vigileo initiated, Stroke volume variation 13- 1L fluid challenege, no\\n change in BP, over course of night SVV increased to 19. Gave 1L IVF\\n and 25g of albumin in 500cc.\\n -attempted calling son x 2 overnight given worsening clinical status\\n -Additional 500cc bolus NS given and 50g IV albumin ordered\\n -ABG 7.14 / 39 / 140 on AC 400 x 30- breathing at a rate of 35 and w/\\n tidal volumes of 500. RR increased to 36, and pt breathing at 40 after\\n this. PaO2 140, PEEP 25, FiO2 100%. 2 amps of bicarb given.\\n -patient dysynchronous w/ the ventilator despite 70 of propofol and\\n 150mcg of fentanyl. Unresponsive. Peak pressures increasing to low\\n 40s (previously mid / low 30s) and unable to control PCO2 / normalize\\n pH- decision made to paralyze.\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin - 10:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\\n Cefipime - 01:15 PM\\n Vancomycin - 10:53 PM\\n Infusions:\\n Vasopressin - 2.4 units/hour\\n Fentanyl (Concentrate) - 150 mcg/hour\\n Dopamine - 3 mcg/Kg/min\\n Phenylephrine - 4 mcg/Kg/min\\n Cisatracurium - 0.1 mg/Kg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\\n Cisatracurium - 07:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 122 (85 - 126) bpm\\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\\n RR: 48 (20 - 48) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 67 Inch\\n Bladder pressure: 15 (14 - 16) mmHg\\n Mixed Venous O2% Sat: 75 - 75\\n Total In:\\n 4,777 mL\\n 3,588 mL\\n PO:\\n TF:\\n IVF:\\n 4,117 mL\\n 2,988 mL\\n Blood products:\\n 200 mL\\n 500 mL\\n Total out:\\n 1,058 mL\\n 540 mL\\n Urine:\\n 818 mL\\n 20 mL\\n NG:\\n 240 mL\\n 120 mL\\n Stool:\\n 400 mL\\n Drains:\\n Balance:\\n 3,719 mL\\n 3,051 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: PCV+\\n Vt (Set): 420 (400 - 420) mL\\n Vt (Spontaneous): 350 (330 - 350) mL\\n PS : 10 cmH2O\\n RR (Set): 36\\n RR (Spontaneous): 7\\n PEEP: 25 cmH2O\\n FiO2: 85%\\n RSBI Deferred: PEEP > 10\\n PIP: 43 cmH2O\\n Plateau: 40 cmH2O\\n SpO2: 96%\\n ABG: 7.18/42/153/15/-12\\n Ve: 12.4 L/min\\n PaO2 / FiO2: 180\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 147 K/uL\\n 8.5 g/dL\\n 102 mg/dL\\n 0.9 mg/dL\\n 15 mEq/L\\n 4.7 mEq/L\\n 8 mg/dL\\n 100 mEq/L\\n 135 mEq/L\\n 26.1 %\\n 19.2 K/uL\\n [image002.jpg]\\n 11:15 AM\\n 01:26 PM\\n 03:18 PM\\n 05:33 PM\\n 05:41 PM\\n 01:50 AM\\n 03:57 AM\\n 04:07 AM\\n 05:30 AM\\n 06:35 AM\\n WBC\\n 19.2\\n Hct\\n 25.6\\n 26.1\\n Plt\\n 147\\n Cr\\n 0.9\\n TCO2\\n 21\\n 21\\n 21\\n 23\\n 19\\n 17\\n 14\\n 16\\n Glucose\\n 102\\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Shock: at this point seems to be related to possible infectious\\n cause, end stage liver disease, propofol. Would also consider adverse\\n reaction to FFP or IV vitamin K. On levo, vaso.\\n - MAP goal > 55\\n - empiric vanc/zosyn/cipro\\n - stress dose steroids\\n - follow UOP, pulse pressure variation to assess intravascular volume\\n - check ECHO\\n - check TSH/FT4\\n - wean propofol\\n - check lytes, hct, ABG, lactate q6h\\n # Respiratory failure/ARDS: Worsening hypoxia on and intubated\\n in setting of receiving volume and severe liver disease. Differential\\n includes volume overload versus infection versus pulm hemorrhage vs\\n TROLI in setting of transfusion though unlikely. Would also consider\\n PCP given IVDU history.\\n - ARDSnet protocol with low tidal volumes\\n - PaO2 > 60, SaO2 > 90\\n - empiric antibx\\n - r/o flu\\n - may consider bronch\\n - hold on diuresis for now but will consider pending creatinine trend,\\n UOP\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis. New hallucinations this morning.\\n - restarted steroids with undetectable HCV viral load\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG , + 1:20\\n -HCV VL < 43\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose and rifaxamin\\n -will obtain OSH previous EGD / if any\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, hepatorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n - follow UOP and trend creatinine\\n - renally dose meds\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\\n and hct stable.\\n -guaiac stools\\n -active type and screen\\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\\n necessary\\n -p.m. hct\\n # ETOH abuse: No evidence of withdrawal\\n - thiamine, folate, MVI daily\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397780,\n \"text\": \"TITLE:\\n Chief Complaint: 49 yoF w/ a h/o hep C and ETOH related cirrhosis\\n presents from hospital with acute hepatic failure.\\n 24 Hour Events:\\n BLOOD CULTURED - At 09:18 AM\\n blood cultures drawn from femoral CVL\\n SPUTUM CULTURE - At 10:00 AM\\n BLOOD CULTURED - At 10:00 AM\\n blood cultures drawn from PICC\\n URINE CULTURE - At 10:20 AM\\n ESOPHOGEAL BALLOON - At 02:30 PM\\n -patient hypotensive requiring max dose levophed and vasopressin, as\\n well as intermittent neosynephrine\\n -hydrocortisone 50mg IV q6hrs started (serving dual purpose for alcohol\\n hepatitis and as stress dose steroids)\\n -given hypotension patient pan-cultured and started on broad spectrum\\n antibiotics\\n -respiratory viral screen negative\\n -50g albumin given\\n -CVO2 75%\\n -Rifaximin started\\n -lactulose uptitrated - pt had 1 BM, started dulcolax and senna\\n -Esophageal balloon placed, PEEP uptitrated to 22\\n -hct relatively stable\\n -insulin drip initiated\\n -Vigileo initiated, Stroke volume variation 13- 1L fluid challenege, no\\n change in BP, over course of night SVV increased to 19. Gave 1L IVF\\n and 25g of albumin in 500cc.\\n -attempted calling son x 2 overnight given worsening clinical status\\n -Additional 500cc bolus NS given and 50g IV albumin ordered\\n -ABG 7.14 / 39 / 140 on AC 400 x 30- breathing at a rate of 35 and w/\\n tidal volumes of 500. RR increased to 36, and pt breathing at 40 after\\n this. PaO2 140, PEEP 25, FiO2 100%. 2 amps of bicarb given.\\n -patient dysynchronous w/ the ventilator despite 70 of propofol and\\n 150mcg of fentanyl. Unresponsive. Peak pressures increasing to low\\n 40s (previously mid / low 30s) and unable to control PCO2 / normalize\\n pH- decision made to paralyze.\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Levofloxacin - 10:00 AM\\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\\n Cefipime - 01:15 PM\\n Vancomycin - 10:53 PM\\n Infusions:\\n Vasopressin - 2.4 units/hour\\n Fentanyl (Concentrate) - 150 mcg/hour\\n Dopamine - 3 mcg/Kg/min\\n Phenylephrine - 4 mcg/Kg/min\\n Cisatracurium - 0.1 mg/Kg/hour\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:00 AM\\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\\n Cisatracurium - 07:30 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.7\\nC (99.8\\n HR: 122 (85 - 126) bpm\\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\\n RR: 48 (20 - 48) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 67 Inch\\n Bladder pressure: 15 (14 - 16) mmHg\\n Mixed Venous O2% Sat: 75 - 75\\n Total In:\\n 4,777 mL\\n 3,588 mL\\n PO:\\n TF:\\n IVF:\\n 4,117 mL\\n 2,988 mL\\n Blood products:\\n 200 mL\\n 500 mL\\n Total out:\\n 1,058 mL\\n 540 mL\\n Urine:\\n 818 mL\\n 20 mL\\n NG:\\n 240 mL\\n 120 mL\\n Stool:\\n 400 mL\\n Drains:\\n Balance:\\n 3,719 mL\\n 3,051 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: PCV+\\n Vt (Set): 420 (400 - 420) mL\\n Vt (Spontaneous): 350 (330 - 350) mL\\n PS : 10 cmH2O\\n RR (Set): 36\\n RR (Spontaneous): 7\\n PEEP: 25 cmH2O\\n FiO2: 85%\\n RSBI Deferred: PEEP > 10\\n PIP: 43 cmH2O\\n Plateau: 40 cmH2O\\n SpO2: 96%\\n ABG: 7.18/42/153/15/-12\\n Ve: 12.4 L/min\\n PaO2 / FiO2: 180\\n Physical Examination\\n GEN: intubated sedated., unresponsive\\n HEENT: PERRL, minimally reactive\\n CARD: RRR, HSM at the LLSB\\n PULM: CTAB ant\\n ABD: soft, obese, NT\\n EXT: WWP, no c/c/e\\n NEURO: sedated, unresponsive, paralyzed, pupils minimally reactive to\\n light. Train of 4: .\\n Labs / Radiology\\n 147 K/uL\\n 8.5 g/dL\\n 102 mg/dL\\n 0.9 mg/dL\\n 15 mEq/L\\n 4.7 mEq/L\\n 8 mg/dL\\n 100 mEq/L\\n 135 mEq/L\\n 26.1 %\\n 19.2 K/uL\\n [image002.jpg]\\n 11:15 AM\\n 01:26 PM\\n 03:18 PM\\n 05:33 PM\\n 05:41 PM\\n 01:50 AM\\n 03:57 AM\\n 04:07 AM\\n 05:30 AM\\n 06:35 AM\\n WBC\\n 19.2\\n Hct\\n 25.6\\n 26.1\\n Plt\\n 147\\n Cr\\n 0.9\\n TCO2\\n 21\\n 21\\n 21\\n 23\\n 19\\n 17\\n 14\\n 16\\n Glucose\\n 102\\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Shock: sepsis versus hepatic failure.\\n - MAP goal > 55\\n - empiric vanc/zosyn/cipro\\n - stress dose steroids\\n - follow UOP, pulse pressure variation to assess intravascular volume\\n - possible swan ganz catheter plcmt today to further evaluate\\n hemodynamics, especially given good BP and Cardiac index response to\\n dopamine\\n - check ECHO\\n - wean fentanyl\\n - q6hrs lactate\\n -send c diff\\n # Respiratory failure/ARDS: intubated related to ARDS.\\n -ECHO\\n -possible swan plcmt\\n -ARDSnet ventilation\\n -attempt to wean FiO2\\n .\\n # Acute hepatic failure:\\n -f/u liver recs\\n -steroids\\n -AFP normal\\n -lactulose and rifaximin\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, hepatorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n - follow UOP and trend creatinine\\n - renally dose meds\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\\n and hct stable.\\n -guaiac stools\\n -active type and screen\\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\\n necessary\\n -p.m. hct\\n # ETOH abuse: No evidence of withdrawal\\n - thiamine, folate, MVI daily\\n # DM: Insulin sliding scale.\\n # FEN: when GI output decreasing can start tube feeds.\\n # PPX: PPI, INR elevated- hct stable so will restart sc heparin\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 02:32 AM\\n PICC Line - 12:40 PM\\n Arterial Line - 06:29 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397800,\n \"text\": \"49 yo woman with history of hepatitis C complicated by cirrhosis,\\n active alcohol abuse with history of alcohol withdrawal seizures,\\n chronic pancreatitis transferred from Hospital with\\n hepatic failure and hypotension.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 397748,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 3\\n Ideal body weight: 61.2\\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 19 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff pressure: 30 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: Green / Thin\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: A/C 400x30/+25/1.0\\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\\n efforts, High flow demand\\n Invasive ventilation assessment:\\n Trigger work assessment: Abnormal trigger efforts (efforts during\\n inspiratory)\\n Dysynchrony assessment: appears dysynchronous\\n Comments: Pt overbreathing vent with high flow demand, rate increased\\n in an effort to match; desat necessitating increased Fi02/peep up to\\n 25; unable to tol recruitment d/t dysynchrony\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures: Unable to measure esophageal pressures d/t\\n dysynchrony; RSBI held d/t peep/Fi02\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 397448,\n \"text\": \"Chief Complaint: transfer from for liver failure\\n HPI:\\n 49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \\n hospital after presenting with worsening jaundice and fatigue. She was\\n noted there to be hypotensive to the low 80s systolic, noted to have an\\n elevated bili and INR- she was given 4 Liters IVF and transferred to\\n the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\\n was given 4 L IVF in hospital, 3 L in the ER at .\\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\\n sat: 94% on 5L O2 NC.\\n Currently the patient complains of generalized abdominal pain, moreso\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\\n her abdominal pain beginning.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Infusions:\\n Norepinephrine - 0.16 mcg/Kg/min\\n Other ICU medications:\\n Morphine Sulfate - 03:30 AM\\n Other medications:\\n (patient unsure of medications, none on list from hospital)\\n patient states she takes insulin.\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Hepatitis C.\\n 2. Alcoholic hepatitis.\\n 3. History of alcohol abuse with withdraw seizures and DTs in the\\n past.\\n 4. History of hypertension.\\n 5. History of chronic pancreatitis.\\n 6. Status post cesarean section and ectopic pregnancies in the past.\\n 7. History of traumatic wrist laceration in the past status post\\n surgical repair with blood transfusions in .\\n 8. S/P ccy, s/p oophorectomy\\n 9. DM II\\n non contributory\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: 6 tabs of tylenol 3 days ago, 1 pint of hard liquor on \\n however the patient's history is relatively unreliable given\\n encephalopathy. She lives w/ friends, smokes and is a current\\n abuser of ETOH (daily)- unable to quantify. H/o opiate abuse but no\\n opiates x 1 year.\\n Review of systems:\\n Flowsheet Data as of 03:54 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n HR: 94 (94 - 95) bpm\\n BP: 115/74(84) {115/74(84) - 115/74(84)} mmHg\\n RR: 22 (12 - 22) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Total In:\\n 6,172 mL\\n PO:\\n TF:\\n IVF:\\n 172 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 90 mL\\n Urine:\\n 60 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 6,082 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n Vitals - T: BP: HR: RR: 02 sat:\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: serum tylenol negative\\n serum etoh negative\\n serum opiates negative\\n serum benzos +\\n Imaging: RUQ ultrasound: (prelim) Very echogenic liver, limited\\n assessment of gallbladder and portal vein. Ascites, predominantly in\\n the RUQ, but not a good window to mark. Consider ultrasound guided\\n paracentesis.\\n CXR: (my read) hilar fullness w/ mild pulm vascular engorgement,\\n infiltrates in the RML and RUL.\\n CT abd / pelvis w/ contrast: . (prelim)\\n liver w/ heterogeneous attenuation, shrunken nodular appearance.\\n Several areas of hypodensities in segement 2 of the liver could\\n represent perfusion defects, dilated bile ducts or could be related to\\n underlying mass effect. Anasarca. No evidence of portal vein\\n thrombosis. Bibasilar atelectasis.\\n Microbiology: BCx x 2 P\\n Peritoneal fluid cx P\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis given history and transaminase pattern.\\n -paracentesis negative for sbp\\n -liver consult\\n -liver ultrasound with doppler was a difficult study,\\n -discriminate function is 172. Will start steroids x 1 week then\\n taper.\\n -will give vitamin K to correct any portion of elevated INR that may be\\n nutritional\\n -thiamine, folate, MVI daily\\n -lactulose- titrate to 3 BMs daily\\n -send AFP given risk of HCC and finding on CT abd\\n -Send Uhcg\\n # Hypotension: no clear cause for hypotension with the exception of\\n worsening liver function and possible infectious etiologies including\\n pneumonia and possible urinary tract infection.\\n -continue levofloxacin / ceftriaxone.\\n -keep MAP > 55\\n -has rec'd 7 liters IVF and likely fluid replete, appears euvolemic on\\n exam\\n # Hyponatremia: possibly related to volume overload / liver disease.\\n -urine lytes\\n # Hypoxia: appears to have R sided opacities which may be pneumonia.\\n She has rec'd ceftriaxone. Will add levofloxacin in addition to CTX\\n for severe CAP.\\n -abx\\n -f/u blood cultures\\n -sputum culture\\n -IS for atelectasis\\n # ETOH abuse: h/o w/d seizures in the past.\\n -CIWA scale w/ valium.\\n # DM: Insulin sliding scale.\\n # FEN: NPO for now until MS clears\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT:\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397449,\n \"text\": \"49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \\n hospital after presenting with worsening jaundice and fatigue. She was\\n noted there to be hypotensive to the low 80s systolic, noted to have an\\n elevated bili and INR- she was given 4 Liters IVF and transferred to\\n the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\\n was given 4 L IVF in hospital, 3 L in the ER at .\\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\\n sat: 94% on 5L O2 NC.\\n Currently the patient complains of generalized abdominal pain, moreso\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\\n her abdominal pain beginning.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397445,\n \"text\": \"Cirrhosis of liver, alcoholic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hepatic encephalopathy\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397450,\n \"text\": \"49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \\n Hospital after worsening abd pain, jaundice and fatigue. She was noted\\n there to be hypotensive w/ SBP to the 80\\ns, w/ an elevated bili and\\n INR. She was given 4L IVF and transferred to the ER.\\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\\n (for concern of SBP) A right femoral line was placed. Pt placed on\\n Levophed & given 3L IVF.\\n Currently the patient complains of generalized abdominal pain, more so\\n of the lower abdomen. No SOB, no Chest pain. She denies any other\\n symptoms. She has given conflicting reports regarding ETOH intake,\\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\\n her abdominal pain beginning. Pt is a poor historian overall.\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hypotension (not Shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 397517,\n \"text\": \"Chief Complaint: 49 yo woman with history of hepatitis C complicated by\\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\\n seizures, chronic pancreatitis transferred from Hospital\\n with hepatic failure and hypotension\\n Hypotension (not Shock)\\n Assessment:\\n Continues on levo gtt to keep MAP > 55, low uo < 30 cc/hr, hr nsr\\n 80\\ns-90\\n Action:\\n Levo gtt weaned down to 0.03 mic/kg/min but not able to keep map> 55 on\\n that dose so gtt titrated back up, 5% albumim 500 cc\\n x 2 today, labs\\n sent as ordered\\n Response:\\n Not able to wean levo off, minimal improvement in uo & bp after albumin\\n Plan:\\n Levo gtt as ordered to keep MAP > 55, ? a-line insertion this PM,\\n frequent labs as ordered\\n Cirrhosis of liver, alcoholic\\n Assessment:\\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o # abdominal pain,\\n oriented x , calm & cooperative, minimal uo, on levo gtt to maintain\\n map > 55\\n Action:\\n Frequent labs sent as ordered, po lactulose as ordered, liver consult\\n placed, chest ct today, bladder pressure done, iv morphine given x 2 &\\n po oxycodone x 1, npo except ice chips, iv albumin given\\n Response:\\n Bladder pressure 17, no stool, abdominal pain down to #1-2 after\\n narcotics, not able to wean levo off, minimal response from iv albumin\\n Plan:\\n Continue to monitor for sepsis/pancreatitis/GI bleeding, po lactulose\\n as ordered, wean levo as able, iv protonix/iv antibiotics as ordered,\\n pain controll\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 397582,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - MELD 27\\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\\n check AFP, GGT, IGG, , hep C viral load\\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\\n paracentesis\\n - Bladder pressure 17\\n - levophed weaned\\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\\n - Son takes care of for the past 6 months or so\\n given worsening mental status. He noticed that she was drinking 1\\n liter of vodka per day. He forced her to stop and then after that she\\n was drinking 3-4 beers per day. She had a male friend that would\\n provide her with klonopin 2mg pills (5 pills at a time). She was only\\n drinking beer and taking klonopin but not eating any other food or\\n leaving her bed. The son then left for two days after getting into a\\n fight with his mother's male friend for one day and then his mother's\\n friend stated that she was becoming more jaundice and was brought to\\n the hospital.\\n -per son the only medication is metformin\\n -per son she is currently full code but will come in for a meeting w/\\n the medical team tomorrow . He also requests if she improves that\\n she has a prolonged 3 month inpt stay somewhere to prevent her from\\n drinking ETOH.\\n -SW consult ordered- son would like to talk to SW when he comes in\\n tomorrow.\\n - friend is \\\"\\\" and we should not provide him w/ any medical\\n information. If comes to see him we should have security search\\n him for substances prior to his visit.\\n History obtained from Patient, Family / Medical records\\n Patient unable to provide history: Encephalopathy\\n Allergies:\\n Librium (Oral) (Chlordiazepoxide Hcl)\\n Confusion/Delir\\n Erythromycin Base\\n Hives;\\n Vasotec (Oral) (Enalapril Maleate)\\n hypertension;\\n Last dose of Antibiotics:\\n Ceftriaxone - 12:05 AM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 04:26 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 93 (90 - 101) bpm\\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\\n RR: 21 (15 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 67 Inch\\n Bladder pressure: 17 (17 - 17) mmHg\\n Total In:\\n 8,915 mL\\n 165 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n 1,715 mL\\n 165 mL\\n Blood products:\\n 1,000 mL\\n Total out:\\n 439 mL\\n 330 mL\\n Urine:\\n 409 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 8,476 mL\\n -165 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n GENERAL: NAD, AOx2\\n HEENT: MM slightly dry, JVP 9cm\\n CARDIAC: RRR, SEM at the USB\\n LUNG: ronchi of R lower and middle lung fields\\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\\n EXT: WWP, no c/c/e\\n NEURO: asterixis, mild confusion and somnolence\\n DERM: jaundice, icterus\\n Labs / Radiology\\n 127 K/uL\\n 8.7 g/dL\\n 182 mg/dL\\n 1.0 mg/dL\\n 21 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 101 mEq/L\\n 134 mEq/L\\n 26.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 06:01 AM\\n 05:20 PM\\n 10:08 PM\\n 02:21 AM\\n 04:15 AM\\n WBC\\n 17.7\\n 10.6\\n Hct\\n 35.2\\n 27.8\\n 26.5\\n 28.0\\n 26.3\\n Plt\\n 238\\n 127\\n Cr\\n 0.9\\n 1.0\\n 1.0\\n Glucose\\n 176\\n 182\\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\\n mg/dL\\n Blood culture x 2 Pending\\n Peritoneal fluid pending (GS negative)\\n HCV viral load pending\\n Assessment and Plan\\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \\n hospital with acute hepatic failure.\\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\\n and hep C) and has had an acute decompensation. Likely related to\\n alcoholic hepatitis.\\n -per liver consult have sent hep C viral load and have stopped steroids\\n -paracentesis negative for SBP\\n -AFP normal, GGT 83, IgG, P\\n -trend LFTs- bili and INR increasing\\n -d/w family (Son today at 1 p.m. w/ social work\\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\\n lactulose will start rifaximin\\n -will obtain OSH previous EGD / if any\\n # ETOH abuse: thiamine, folate, MVI daily\\n -CIWA scale\\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\\n negative.\\n -guaiac stools\\n -type and screen.\\n -transfuse for hct < 25, transfuse w/ Lasix when necessary\\n -p.m. hct\\n -if hct < 25 give FFP for elevated PTT and INR\\n # Hypotension: at this point seems to be related to possible infectious\\n cause but more likely to significant end stage liver disease. Off\\n pressors since 3:30 a.m. .\\n -MAP goal > 55\\n -were treating pneumonia mainly on the basis of radiographic findings,\\n but given new CT findings w/o any infiltrate and only volume overload\\n can stop antibiotics at this point. WBC normal, patient is afebrile\\n and without cough.\\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\\n that has now started to improve, heptorenal (although Cr not above 1.5\\n and pt does have other reason to have renal failure such as shock, also\\n has seemed to respond to albumin challenge). Contrast nepropathy\\n (although worsening renal function occurred too early for this) or ATN\\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\\n further volume depletion, monitor urine output.\\n -given additional 50g of albumin this a.m.\\n -avoid volume depletion\\n -d/w hepatology any further treatment such as octreotide/midodrine, at\\n this point may not be useful given stabilization of cr\\n # Hyponatremia:\\n -improved\\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\\n point will tolerate hypoxia related to volume overload, will be able to\\n diurese when creatinine has fully stabilized. When diuresing will\\n likely need to use albumin to help avoid further renal hypoperfusion.\\n -IS for atelectasis\\n # DM: Insulin sliding scale.\\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\\n as pt likely will need dobhoff for feeding\\n # PPX: PPI, INR elevated, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: (son) (this\\n is younger brother, if patient dies do not call the younger\\n brother, would like to be notified first so he can tell his\\n younger brother).\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 02:00 AM\\n Multi Lumen - 02:32 AM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: Other)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1114503,\n \"text\": \" 11:23 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Plesea read for right basilic PICC, 46cm. Thanks! #\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with need for PICC line for access.\\n REASON FOR THIS EXAMINATION:\\n Plesea read for right basilic PICC, 46cm. Thanks! #\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST OF \\n\\n COMPARISON: Radiograph .\\n\\n INDICATION: PICC placement.\\n\\n FINDINGS: Right PICC is malpositioned, coursing cephalad in the right\\n internal jugular vein with tip outside of the field of view. This finding was\\n communicated by phone with the IV nurse, .\\n\\n Cardiac silhouette is mildly enlarged and there is persistent widening of the\\n right mediastinal contour, corresponding to prominent mediastinal fat and\\n vascular distention on the recent CT of one day earlier.\\n\\n Interstitial edema has worsened in the interval, and there are also increasing\\n scattered patchy opacities in the right mid and lower lung. These are\\n nonspecific but could potentially represent an early developing\\n bronchopneumonia in the appropriate clinical setting. Opacities in the left\\n base have improved and a small left effusion has decreased in size.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1114296,\n \"text\": \" 10:33 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: assess for pna\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with liver failure, ?pna.\\n REASON FOR THIS EXAMINATION:\\n assess for pna\\n CONTRAINDICATIONS for IV CONTRAST:\\n arf\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE CHEST WITHOUT CONTRAST, \\n\\n INDICATION: Liver failure, and concern for pneumonia.\\n\\n COMPARISON: Abdominal CT, , 00:27 hours.\\n\\n TECHNIQUE: Volumetric CT of the chest was performed without contrast per\\n departmental protocol, including multiplanar reformatted images.\\n\\n CT CHEST: Heart size is upper limits of normal. There are three-vessel\\n coronary artery calcifications. There is no pericardial effusion. Thoracic\\n aorta is normal in caliber and contour throughout. There are mild\\n atherosclerotic calcifications in the arch and descending thoracic aorta.\\n\\n Central airways are patent to the subsegmental level. There are scattered\\n mediastinal small lymph nodes, none meeting specific CT criteria for\\n pathologic enlargement. Thyroid gland is normal.\\n\\n Evaluation of the lung parenchyma shows no focal airspace consolidation.\\n However, there is mild diffuse thickening of the interlobular septa, and\\n irregular areas of linear airspace opacity in the bilateral lower lobes.\\n There are small bilateral pleural effusions, and mild dependent bibasilar\\n atelectasis. Note is also made of mild biapical pleural/parenchymal scarring.\\n\\n This study is not specifically tailored for subdiaphragmatic evaluation.\\n Within the visualized upper abdomen, note is made of moderate ascites around\\n the liver and spleen. However, in contrast to recent abdominal CT of less\\n than 12 hours prior, the ascitic fluid is now high in density, worrisome for\\n development of intraperitoneal hemorrhage. Diffusely hypodense liver, most\\n consistent with fatty liver or changes related to clinically reported liver\\n failure, is unchanged. Geographic areas of slightly different hepatic density\\n probably reflect differing degrees of steatosis.\\n\\n Calcifications within the pancreas consistent with chronic pancreatitis, and\\n cholecystectomy clips are unchanged.\\n\\n OSSEOUS STRUCTURES: There is no osseous lesion suspicious for malignancy.\\n\\n IMPRESSION:\\n\\n (Over)\\n\\n 10:33 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: assess for pna\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 1. No evidence of lobar/bacterial pneumonia. Findings most consistent with\\n volume overload, probably with superimposed areas of linear and dependent\\n atelectasis. A concurrent atypical pneumonia is difficult to exclude.\\n\\n 2. Slight increase in ascites, which is now hyperdense, most consistent with\\n hemorrhage. Findings are very concerning for new intraperitoneal hemorrhage,\\n particularly if there has been a recent procedure such as paracentesis.\\n\\n 3. Unchanged markedly hypodense liver, consistent with fatty liver,\\n presumably related to reported clinical history of liver failure.\\n\\n Findings discussed via telephone with Dr. at 11:30 on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1114551,\n \"text\": \" 4:54 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: SOB\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with liver cirrhosis\\n REASON FOR THIS EXAMINATION:\\n SOB\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: 49-year-old female patient with liver cirrhosis, shortness of\\n breath. Followup examination.\\n\\n FINDINGS: AP single view of the chest obtained with patient in sitting\\n semi-upright position is analyzed in direct comparison with the next preceding\\n similar study obtained four hours earlier during the same day. No significant\\n interval change can be identified. No pneumothorax has developed. The\\n scattered bilateral patchy densities are still present and there is no\\n evidence of gross pleural effusion as the lateral pleural sinuses remain free.\\n\\n IMPRESSION: No significant interval change during last four hours examination\\n interval.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1114713,\n \"text\": \" 8:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: tube placement\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with resp failure\\n REASON FOR THIS EXAMINATION:\\n tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, .\\n\\n HISTORY: 49-year-old woman with respiratory failure and tube placement.\\n\\n FINDINGS: Comparison is made to the previous study from .\\n\\n The tip of the endotracheal tube is 8 cm above the carina, could be advanced 1\\n to 2 cm for optimal placement. The ETT tube has been pulled back since the\\n previous study. The nasogastric tube and side port are well below the\\n gastroesophageal junction. There has been mild improvement of the airspace\\n opacities since the previous study. However, they remain diffuse. There is a\\n right-sided PICC line with the distal lead tip at the distal SVC.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1114598,\n \"text\": \" 3:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with alcohol/hep c cirrhosis s/p intubation\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Status post intubation, cirrhosis, evaluate for change.\\n\\n CHEST:The bilateral densities are now somewhat more confluent than on the\\n prior film of six hours ago and is noticeably worse than the prior film of ten\\n hours before.\\n\\n The position of the various lines and tubes is satisfactory. A nasogastric\\n tube has been placed and the tip lies within the stomach.\\n\\n IMPRESSION: Worsening lung densities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1114578,\n \"text\": \" 10:09 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: intubated\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with intubated\\n REASON FOR THIS EXAMINATION:\\n intubated\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Liver cirrhosis, SOB.\\n\\n CHEST: An endotracheal tube has been placed with the tip at the thoracic\\n inlet. There has been a subtle increase in the bilateral densities since\\n prior scan of four hours previous.\\n\\n IMPRESSION: Endotracheal tube placed. Slight increase in density.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-27 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1114516,\n \"text\": \" 12:20 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: pic repositioned. check tip now\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with new picc\\n REASON FOR THIS EXAMINATION:\\n pic repositioned. check tip now\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE AP CHEST, \\n\\n INDICATION: New PICC.\\n\\n FINDINGS: Comparison is made to 11:42 hours. Since\\n previous exam, right PICC has been repositioned, now with tip pointing\\n inferiorly, at roughly the position of the superior cavoatrial junction. Lung\\n volumes are extremely low, limiting evaluation of cardiomediastinal contours,\\n which are probably unchanged. Interstitial pulmonary edema appears slightly\\n worse.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1114242,\n \"text\": \" 12:04 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with acute liver failure\\n REASON FOR THIS EXAMINATION:\\n eval for acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 49-year-old female with acute liver failure. Evaluate for acute\\n process.\\n\\n COMPARISON: CT and chest radiograph of .\\n\\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Evaluation is limited by low lung volumes.\\n Within this limitation, there is right retrocardiac and peripheral mid-lung\\n opacity that may represent atelectasis, but underlying infection is not\\n excluded. There is no pneumothorax. The heart size is normal. Widened\\n mediastinum is most likely a combination of tortuous aorta, low lung volumes\\n and mild overload. Pulmonary vasculature is slightly engorged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-26 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1114244,\n \"text\": \" 12:27 AM\\n CT ABDOMEN W/CONTRAST Clip # \\n Reason: eval for acute process, clot in portal system. Please do CT\\n Field of view: 50 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with abd pain, acute liver failure\\n REASON FOR THIS EXAMINATION:\\n eval for acute process, clot in portal system. Please do CTA\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: EAGg WED 1:53 AM\\n Portal vein patent. Cirrhotic liver with moderate ascites. Atelectatis at b/l\\n lung bases, underlying infection not excluded. Wedge deformity of an upper\\n lumbar vertebra (??L2), new since , but uncertain chronicity.\\n WET READ VERSION #1 EAGg WED 1:48 AM\\n Portal vein patent. Cirrhotic liver with moderate ascites.\\n WET READ VERSION #2 EAGg WED 1:51 AM\\n Portal vein patent. Cirrhotic liver with moderate ascites. Wedge deformity of\\n an upper lumbar vertebra (??L2), new since , but uncertain chronicity.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 49-year-old female with abdominal pain and acute liver failure.\\n Evaluate portal vein.\\n\\n COMPARISON: CT abdomen and CT chest .\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen after\\n administration of 130 cc IV Optiray contrast. Coronal and sagittal reformats\\n were displayed.\\n\\n CT ABDOMEN WITH IV CONTRAST: There is extensive bibasilar atelectasis in the\\n lungs with trace pleural effusion bilaterally. Underlying infection is not\\n excluded. Coronary artery calcifications are noted, but the heart is\\n otherwise unremarkable.\\n\\n The liver demonstrates low and heterogeneous attenuation with shrunken nodular\\n contour. Several areas of hypodensity are noted within segment II of the\\n liver and may represent perfusion abnormality, focal hepatitis, or dilated\\n bile ducts, but underlying mass lesion is not excluded in context of\\n cirrhosis. There is enlargement of the caudate lobe with exaggerated\\n hypoattenuation consistent with severe fatty infiltration, particularly at the\\n inferior of the caudate. There is a 4-mm newly apparent round hypodensity in\\n segment VII of the liver (2:27), which is incompletely evaluated but may\\n represent a cyst. There is no extrahepatic biliary ductal dilatation.\\n\\n The main portal vein and major branches are patent without filling defect.\\n Gastric and splenic varices are noted.\\n\\n There is moderate diffuse ascites and anasarca.\\n\\n The patient is status post cholecystectomy. The pancreas demonstrates diffuse\\n calcification, as before, consistent with chronic pancreatitis. Splenomegaly\\n (Over)\\n\\n 12:27 AM\\n CT ABDOMEN W/CONTRAST Clip # \\n Reason: eval for acute process, clot in portal system. Please do CT\\n Field of view: 50 Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n is less apparent than on concurrent ultrasound, measuring up to 12 cm. The\\n bilateral adrenal glands are unremarkable. The kidneys enhance and excrete\\n contrast symmetrically, without evidence of hydronephrosis or hydroureter.\\n There are small nonspecific portacaval and periaortic lymph nodes not meeting\\n CT criteria for pathologic enlargement. No mesenteric lymphadenopathy meeting\\n CT criteria for pathologic enlargement is noted. The stomach and\\n intra-abdominal loops of bowel are unremarkable. There is an\\n ascites-containing ventral abdominal wall hernia. There is no free air in the\\n abdomen.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\\n There is a wedge deformity of the L2 vertebral body, likely chronic in nature\\n but new since . There is atherosclerotic calcification of the abdominal\\n aorta.\\n\\n IMPRESSION:\\n\\n 1. No evidence of portal vein thrombosis.\\n\\n 2. Cirrhotic liver with stigmata of liver disease. New segmental regions of\\n hypodensity in segment II of the liver which may represent perfusion\\n abnormality, focal hepatitis or dilated intrahepatic ducts, but underlying\\n mass lesion is not excluded. Further assessment could be performed by MRI once\\n the patient is able to cooperate with breathhold instructions.\\n\\n 3. Moderate ascites and anasarca.\\n\\n 4. Bibasilar atelectasis, underlying infection is not excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-25 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1114235,\n \"text\": \" 10:25 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: eval for acute process/thrombus. Also please mark for parac\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with acute liver failure\\n REASON FOR THIS EXAMINATION:\\n eval for acute process/thrombus. Also please mark for paracentesis.\\n ______________________________________________________________________________\\n WET READ: EAGg TUE 11:42 PM\\n Very echogenic liver, limited assessment of gallbladder and portal vein.\\n Ascites, predominantly in the RUQ, but not a good window to mark. Consider\\n ultrasound guided paracentesis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 49-year-old female with acute liver failure. Evaluate for acute\\n process or thrombus. Mark for paracentesis.\\n\\n COMPARISON: Ultrasound of and CT, .\\n\\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic and\\n shrunken. No focal hepatic lesion is identified on this limited exam. The\\n gallbladder is not identified. The main portal vein could not be assessed.\\n Visualized portion of the pancreas is unremarkable. The spleen appears mildly\\n enlarged measuring approximately 13 cm. There is a small-to-moderate amount of\\n ascites, predominantly in the right upper quadrant but there is no suitable\\n site to mark for paracentesis.\\n\\n IMPRESSION:\\n\\n 1. Limited ultrasound of the right upper quadrant with diffusely echogenic\\n liver. Slightly shrunken morphology suggests more advanced forms of liver\\n disease such as fibrosis or cirrhosis.\\n\\n 2. Gallbladder and main portal vein not visualized.\\n\\n 3. Small-to-moderate amount of ascites, predominantly in the right upper\\n quadrant but there is no suitable window to mark.\\n\\n 4. Splenomegaly.\\n\\n Findings were discussed with Dr. at 11:40 p.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1114758,\n \"text\": \" 11:21 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \\n Reason: please evaluate for portal vein thrombosis or budd chiari w/\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with alk hep now w/ worsening pressor requirement and rising\\n lactate\\n REASON FOR THIS EXAMINATION:\\n please evaluate for portal vein thrombosis or budd chiari w/ doppler\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SAT 2:55 PM\\n Non-diagnostic study due to technical limitations. Hepatic steatosis is\\n _____.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Rising lactate, evaluate for portal vein thrombosis or Budd-Chiari\\n syndrome.\\n\\n COMPARISON: .\\n\\n FINDINGS: This is a non-diagnostic study. Due to the patient's body habitus\\n and intubated state, diagnostic Doppler studies could not be obtained. Fatty\\n infiltration of the liver is again noted in visualized regions of the liver\\n parenchyma.\\n\\n IMPRESSION: Non-diagnostic study due to technical limitations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-12-29 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1114759,\n \"text\": \", D. MED MICU-7 11:21 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \\n Reason: please evaluate for portal vein thrombosis or budd chiari w/\\n Admitting Diagnosis: ACUTE LIVER FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old woman with alk hep now w/ worsening pressor requirement and rising\\n lactate\\n REASON FOR THIS EXAMINATION:\\n please evaluate for portal vein thrombosis or budd chiari w/ doppler\\n ______________________________________________________________________________\\n PFI REPORT\\n Non-diagnostic study due to technical limitations. Hepatic steatosis is\\n _____.\\n\\n\"\n }\n]"}}},{"rowIdx":24295,"cells":{"subject_id":{"kind":"number","value":48368,"string":"48,368"},"hadm_id":{"kind":"number","value":109685,"string":"109,685"},"target_text":{"kind":"string","value":"He arrived via med flight to ED awake and alert. In ED noted to have expanding hematoma tracking up arm from fistula into the chest wall with a very large amt of blood in the chest wall. A CT torso at was negative for aortic abnormality or retroperitoneal bleed. Three liters of fluid and 2 units of PRBC were given at then he received aother unit of PRBC here at as well as 2 units of FFP and a six pack of platelets. A small needle hole was noted in AVF. A single stitch was placed with hemostasis. HCT slowly trended down each day to 23.4 on . Epogen was given at dialysis. He was admitted to the SICU for monitoring with serial hematocrits drawn. An U/S was done to assess for active bleeding. This was a limited study due to extensive hematoma. No pseudoaneurysm was visualized. His arm was kept elevated. Tylenol was given for comfort. On , Hct decreased to 23. He was transfused with 2 units of PRBC while in hemodialsyis. Hemodialsyis was done via the R tunnelled HD line. Upon admission, cardiac enzymes were cycled for previously noted T wave changes. These were negative for MI. He was dialyzed via the tunnelled HD line on for 1.5 liters and again on . Vital signs remained stable. The LUE arm circumference measured 12 inches with extensive bruising. Sensation was intact. Diet was advanced and tolerated. Ileo conduit was draining well. PT and OT evaluated him given that his wife reported that he had fallen at home and that she was not strong enough to assist him to get up. PT recommended rehab. He will be discharged to at , ."},"extractive_notes_summ":{"kind":"string","value":"Non-specific inferolateral T waveflattening. Left axisdeviation. Consider left anterior fascicular block. Cannot exclude ischemia. Prolonged Q-T interval. Probable sinus rhythm with premature atrial beats, although baseline artifactmakes P wave morphology difficult. T wave inversion inleads V1-V4."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2191-09-09 00:00:00.000","description":"Report","row_id":265068,"text":"Probable sinus rhythm with premature atrial beats, although baseline artifact\nmakes P wave morphology difficult. Prolonged Q-T interval. Left axis\ndeviation. Consider left anterior fascicular block. T wave inversion in\nleads V1-V4. Cannot exclude ischemia. Non-specific inferolateral T wave\nflattening. No previous tracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2191-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 265068,\n \"text\": \"Probable sinus rhythm with premature atrial beats, although baseline artifact\\nmakes P wave morphology difficult. Prolonged Q-T interval. Left axis\\ndeviation. Consider left anterior fascicular block. T wave inversion in\\nleads V1-V4. Cannot exclude ischemia. Non-specific inferolateral T wave\\nflattening. No previous tracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24296,"cells":{"subject_id":{"kind":"number","value":10212,"string":"10,212"},"hadm_id":{"kind":"number","value":157506,"string":"157,506"},"target_text":{"kind":"string","value":"The patient was initially admitted to the Endoscopic retrograde cholangiopancreatography Service and status post performance of her endoscopic retrograde cholangiopancreatography, she was transferred to the Intensive Care Unit and later to the regular medical floor. The patient's vital signs remained stable. Her abdominal pain improved. She was initially NPO and was advanced to clear liquids. However, she had some vomiting which was responsive to Compazine and Droperidol. She was later changed back to NPO for this and her diet was subsequently advanced to the point where she was tolerating solids on the day of discharge. The patient was also started on Protonix, Ciprofloxacin and Flagyl during this admission for treatment of potential biliary infection and gastrointestinal prophylaxis. The patient has been doing well since transfer to the medical floor. She is being discharged home on ."},"extractive_notes_summ":{"kind":"string","value":"S/P cholecystectomy with intact cystic duct remnant. Mild pancreatic ductal dilatation is associated with this finding. IMPRESSION: Multiple calculi and slightly dilated common bile duct. #20 ANGIO LEFT ANTECUBITAL IV ACCESS.GI: PT IS NPO. 2) Right cardiophrenic angle opacity, probably due to a prominent pericardial fat pad. FINDINGS: Transabdominal images reveal post cholecystectomy changes including common bile duct dilatation. There is dilatation of the common bile duct with multiple filling defects consistent with calculi. Increased amylase/lipase, increasaed lfts/wbc and dilated CBD with ? S/P biliary sphincterotomy and extraction of multiple calculi. IMPRESSION: 1) Findings suggest obstructing common bile duct stone, causing common bile duct dilatation and mild pancreatic duct dilatation. At this level, intraluminal fluid surrounds a hyperechoic structure which casts an acoustic shadow and lies approximately at the head of the pancreas. Left ventricular hypertrophy.Anterolateral ST-T wave abnormalities may be due to ischemia.TRACING #1 There is contrast filling of the common bile duct, common hepatic duct, right and left hepatic ducts and multiple intrahepatic biliary divisions. However, the distal portion of the duct appears dramatically dilated, measuring as great as 1.8 cm. ALT IN COMFORT: PT C/O HEADACHE AT545 AM, GIVEN TYLENOL AS ORDERED. IV D51/2NS INFUSING, CHANGED TO IV NS AT 150CC/H. thanx FINAL REPORT ABDOMINAL ULTRASOUND, : CLINICAL: 63 y/o/f with abdominal pain and findings of acute pancreatitis. TMAX=101.5 BLOOD CULTS WERE DONE. PMH: CHOLECYSTECTOMY,APPY 84, PANCREATITIS 84. filling defect at distal end. DURING ERCP PT : DROPERIDOL 5MG, FENTANYL 350MG, VERSED 7.5 MG, AND GLUCAGON 0.2MG. Assess for free intraperitoneal air. MANY STONES WERE EXTRACTED FROM THE COMMON BILE DUCT WHICH WERE CAUSING OBSTRUCTION OF BILIARY TREE.IN ER SHE RECEIVED: MSO4 4MG IV,ASA 325 MG, LOPRESSOR 5MG IV,ZANTAC 50MG IV, FLAGYL 500MG IV,CIPRO 400MG IV, AND TYLENOL. Sinus rhythm. Sinus rhythm. ALLERGY: PCN. SHE HAD ABDOMENAL CT THEN WAS SENT TO FOR A ERCP. SUPINE ABDOMEN: Gas and feces can be seen throughout the large bowel. The lungs reveal apparent focal area of increased opacity in the right cardiophrenic angle region, possibly due to a prominent pericardial fat pad. REASON FOR THIS EXAMINATION: R/O CBD stone FINAL REPORT ERCP. HISTORY: Acute pancreatitis with increasing LFT's, and dilated common bile duct on son with possible stone in distal duct. NO N&V CURRENTLY, +BS.GU: FOLEY CATH IN PLACE, CLEAR YELLOW URINE, LARGE AMTS.SKIN: NO RED OR OPEN AREAS NOTED.RESP: LUNG SOUNDS CLEAR, O2 2L NC, SATS 97-99%SOCIAL: DAUGHTER VISITED PT AND SPOKE WITH RESIDENT AFTER ARRIVAL HERE.PLAN: IV ANTIBIOTICS, IV FLUIDS. please page with prelim report. IV NS AT 150CC/H SHE CAME TO THE ER 10/25AM AFTER 12HOURS OF ABDOMENAL PAIN, CHEST PAIN, SOB, FEVER,CHILLS AND N&V-CLEAR FLUID. Dedicated PA and lateral chest radiograph may be helpful for more complete assessment of this region, when the patient's condition permits. HR NSR NO ECTOPY 80'S. Abnormal left axis deviation. S/P biliary sphincterotomy and extraction of multiple calculi with aid of balloon and basket. NO WEAKNESSES JUST VERY SLEEPY.CARDIOVASCULAR: AFEBRILE. ALL PERIPHERAL PULSES PALPABLE. There is also filling of the cystic duct remnant. 5:21 AM PORTABLE ABDOMEN Clip # Reason: rule out free air, abnormal bowel loops MEDICAL CONDITION: 63 year old woman with abdominal pain REASON FOR THIS EXAMINATION: rule out free air, abnormal bowel loops FINAL REPORT INDICATION: Abdominal pain. IMPRESSION: 1) No radiographic evidence of free intraperitoneal air. There is a dextroconcave curvature to the lower lumbar spine. PUPILS =+. The pancreatic tail is not visualized. Five fluoroscopic spot films are provided. The aorta is slightly unfolded. The exam also demonstrates a normal-appearing spleen, a 10.6 cm normal- appearing left kidney, and a normal-appearing 10.5 cm right kidney. 7:49 AM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: 64 yo female with acute pancreatitis s/p ccy in1984, please MEDICAL CONDITION: 63 year old woman with see above REASON FOR THIS EXAMINATION: 64 yo female with acute pancreatitis s/p ccy in1984, please evaluate for intraductal dilation and /or other findings sig for pancreatitis. RECOGNIZES FAMILY, DOES NOT SPEAK MUCH ENGLISH.NEURO: NO DEFICITS NOTED. 5:21 AM CHEST (PORTABLE AP) Clip # Reason: rule out free air MEDICAL CONDITION: 63 year old woman with abdominal pain REASON FOR THIS EXAMINATION: rule out free air FINAL REPORT PORTABLE CHEST, : CLINICAL INDICATION: Abdominal pain."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2164-11-15 00:00:00.000","description":"Report","row_id":112262,"text":"Sinus rhythm. No change since earlier this date.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2164-11-15 00:00:00.000","description":"Report","row_id":112263,"text":"Sinus rhythm. Abnormal left axis deviation. Left ventricular hypertrophy.\nAnterolateral ST-T wave abnormalities may be due to ischemia.\nTRACING #1\n\n"},{"category":"Nursing/other","chartdate":"2164-11-16 00:00:00.000","description":"Report","row_id":1397237,"text":"ALT IN COMFORT: PT C/O HEADACHE AT545 AM, GIVEN TYLENOL AS ORDERED. ALERT AND ORIENTED,NEUROS INTACT. VSS. IV NS AT 150CC/H\n"},{"category":"Radiology","chartdate":"2164-11-15 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":745225,"text":" 5:21 AM\n PORTABLE ABDOMEN Clip # \n Reason: rule out free air, abnormal bowel loops\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n rule out free air, abnormal bowel loops\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain.\n\n SUPINE ABDOMEN: Gas and feces can be seen throughout the large bowel. No\n abnormal small bowel loops are seen. There is a dextroconcave curvature to\n the lower lumbar spine.\n\n IMPRESSION: No evidence of ileus or obstruction.\n\n"},{"category":"Radiology","chartdate":"2164-11-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":745224,"text":" 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n rule out free air\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST, :\n\n CLINICAL INDICATION: Abdominal pain. Assess for free intraperitoneal air.\n\n No prior films are available for comparison.\n\n The heart size is normal. The aorta is slightly unfolded. The lungs reveal\n apparent focal area of increased opacity in the right cardiophrenic angle\n region, possibly due to a prominent pericardial fat pad. No free\n intraperitoneal air is identified, and no pleural effusions or pneumothoraces\n are detected.\n\n IMPRESSION: 1) No radiographic evidence of free intraperitoneal air.\n 2) Right cardiophrenic angle opacity, probably due to a prominent pericardial\n fat pad. Dedicated PA and lateral chest radiograph may be helpful for more\n complete assessment of this region, when the patient's condition permits.\n\n"},{"category":"Radiology","chartdate":"2164-11-15 00:00:00.000","description":"ERCP S&I (74330)","row_id":745297,"text":" 9:42 AM\n ERCP S&I () Clip # \n Reason: R/O CBD stone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with acute onset abd pain. Increased amylase/lipase,\n increasaed lfts/wbc and dilated CBD with ? filling defect at distal end.\n REASON FOR THIS EXAMINATION:\n R/O CBD stone\n ______________________________________________________________________________\n FINAL REPORT\n ERCP.\n\n HISTORY: Acute pancreatitis with increasing LFT's, and dilated common bile\n duct on son with possible stone in distal duct.\n\n Five fluoroscopic spot films are provided.\n There is contrast filling of the common bile duct, common hepatic duct, right\n and left hepatic ducts and multiple intrahepatic biliary divisions. There is\n also filling of the cystic duct remnant. There is dilatation of the common\n bile duct with multiple filling defects consistent with calculi. S/P biliary\n sphincterotomy and extraction of multiple calculi with aid of balloon and\n basket.\n\n IMPRESSION: Multiple calculi and slightly dilated common bile duct. S/P\n cholecystectomy with intact cystic duct remnant. S/P biliary sphincterotomy\n and extraction of multiple calculi.\n\n\n"},{"category":"Radiology","chartdate":"2164-11-15 00:00:00.000","description":"ABDOMEN U.S. (COMPLETE STUDY)","row_id":745230,"text":" 7:49 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: 64 yo female with acute pancreatitis s/p ccy in1984, please\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with see above\n REASON FOR THIS EXAMINATION:\n 64 yo female with acute pancreatitis s/p ccy in1984, please evaluate for\n intraductal dilation and /or other findings sig for pancreatitis.\n please page with prelim report.\n thanx\n \n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND, :\n\n CLINICAL: 63 y/o/f with abdominal pain and findings of acute pancreatitis.\n\n FINDINGS: Transabdominal images reveal post cholecystectomy changes including\n common bile duct dilatation. Proximally, the duct measures approximately 9\n mm. However, the distal portion of the duct appears dramatically dilated,\n measuring as great as 1.8 cm. At this level, intraluminal fluid surrounds a\n hyperechoic structure which casts an acoustic shadow and lies approximately at\n the head of the pancreas. Mild pancreatic ductal dilatation is associated\n with this finding. No ascites, intrahepatic ductal dilatation, or clearly\n visualized additional common bile duct stone is present.\n\n The exam also demonstrates a normal-appearing spleen, a 10.6 cm normal-\n appearing left kidney, and a normal-appearing 10.5 cm right kidney.\n\n No peripancreatic fluid collections are identified. The pancreatic tail is\n not visualized.\n\n IMPRESSION:\n 1) Findings suggest obstructing common bile duct stone, causing common bile\n duct dilatation and mild pancreatic duct dilatation.\n\n"},{"category":"Nursing/other","chartdate":"2164-11-15 00:00:00.000","description":"Report","row_id":1397236,"text":"ADMISSION NOTE: PTISA 64 YEAR OLD RUSSIAN SPEAKING WOMAN. SHE CAME TO THE ER 10/25AM AFTER 12HOURS OF ABDOMENAL PAIN, CHEST PAIN, SOB, FEVER,CHILLS AND N&V-CLEAR FLUID. PMH: CHOLECYSTECTOMY,APPY 84, PANCREATITIS 84. ALLERGY: PCN. SHE HAD ABDOMENAL CT THEN WAS SENT TO FOR A ERCP. MANY STONES WERE EXTRACTED FROM THE COMMON BILE DUCT WHICH WERE CAUSING OBSTRUCTION OF BILIARY TREE.\nIN ER SHE RECEIVED: MSO4 4MG IV,ASA 325 MG, LOPRESSOR 5MG IV,ZANTAC 50MG IV, FLAGYL 500MG IV,CIPRO 400MG IV, AND TYLENOL. TMAX=101.5 BLOOD CULTS WERE DONE. DURING ERCP PT : DROPERIDOL 5MG, FENTANYL 350MG, VERSED 7.5 MG, AND GLUCAGON 0.2MG. SHE WAS SUPPOSED TO BE ADMITTED TO MICU BUT NO BED WAS AVAILABLE.\n\nSHE ARRIVED AT 9PM BY AMBULANCE IN MICU WITH NO REPORT CALLED TO US.\nMENTAL STATUS: PT IS VERY LETHARGIC BUT AROUSABLE. MOVES ALL EXTREMITIES,OPENS EYES AND FOLLOWS COMMANDS. RECOGNIZES FAMILY, DOES NOT SPEAK MUCH ENGLISH.\nNEURO: NO DEFICITS NOTED. PUPILS =+. NO WEAKNESSES JUST VERY SLEEPY.\nCARDIOVASCULAR: AFEBRILE. HR NSR NO ECTOPY 80'S. SBP 130-140. SKIN IS WARM AND DRY. IV D51/2NS INFUSING, CHANGED TO IV NS AT 150CC/H. ALL PERIPHERAL PULSES PALPABLE. #20 ANGIO LEFT ANTECUBITAL IV ACCESS.\nGI: PT IS NPO. NO N&V CURRENTLY, +BS.\nGU: FOLEY CATH IN PLACE, CLEAR YELLOW URINE, LARGE AMTS.\nSKIN: NO RED OR OPEN AREAS NOTED.\nRESP: LUNG SOUNDS CLEAR, O2 2L NC, SATS 97-99%\nSOCIAL: DAUGHTER VISITED PT AND SPOKE WITH RESIDENT AFTER ARRIVAL HERE.\nPLAN: IV ANTIBIOTICS, IV FLUIDS. MONITOR OVERNIGHT THEN TRANSFER TO FLOOR.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 112262,\n \"text\": \"Sinus rhythm. No change since earlier this date.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 112263,\n \"text\": \"Sinus rhythm. Abnormal left axis deviation. Left ventricular hypertrophy.\\nAnterolateral ST-T wave abnormalities may be due to ischemia.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2164-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1397237,\n \"text\": \"ALT IN COMFORT: PT C/O HEADACHE AT545 AM, GIVEN TYLENOL AS ORDERED. ALERT AND ORIENTED,NEUROS INTACT. VSS. IV NS AT 150CC/H\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 745225,\n \"text\": \" 5:21 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: rule out free air, abnormal bowel loops\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman with abdominal pain\\n REASON FOR THIS EXAMINATION:\\n rule out free air, abnormal bowel loops\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Abdominal pain.\\n\\n SUPINE ABDOMEN: Gas and feces can be seen throughout the large bowel. No\\n abnormal small bowel loops are seen. There is a dextroconcave curvature to\\n the lower lumbar spine.\\n\\n IMPRESSION: No evidence of ileus or obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 745224,\n \"text\": \" 5:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: rule out free air\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman with abdominal pain\\n REASON FOR THIS EXAMINATION:\\n rule out free air\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n PORTABLE CHEST, :\\n\\n CLINICAL INDICATION: Abdominal pain. Assess for free intraperitoneal air.\\n\\n No prior films are available for comparison.\\n\\n The heart size is normal. The aorta is slightly unfolded. The lungs reveal\\n apparent focal area of increased opacity in the right cardiophrenic angle\\n region, possibly due to a prominent pericardial fat pad. No free\\n intraperitoneal air is identified, and no pleural effusions or pneumothoraces\\n are detected.\\n\\n IMPRESSION: 1) No radiographic evidence of free intraperitoneal air.\\n 2) Right cardiophrenic angle opacity, probably due to a prominent pericardial\\n fat pad. Dedicated PA and lateral chest radiograph may be helpful for more\\n complete assessment of this region, when the patient's condition permits.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"ERCP S&I (74330)\",\n \"row_id\": 745297,\n \"text\": \" 9:42 AM\\n ERCP S&I () Clip # \\n Reason: R/O CBD stone\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman with acute onset abd pain. Increased amylase/lipase,\\n increasaed lfts/wbc and dilated CBD with ? filling defect at distal end.\\n REASON FOR THIS EXAMINATION:\\n R/O CBD stone\\n ______________________________________________________________________________\\n FINAL REPORT\\n ERCP.\\n\\n HISTORY: Acute pancreatitis with increasing LFT's, and dilated common bile\\n duct on son with possible stone in distal duct.\\n\\n Five fluoroscopic spot films are provided.\\n There is contrast filling of the common bile duct, common hepatic duct, right\\n and left hepatic ducts and multiple intrahepatic biliary divisions. There is\\n also filling of the cystic duct remnant. There is dilatation of the common\\n bile duct with multiple filling defects consistent with calculi. S/P biliary\\n sphincterotomy and extraction of multiple calculi with aid of balloon and\\n basket.\\n\\n IMPRESSION: Multiple calculi and slightly dilated common bile duct. S/P\\n cholecystectomy with intact cystic duct remnant. S/P biliary sphincterotomy\\n and extraction of multiple calculi.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"ABDOMEN U.S. (COMPLETE STUDY)\",\n \"row_id\": 745230,\n \"text\": \" 7:49 AM\\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \\n Reason: 64 yo female with acute pancreatitis s/p ccy in1984, please\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman with see above\\n REASON FOR THIS EXAMINATION:\\n 64 yo female with acute pancreatitis s/p ccy in1984, please evaluate for\\n intraductal dilation and /or other findings sig for pancreatitis.\\n please page with prelim report.\\n thanx\\n \\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMINAL ULTRASOUND, :\\n\\n CLINICAL: 63 y/o/f with abdominal pain and findings of acute pancreatitis.\\n\\n FINDINGS: Transabdominal images reveal post cholecystectomy changes including\\n common bile duct dilatation. Proximally, the duct measures approximately 9\\n mm. However, the distal portion of the duct appears dramatically dilated,\\n measuring as great as 1.8 cm. At this level, intraluminal fluid surrounds a\\n hyperechoic structure which casts an acoustic shadow and lies approximately at\\n the head of the pancreas. Mild pancreatic ductal dilatation is associated\\n with this finding. No ascites, intrahepatic ductal dilatation, or clearly\\n visualized additional common bile duct stone is present.\\n\\n The exam also demonstrates a normal-appearing spleen, a 10.6 cm normal-\\n appearing left kidney, and a normal-appearing 10.5 cm right kidney.\\n\\n No peripancreatic fluid collections are identified. The pancreatic tail is\\n not visualized.\\n\\n IMPRESSION:\\n 1) Findings suggest obstructing common bile duct stone, causing common bile\\n duct dilatation and mild pancreatic duct dilatation.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2164-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1397236,\n \"text\": \"ADMISSION NOTE: PTISA 64 YEAR OLD RUSSIAN SPEAKING WOMAN. SHE CAME TO THE ER 10/25AM AFTER 12HOURS OF ABDOMENAL PAIN, CHEST PAIN, SOB, FEVER,CHILLS AND N&V-CLEAR FLUID. PMH: CHOLECYSTECTOMY,APPY 84, PANCREATITIS 84. ALLERGY: PCN. SHE HAD ABDOMENAL CT THEN WAS SENT TO FOR A ERCP. MANY STONES WERE EXTRACTED FROM THE COMMON BILE DUCT WHICH WERE CAUSING OBSTRUCTION OF BILIARY TREE.\\nIN ER SHE RECEIVED: MSO4 4MG IV,ASA 325 MG, LOPRESSOR 5MG IV,ZANTAC 50MG IV, FLAGYL 500MG IV,CIPRO 400MG IV, AND TYLENOL. TMAX=101.5 BLOOD CULTS WERE DONE. DURING ERCP PT : DROPERIDOL 5MG, FENTANYL 350MG, VERSED 7.5 MG, AND GLUCAGON 0.2MG. SHE WAS SUPPOSED TO BE ADMITTED TO MICU BUT NO BED WAS AVAILABLE.\\n\\nSHE ARRIVED AT 9PM BY AMBULANCE IN MICU WITH NO REPORT CALLED TO US.\\nMENTAL STATUS: PT IS VERY LETHARGIC BUT AROUSABLE. MOVES ALL EXTREMITIES,OPENS EYES AND FOLLOWS COMMANDS. RECOGNIZES FAMILY, DOES NOT SPEAK MUCH ENGLISH.\\nNEURO: NO DEFICITS NOTED. PUPILS =+. NO WEAKNESSES JUST VERY SLEEPY.\\nCARDIOVASCULAR: AFEBRILE. HR NSR NO ECTOPY 80'S. SBP 130-140. SKIN IS WARM AND DRY. IV D51/2NS INFUSING, CHANGED TO IV NS AT 150CC/H. ALL PERIPHERAL PULSES PALPABLE. #20 ANGIO LEFT ANTECUBITAL IV ACCESS.\\nGI: PT IS NPO. NO N&V CURRENTLY, +BS.\\nGU: FOLEY CATH IN PLACE, CLEAR YELLOW URINE, LARGE AMTS.\\nSKIN: NO RED OR OPEN AREAS NOTED.\\nRESP: LUNG SOUNDS CLEAR, O2 2L NC, SATS 97-99%\\nSOCIAL: DAUGHTER VISITED PT AND SPOKE WITH RESIDENT AFTER ARRIVAL HERE.\\nPLAN: IV ANTIBIOTICS, IV FLUIDS. MONITOR OVERNIGHT THEN TRANSFER TO FLOOR.\\n\"\n }\n]"}}},{"rowIdx":24297,"cells":{"subject_id":{"kind":"number","value":29703,"string":"29,703"},"hadm_id":{"kind":"number","value":128711,"string":"128,711"},"target_text":{"kind":"string","value":"A/P: Pt is a 19 yo male with an extensive psychiatric history as well as a history of poly-substance abuse in the past who presents with fever, sore throat and respiratory distress. . # Multifocal pneumonia: Initially, due to concern for respiratory distress and fever, Pt was assessed by CT scan for pharyngeal abscess, which was negative. His initial CXR, however, showed a multifocal pneumonia by CXR. Pt received Azithromycin, Ceftriaxone, and Vancomycin in the ED as well as solumedrol and stablized from a respiratory standpoint. He was admitted to the ICU because of the extent of his initial respiratory distress, but was saturating at or near 100% on RA at that point. Upon transfer to the floor pt remained febrile, but was saturating in the mid 90s on room air. Vancomycin was discontinued in the setting of 72 hours of negative blood cultures. . With continued fevers, Clindamycin was added given concern for the possibility of aspiration pneumonia. This concern was raised in the setting of a multilobular process combined with the fact that Pt has been taking multiple sedating medications at relatively large doses. Pt defervesced following the addition of clindamycin with decreased cough and improved SaO2, including the maintanence of SaO2 in the 90's during ambulation on . . Given risk factors of IVDU and unprotected sex Pt was tested for HIV and both Antibody and viral load were negative. Influenza a/b DFA was negative. GAHS throat swab was negative as was urine legionella, GC, and Chlamydia. . Pt was discharged in stable condition and was instructed to complete a 14 day course of levofloxacin and clindamycin for likely community acquired pneumonia. . # OCD/MDD: Pt did not manifest any signs or symptoms of active OCD or depression during this admission. He was made aware of the fact that there was concern for the possibility of an aspiration event secondary to over-sedation, but deferred psychiatric consultation on numerous occasions as he prefers to have his medications managed by his outside psychiatrist. A detailed message regarding Pt's clinical course and concern for the possibility of overmedication was left with Pt's psychiatrist on the day of discharge. Pt was otherwise maintained on his home doses of psychiatric medications during this hospitalization."},"extractive_notes_summ":{"kind":"string","value":"LP done, ruled out for meningitis. Droplet precautions D/C'd, flu ruled out. Non pathologically enlarged lymph nodes in mediastinum, most likely reactive. Nursing Progress Note MICU 7Admx Date: Allergies: NKDAAccess: 1 PIVNeuro: Pt. Question of abscess or effusion/empyema formation. ruled out for flu. CXR showed multilobar PNA. Concern for lung abscesses/epmpyema. Slightly prominent lymph nodes are seen within the jugular chain at the level of the mandible (measuring 11 mm in short axis), likely reactive. Resolution of consolidation FINAL REPORT CHEST RADIOGRAPHS INDICATION: Follow up. Tylenol given.GI/GU: Pt. BP 90's to 110's systolic. There are at least two mediastinal lymph nodes measuring 9.9 mm and 3.9 mm along with axillary lymphadenopathy, likely reactive to the underlying pneumonic consolidation. WAS BETWEEN 110-120'S, NOW SR 80'S AND B/P DROPPED TO 91/47. He was given PCN for possible strep throat/tonsillar or retropharygneal abscess. He was given azithromycin IV. 9:34 AM CHEST (PA & LAT) Clip # Reason: Progression vs. Lung sounds coarse at beginning of shift, now decreased.ID: ID following patient. Concern for lung abscesses or empyema. Labs showed leukocytosis and bandemia. INDICATION: Multilobar pneumonia. PMH OCD, h/o IVDU, depression. Incidentally noted is excretion of contrast into bilateral renal collecting systems (from recent CECT neck); there may be UPJ obstruction on the right. CT of neck neg for abscess, cxr showed multilobar pna. The lung volumes remain low and (allowing for technical differences) the patchy airspace process involving the right mid lung and both lung bases has become slightly more confluent. Modest inferior ST-T wave changes which are non-specific.Findings are within normal limits. on Ceftriaxone and Azithromycin. Sinus rhythm. Afebrile.a. Small left pleural effusion with apparent loculation is also demonstrated, new in the interval. pt has some course breath sounds with expiratory wheezing given Alb tx two doses tol well, will continue to monitor. Pt arrived MICU 7 0100am on 100% Nonrebreather o2 sat 100% lungs coarse with faint expiratory wheezing. FINDINGS: In comparison to the previous radiograph from , there is further progression of bilateral parenchymal consolidations. PA AND LATERAL VIEWS OF THE CHEST: Two foci of consolidation are seen; in the lingula and the right upper lobe. Desats to mid 80's when oxygen is off. Additionally, new patchy ill-defined areas of consolidation have developed within the upper lungs, right greater than left. Prevertebral soft tissues appear unremarkable. He was given levofloxacin 750mg iv x1. RECEIVED 1 LITER FOR THIS. (Over) 11:11 AM CT CHEST W/CONTRAST Clip # Reason: Pt with multifocal pneumonia, excessive sputum production. Widespread, multifocal areas of consolidation have progressed in the interval, particularly in the mid and lower lungs bilaterally. DR. Strep swab sent this shift pending. fevers leukocytosis cxr pna has h/o IVDU and unprotected sex r/o HIV pcpOCD, depression. 11:11 AM CT CHEST W/CONTRAST Clip # Reason: Pt with multifocal pneumonia, excessive sputum production. and (ED). Thinner slice 5 mm and 1.25 mm were reconstructed in the axial plane. REASON FOR THIS EXAMINATION: Progression vs. Below the diaphragm, the abdominal structures are unremarkable. PT'S HR. Sating mid 90's on 3 liters. Receiving IVF at 200cc/hr.Resp: Pt. Q Admitting Diagnosis: PNEUMONIA FINAL REPORT (Cont) Continue abx. pt. Pt. Pt. Pt. Pt. PT. PT. PT. PT. IMPRESSION: Worsening widespread multifocal pneumonia with new small partially loculated left pleural effusion. Benzo with drawal. Labs showing positive leukocytosis and bandemia. restarted on home dose of Xanax. IMPRESSION: 1. IMPRESSION: 1. o2 was turned down to 60% he maintained o2 sat of >98%. IMPRESSION: Rapidly progressing right lung and slower but also progressing left lower lobe consolidations. The piriform sinuses contain small foci of air with a normal appearance. NKDA. The epiglottis is normal. No contraindications for IV contrast FINAL REPORT CHEST CT WITHOUT CONTRAST ON TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the subdiaphragmatic area without IV contrast. Does have a smoking hx, has not had a drink since .O. in sinus tach HR 100's up to 120's at end of shift. T max today 100.1 axillary. UA/cx pending. TECHNIQUE: MDCT-acquired axial images were obtained through the neck after the administration of intravenous contrast material. IMPRESSION: Bilateral airspace consolidation in the lingula and right upper lobe, consistent with pneumonia. Urine specs sent including tox screen which is pending.Plan: Pt. BLOOD CULTURES X4 AND SPUTUM CULTURE SENT. not feeling well at time. REMAINS A CALL OUT TO THE FLOOR. The upper lungs are unremarkable."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2201-01-01 00:00:00.000","description":"CHEST (PA & LAT)","row_id":998959,"text":" 9:34 AM\n CHEST (PA & LAT) Clip # \n Reason: Progression vs. Resolution of consolidation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with fever, SOB, productive cough, and multifocal opacification\n on previous CXR.\n REASON FOR THIS EXAMINATION:\n Progression vs. Resolution of consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHS\n\n INDICATION: Follow up.\n\n FINDINGS: In comparison to the previous radiograph from ,\n there is further progression of bilateral parenchymal consolidations.\n Otherwise, the radiograph is unchanged. The size of the cardiac silhouette is\n normal, no evidence of pleural effusions.\n\n IMPRESSION: In comparison to , bilateral opacities have\n further increased. Otherwise unchanged.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2200-12-29 00:00:00.000","description":"CHEST (PA & LAT)","row_id":998475,"text":" 2:20 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with cough and fever\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n WET READ: CXWc MON 3:23 PM\n Bilateral airspace consolidations in the lingula and RUL, concerning for PNA.-\n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man with cough and fever.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: Two foci of consolidation are seen; in the\n lingula and the right upper lobe. There is no pleural effusion. There is no\n pneumothorax. The cardiomediastinal silhouette is normal. Soft tissues and\n osseous structures are unremarkable.\n\n IMPRESSION: Bilateral airspace consolidation in the lingula and right upper\n lobe, consistent with pneumonia.\n\n"},{"category":"Radiology","chartdate":"2200-12-31 00:00:00.000","description":"CHEST (PA & LAT)","row_id":998794,"text":" 10:58 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multilobar PNA\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, \n\n COMPARISON: and radiographs.\n\n INDICATION: Multilobar pneumonia.\n\n Widespread, multifocal areas of consolidation have progressed in the interval,\n particularly in the mid and lower lungs bilaterally. Additionally, new patchy\n ill-defined areas of consolidation have developed within the upper lungs,\n right greater than left. Small left pleural effusion with apparent loculation\n is also demonstrated, new in the interval.\n\n IMPRESSION: Worsening widespread multifocal pneumonia with new small\n partially loculated left pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2200-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":998522,"text":" 5:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with acute onset hypoxia\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, DATED \n\n HISTORY: 19-year-old man with acute-onset hypoxia; rule out pneumothorax.\n\n FINDINGS: Single bedside AP examination labeled \"upright with grid\" is\n compared with the study obtained some two hours earlier. The lung volumes\n remain low and (allowing for technical differences) the patchy airspace\n process involving the right mid lung and both lung bases has become slightly\n more confluent. There is no pneumothorax or pleural effusion and the\n cardiomediastinal silhouette and pulmonary vessels are unchanged, with no\n evidence of hilar adenopathy. Incidentally noted is excretion of contrast into\n bilateral renal collecting systems (from recent CECT neck); there may be UPJ\n obstruction on the right. Large-bore tubing overlies the upper abdomen.\n\n COMMENT: Findings reviewed with Drs. and (ED).\n\n"},{"category":"Radiology","chartdate":"2201-01-01 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":998984,"text":" 11:11 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Pt with multifocal pneumonia, excessive sputum production. Q\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with h/o IVDU, fever, productive cough, s/p ICU stay, now\n sating 90% on RA with continued sputum production. Concern for lung\n abscesses/epmpyema.\n REASON FOR THIS EXAMINATION:\n Pt with multifocal pneumonia, excessive sputum production. Question of abscess\n or effusion/empyema formation.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT WITHOUT CONTRAST ON \n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the subdiaphragmatic area without IV contrast. Thinner slice 5 mm and 1.25 mm\n were reconstructed in the axial plane. Sagittal/coronal reformatted images\n were also obtained.\n\n COMPARISON: None similar. Multiple previous chest radiographs and a CT of\n the neck.\n\n HISTORY: 19-year-old man with a history of IVDU, fever, productive cough,\n status post ICU stay, now saturating at 90% on room air with continued sputum\n production. Concern for lung abscesses or empyema.\n\n FINDINGS: There is extensive multifocal pneumonic consolidation seen in all\n lung segments but mainly be localized in the mid and lower zones. In\n addition, there are bilateral small pleural effusions. There are at least two\n mediastinal lymph nodes measuring 9.9 mm and 3.9 mm along with axillary\n lymphadenopathy, likely reactive to the underlying pneumonic consolidation.\n These consolidations have been rapidly progressing over the period of last 4\n days according to chest radiographs.\n\n The heart is not enlarged. There is no pericardial effusion. The osseous\n structures do not show any lesion suspicious for infectious process or\n malignancy. Below the diaphragm, the abdominal structures are unremarkable.\n\n IMPRESSION:\n 1. Multifocal pneumonia characterized by the presence of consolidation in all\n lung segments along with some reactive lymphadenopathy and accompaning\n pleural fluid bilaterally.\n 2. Non pathologically enlarged lymph nodes in mediastinum, most likely\n reactive.\n\n (Over)\n\n 11:11 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Pt with multifocal pneumonia, excessive sputum production. Q\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2200-12-29 00:00:00.000","description":"CT NECK W/CONTRAST (EG:PAROTIDS)","row_id":998459,"text":" 1:25 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval for epiglottitis, retropharyngeal abscess\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with fever, sore throat, difficulty swallowing and decreased O2\n sats. Throat exam not impressive\n REASON FOR THIS EXAMINATION:\n eval for epiglottitis, retropharyngeal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 3:22 PM\n No tonsillar, retropharyngeal or parapharyngeal abscess. Mild uniform\n thickening of prevert soft tissues without loss of fat planes. -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man with fever, sore throat, difficulty swallowing,\n and decreased oxygen saturation.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the neck after\n the administration of intravenous contrast material. Multiplanar reformatted\n images were also obtained.\n\n FINDINGS: No focal collections suspicious for abscess are seen. No abnormal\n foci of gas within the soft tissues are identified. The piriform sinuses\n contain small foci of air with a normal appearance. The epiglottis is normal.\n Prevertebral soft tissues appear unremarkable.\n\n Slightly prominent lymph nodes are seen within the jugular chain at the level\n of the mandible (measuring 11 mm in short axis), likely reactive. The lingual\n tonsils and adenoids are not significantly enlarged given the patient's age.\n\n Evaluation of the lung apices is limited due to respiratory motion, however,\n no large foci of consolidation are identified in the included upper lobes.\n\n Osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. No acute abnormality.\n\n\n"},{"category":"Radiology","chartdate":"2200-12-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":998554,"text":" 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Re-assess pna\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multilobar pna, hypoxia\n REASON FOR THIS EXAMINATION:\n Re-assess pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia in a patient with multifocal pneumonia.\n\n COMPARISON: Two chest radiographs from , dating 12:52 and\n 5:47 p.m.\n\n A rapid progression in the right lung consolidation is demonstrated with\n currently widespread right lower lobe and anterior segment of right upper lobe\n consolidations demonstrated. The left lower lobe consolidation has also\n progressed in the interim, although less compared to the right lung. There is\n no appreciable pleural effusion, although small amount of right pleural fluid\n cannot be excluded. The upper lungs are unremarkable. The cardiomediastinal\n silhouette is stable.\n\n IMPRESSION:\n\n Rapidly progressing right lung and slower but also progressing left lower lobe\n consolidations. Differential diagnosis in an appropriate clinical setting\n would include rapidly progressing pneumonia. Aspiration or acute drug\n toxicity associated with recreational drug use should be considered, although\n less likely.\n\n\n Findings discussed with Dr at the time of dictation over a phone bbu dr\n \n\n DL\n\n\n DR. \n"},{"category":"Nursing/other","chartdate":"2200-12-30 00:00:00.000","description":"Report","row_id":1646334,"text":"Nursing Progress Note MICU 7\nAdmx Date: \nAllergies: NKDA\nAccess: 1 PIV\n\nNeuro: Pt. lethargic, sleeping most of shift, but easily arousable. Pleasant and cooperative. Answers questions appropriately.\n\nCV: Pt. in sinus tach HR 100's up to 120's at end of shift. ? Benzo with drawal. Pt. restarted on home dose of Xanax. BP 90's to 110's systolic. Receiving IVF at 200cc/hr.\n\nResp: Pt. weaned from high flow face mask to 3 liters nasal cannula. Sating mid 90's on 3 liters. Desats to mid 80's when oxygen is off. CXR showed multilobar PNA. Droplet precautions D/C'd, flu ruled out. Lung sounds coarse at beginning of shift, now decreased.\n\nID: ID following patient. Multiple cultures pending. UA/cx pending. Sputum cultures, blood cultures, HIV/viral load all pending. Pt. ruled out for flu. LP done, ruled out for meningitis. Strep swab sent this shift pending. Labs showing positive leukocytosis and bandemia. Pt. on Ceftriaxone and Azithromycin. T max today 100.1 axillary. Tylenol given.\n\nGI/GU: Pt. tolerating regular diet. Voiding in urinal. Urine specs sent including tox screen which is pending.\n\nPlan: Pt. is a call out. Await cultures. Continue abx. mother is contact person. Pt. to have social work consult. Social work came by today, will come back to see pt. pt. not feeling well at time.\n"},{"category":"Nursing/other","chartdate":"2200-12-31 00:00:00.000","description":"Report","row_id":1646335,"text":"PT. REMAINS A CALL OUT TO THE FLOOR. REFER TO TRANSFER NOTE. PT. REMAINED IN ICU OVERNIGHT DUE TO INCREASE IN O2 DEMAND WHEN O2 SATS DROPPED TO 87% AND PT. REQUIRED 5L/MIN VIA N/C. PT'S HR. WAS BETWEEN 110-120'S, NOW SR 80'S AND B/P DROPPED TO 91/47. PT. RECEIVED 1 LITER FOR THIS. TEMP HAD BEEN 98.3 AT , THEN 101.2 AT 2300. BLOOD CULTURES X4 AND SPUTUM CULTURE SENT. OTHERWISE, PT'S DENIED PAIN OR DISCOMFORT, PT. REMAINS SLIGHTLY ANXIOUS REGARDING HIV TEST RESULTS. PT. CONTINUES TO VOID LARGE AMT'S OF CLEAR YELLOW URINE. PLAN REMAINS TO TRANSFER TO FLOOR, TRANSFER NOTED WRITTEN.\n"},{"category":"Nursing/other","chartdate":"2200-12-30 00:00:00.000","description":"Report","row_id":1646332,"text":"19 yo male with past h/o IVDA (according to patient he has not done IV drugs or cocaine for yrs) had three days of sore throat, cough, sob, ha, decrease po intake, fever, dizziness. He went to ED via ambulance In ED temp 101.2 tachycardiac o2 sats 94% on room air. Labs showed leukocytosis and bandemia. He was given PCN for possible strep throat/tonsillar or retropharygneal abscess. CT of neck neg for abscess, cxr showed multilobar pna. He was given levofloxacin 750mg iv x1. Patient became hypoxic in ED to 80% on nasal canula and he was given methlprednisolone 125mg x1, vanco, ceftriaxone along with 3500cc of NS. LP was also done in ED because of decreased mental status and fever to r/o meningitis. PMH OCD, h/o IVDU, depression. NKDA. Social lives in at where he is a freshman he has a h/o IVDU unclear exactly when he stopped. He had unprotected sex 5 days ago. He is from his mother is his next of phone number , he stated that he did not have a father. Does have a smoking hx, has not had a drink since .\nO. Pt arrived MICU 7 0100am on 100% Nonrebreather o2 sat 100% lungs coarse with faint expiratory wheezing. Resp rate 16 he was placed on a high flow face mask and given neb tx. o2 was turned down to 60% he maintained o2 sat of >98%. Patient rested comfortably for the rest of the night resp rate <18 VSS. IVF NS at 200cc q hr. He was given azithromycin IV. Afebrile.\na. fevers leukocytosis cxr pna has h/o IVDU and unprotected sex r/o HIV pcp\nOCD, depression\n. follow cultures obtain blood cultures this am, antibiotics as ordered, sputum induction for gram stain, cx and pcp, HIV and viral load, nebs prn, wean o2 as tolerated, send DFA for flu droplet precautions until flu r/o, continue home psych meds, SW consult\n"},{"category":"Nursing/other","chartdate":"2200-12-30 00:00:00.000","description":"Report","row_id":1646333,"text":"Respiratory\nPt changed from a NRM to a high flow on 95% seem to tol well, weaned down to 60% maintains sats 98% slept most of the am, plan to get a nasal aspirate and a sputum indution this am. pt has some course breath sounds with expiratory wheezing given Alb tx two doses tol well, will continue to monitor.\n"},{"category":"ECG","chartdate":"2201-01-02 00:00:00.000","description":"Report","row_id":214279,"text":"Sinus rhythm. Modest inferior ST-T wave changes which are non-specific.\nFindings are within normal limits. No previous tracing available\nfor comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-01-01 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 998959,\n \"text\": \" 9:34 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Progression vs. Resolution of consolidation\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with fever, SOB, productive cough, and multifocal opacification\\n on previous CXR.\\n REASON FOR THIS EXAMINATION:\\n Progression vs. Resolution of consolidation\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPHS\\n\\n INDICATION: Follow up.\\n\\n FINDINGS: In comparison to the previous radiograph from ,\\n there is further progression of bilateral parenchymal consolidations.\\n Otherwise, the radiograph is unchanged. The size of the cardiac silhouette is\\n normal, no evidence of pleural effusions.\\n\\n IMPRESSION: In comparison to , bilateral opacities have\\n further increased. Otherwise unchanged.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-12-29 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 998475,\n \"text\": \" 2:20 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with cough and fever\\n REASON FOR THIS EXAMINATION:\\n r/o pna\\n ______________________________________________________________________________\\n WET READ: CXWc MON 3:23 PM\\n Bilateral airspace consolidations in the lingula and RUL, concerning for PNA.-\\n \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 19-year-old man with cough and fever.\\n\\n COMPARISON: None.\\n\\n PA AND LATERAL VIEWS OF THE CHEST: Two foci of consolidation are seen; in the\\n lingula and the right upper lobe. There is no pleural effusion. There is no\\n pneumothorax. The cardiomediastinal silhouette is normal. Soft tissues and\\n osseous structures are unremarkable.\\n\\n IMPRESSION: Bilateral airspace consolidation in the lingula and right upper\\n lobe, consistent with pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-12-31 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 998794,\n \"text\": \" 10:58 AM\\n CHEST (PA & LAT) Clip # \\n Reason: assess for interval change\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with multilobar PNA\\n REASON FOR THIS EXAMINATION:\\n assess for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO VIEW CHEST, \\n\\n COMPARISON: and radiographs.\\n\\n INDICATION: Multilobar pneumonia.\\n\\n Widespread, multifocal areas of consolidation have progressed in the interval,\\n particularly in the mid and lower lungs bilaterally. Additionally, new patchy\\n ill-defined areas of consolidation have developed within the upper lungs,\\n right greater than left. Small left pleural effusion with apparent loculation\\n is also demonstrated, new in the interval.\\n\\n IMPRESSION: Worsening widespread multifocal pneumonia with new small\\n partially loculated left pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 998522,\n \"text\": \" 5:40 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with acute onset hypoxia\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE VIEW OF THE CHEST, DATED \\n\\n HISTORY: 19-year-old man with acute-onset hypoxia; rule out pneumothorax.\\n\\n FINDINGS: Single bedside AP examination labeled \\\"upright with grid\\\" is\\n compared with the study obtained some two hours earlier. The lung volumes\\n remain low and (allowing for technical differences) the patchy airspace\\n process involving the right mid lung and both lung bases has become slightly\\n more confluent. There is no pneumothorax or pleural effusion and the\\n cardiomediastinal silhouette and pulmonary vessels are unchanged, with no\\n evidence of hilar adenopathy. Incidentally noted is excretion of contrast into\\n bilateral renal collecting systems (from recent CECT neck); there may be UPJ\\n obstruction on the right. Large-bore tubing overlies the upper abdomen.\\n\\n COMMENT: Findings reviewed with Drs. and (ED).\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-01-01 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 998984,\n \"text\": \" 11:11 AM\\n CT CHEST W/CONTRAST Clip # \\n Reason: Pt with multifocal pneumonia, excessive sputum production. Q\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with h/o IVDU, fever, productive cough, s/p ICU stay, now\\n sating 90% on RA with continued sputum production. Concern for lung\\n abscesses/epmpyema.\\n REASON FOR THIS EXAMINATION:\\n Pt with multifocal pneumonia, excessive sputum production. Question of abscess\\n or effusion/empyema formation.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST CT WITHOUT CONTRAST ON \\n\\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\\n the subdiaphragmatic area without IV contrast. Thinner slice 5 mm and 1.25 mm\\n were reconstructed in the axial plane. Sagittal/coronal reformatted images\\n were also obtained.\\n\\n COMPARISON: None similar. Multiple previous chest radiographs and a CT of\\n the neck.\\n\\n HISTORY: 19-year-old man with a history of IVDU, fever, productive cough,\\n status post ICU stay, now saturating at 90% on room air with continued sputum\\n production. Concern for lung abscesses or empyema.\\n\\n FINDINGS: There is extensive multifocal pneumonic consolidation seen in all\\n lung segments but mainly be localized in the mid and lower zones. In\\n addition, there are bilateral small pleural effusions. There are at least two\\n mediastinal lymph nodes measuring 9.9 mm and 3.9 mm along with axillary\\n lymphadenopathy, likely reactive to the underlying pneumonic consolidation.\\n These consolidations have been rapidly progressing over the period of last 4\\n days according to chest radiographs.\\n\\n The heart is not enlarged. There is no pericardial effusion. The osseous\\n structures do not show any lesion suspicious for infectious process or\\n malignancy. Below the diaphragm, the abdominal structures are unremarkable.\\n\\n IMPRESSION:\\n 1. Multifocal pneumonia characterized by the presence of consolidation in all\\n lung segments along with some reactive lymphadenopathy and accompaning\\n pleural fluid bilaterally.\\n 2. Non pathologically enlarged lymph nodes in mediastinum, most likely\\n reactive.\\n\\n (Over)\\n\\n 11:11 AM\\n CT CHEST W/CONTRAST Clip # \\n Reason: Pt with multifocal pneumonia, excessive sputum production. Q\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-12-29 00:00:00.000\",\n \"description\": \"CT NECK W/CONTRAST (EG:PAROTIDS)\",\n \"row_id\": 998459,\n \"text\": \" 1:25 PM\\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \\n Reason: eval for epiglottitis, retropharyngeal abscess\\n Contrast: OPTIRAY Amt: 70\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with fever, sore throat, difficulty swallowing and decreased O2\\n sats. Throat exam not impressive\\n REASON FOR THIS EXAMINATION:\\n eval for epiglottitis, retropharyngeal abscess\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: CXWc MON 3:22 PM\\n No tonsillar, retropharyngeal or parapharyngeal abscess. Mild uniform\\n thickening of prevert soft tissues without loss of fat planes. -\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 19-year-old man with fever, sore throat, difficulty swallowing,\\n and decreased oxygen saturation.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MDCT-acquired axial images were obtained through the neck after\\n the administration of intravenous contrast material. Multiplanar reformatted\\n images were also obtained.\\n\\n FINDINGS: No focal collections suspicious for abscess are seen. No abnormal\\n foci of gas within the soft tissues are identified. The piriform sinuses\\n contain small foci of air with a normal appearance. The epiglottis is normal.\\n Prevertebral soft tissues appear unremarkable.\\n\\n Slightly prominent lymph nodes are seen within the jugular chain at the level\\n of the mandible (measuring 11 mm in short axis), likely reactive. The lingual\\n tonsils and adenoids are not significantly enlarged given the patient's age.\\n\\n Evaluation of the lung apices is limited due to respiratory motion, however,\\n no large foci of consolidation are identified in the included upper lobes.\\n\\n Osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No acute abnormality.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-12-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 998554,\n \"text\": \" 3:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Re-assess pna\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 19 year old man with multilobar pna, hypoxia\\n REASON FOR THIS EXAMINATION:\\n Re-assess pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Hypoxia in a patient with multifocal pneumonia.\\n\\n COMPARISON: Two chest radiographs from , dating 12:52 and\\n 5:47 p.m.\\n\\n A rapid progression in the right lung consolidation is demonstrated with\\n currently widespread right lower lobe and anterior segment of right upper lobe\\n consolidations demonstrated. The left lower lobe consolidation has also\\n progressed in the interim, although less compared to the right lung. There is\\n no appreciable pleural effusion, although small amount of right pleural fluid\\n cannot be excluded. The upper lungs are unremarkable. The cardiomediastinal\\n silhouette is stable.\\n\\n IMPRESSION:\\n\\n Rapidly progressing right lung and slower but also progressing left lower lobe\\n consolidations. Differential diagnosis in an appropriate clinical setting\\n would include rapidly progressing pneumonia. Aspiration or acute drug\\n toxicity associated with recreational drug use should be considered, although\\n less likely.\\n\\n\\n Findings discussed with Dr at the time of dictation over a phone bbu dr\\n \\n\\n DL\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1646334,\n \"text\": \"Nursing Progress Note MICU 7\\nAdmx Date: \\nAllergies: NKDA\\nAccess: 1 PIV\\n\\nNeuro: Pt. lethargic, sleeping most of shift, but easily arousable. Pleasant and cooperative. Answers questions appropriately.\\n\\nCV: Pt. in sinus tach HR 100's up to 120's at end of shift. ? Benzo with drawal. Pt. restarted on home dose of Xanax. BP 90's to 110's systolic. Receiving IVF at 200cc/hr.\\n\\nResp: Pt. weaned from high flow face mask to 3 liters nasal cannula. Sating mid 90's on 3 liters. Desats to mid 80's when oxygen is off. CXR showed multilobar PNA. Droplet precautions D/C'd, flu ruled out. Lung sounds coarse at beginning of shift, now decreased.\\n\\nID: ID following patient. Multiple cultures pending. UA/cx pending. Sputum cultures, blood cultures, HIV/viral load all pending. Pt. ruled out for flu. LP done, ruled out for meningitis. Strep swab sent this shift pending. Labs showing positive leukocytosis and bandemia. Pt. on Ceftriaxone and Azithromycin. T max today 100.1 axillary. Tylenol given.\\n\\nGI/GU: Pt. tolerating regular diet. Voiding in urinal. Urine specs sent including tox screen which is pending.\\n\\nPlan: Pt. is a call out. Await cultures. Continue abx. mother is contact person. Pt. to have social work consult. Social work came by today, will come back to see pt. pt. not feeling well at time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-12-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1646335,\n \"text\": \"PT. REMAINS A CALL OUT TO THE FLOOR. REFER TO TRANSFER NOTE. PT. REMAINED IN ICU OVERNIGHT DUE TO INCREASE IN O2 DEMAND WHEN O2 SATS DROPPED TO 87% AND PT. REQUIRED 5L/MIN VIA N/C. PT'S HR. WAS BETWEEN 110-120'S, NOW SR 80'S AND B/P DROPPED TO 91/47. PT. RECEIVED 1 LITER FOR THIS. TEMP HAD BEEN 98.3 AT , THEN 101.2 AT 2300. BLOOD CULTURES X4 AND SPUTUM CULTURE SENT. OTHERWISE, PT'S DENIED PAIN OR DISCOMFORT, PT. REMAINS SLIGHTLY ANXIOUS REGARDING HIV TEST RESULTS. PT. CONTINUES TO VOID LARGE AMT'S OF CLEAR YELLOW URINE. PLAN REMAINS TO TRANSFER TO FLOOR, TRANSFER NOTED WRITTEN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1646332,\n \"text\": \"19 yo male with past h/o IVDA (according to patient he has not done IV drugs or cocaine for yrs) had three days of sore throat, cough, sob, ha, decrease po intake, fever, dizziness. He went to ED via ambulance In ED temp 101.2 tachycardiac o2 sats 94% on room air. Labs showed leukocytosis and bandemia. He was given PCN for possible strep throat/tonsillar or retropharygneal abscess. CT of neck neg for abscess, cxr showed multilobar pna. He was given levofloxacin 750mg iv x1. Patient became hypoxic in ED to 80% on nasal canula and he was given methlprednisolone 125mg x1, vanco, ceftriaxone along with 3500cc of NS. LP was also done in ED because of decreased mental status and fever to r/o meningitis. PMH OCD, h/o IVDU, depression. NKDA. Social lives in at where he is a freshman he has a h/o IVDU unclear exactly when he stopped. He had unprotected sex 5 days ago. He is from his mother is his next of phone number , he stated that he did not have a father. Does have a smoking hx, has not had a drink since .\\nO. Pt arrived MICU 7 0100am on 100% Nonrebreather o2 sat 100% lungs coarse with faint expiratory wheezing. Resp rate 16 he was placed on a high flow face mask and given neb tx. o2 was turned down to 60% he maintained o2 sat of >98%. Patient rested comfortably for the rest of the night resp rate <18 VSS. IVF NS at 200cc q hr. He was given azithromycin IV. Afebrile.\\na. fevers leukocytosis cxr pna has h/o IVDU and unprotected sex r/o HIV pcp\\nOCD, depression\\n. follow cultures obtain blood cultures this am, antibiotics as ordered, sputum induction for gram stain, cx and pcp, HIV and viral load, nebs prn, wean o2 as tolerated, send DFA for flu droplet precautions until flu r/o, continue home psych meds, SW consult\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1646333,\n \"text\": \"Respiratory\\nPt changed from a NRM to a high flow on 95% seem to tol well, weaned down to 60% maintains sats 98% slept most of the am, plan to get a nasal aspirate and a sputum indution this am. pt has some course breath sounds with expiratory wheezing given Alb tx two doses tol well, will continue to monitor.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2201-01-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 214279,\n \"text\": \"Sinus rhythm. Modest inferior ST-T wave changes which are non-specific.\\nFindings are within normal limits. No previous tracing available\\nfor comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":24298,"cells":{"subject_id":{"kind":"number","value":98024,"string":"98,024"},"hadm_id":{"kind":"number","value":126482,"string":"126,482"},"target_text":{"kind":"string","value":"1. Coronary artery disease - The patient's CKs were cycled during hospital course. The patient had a peak CK MB of 157 with an index of 10 at 10:00 p.m. on . The patient's troponin was measured to be greater than 50. The patient was treated with Aspirin, Plavix, Lopressor, Captopril, bedrest, ReoPro drip for twelve hours and then discontinued. Nitroglycerin drip was titrated and discontinued. The patient was maintained on telemetry. The patient had episodes of nonsustained supraventricular tachycardia on telemetry as well as bradycardia after Lopressor treatment began. LDL was checked which was 120. The patient was started on Lipitor 10 milligrams p.o. q.d. During the hospital course, the patient was adequately beta blocked to a heart rate of 80 with a systolic blood pressure of 100 to 120 on 50 milligrams b.i.d. Lopressor. The patient was also treated with Captopril 12.5 milligrams p.o. t.i.d. His blood pressure tolerated this treatment. The patient was provided nutritional counseling for cardiac diet. The patient's urine output was within normal limits during hospital course. After contrast during cardiac catheterization, blood urea nitrogen and creatinine were within normal limits. After ReoPro drip and Heparin treatment, the patient's platelets were within normal limits. During hospital course, the patient complained of chest pain within the hour after arrival to the CCU. Serial electrocardiograms were obtained showing no electrocardiographic changes and no evidence of in stent restenosis. Stat transthoracic echocardiogram was obtained which showed normal left atrium, mild symmetric left ventricular hypertrophy, mild regional left ventricular systolic dysfunction with hypokinesis of the posterior wall and basal inferior wall. Aortic leaflets appeared within normal limits. Mitral leaflets were structurally normal. No mitral valve prolapse and 1+ mitral regurgitation was noted. No pericardial effusion. For further workup of the patient's predisposition for myocardial infarction, lipid protein A and homocystine laboratories were sent which are pending at the time of discharge. The patient complained of gastric upset. He was treated with Prilosec 20 milligrams p.o. q.d. as well as Maalox p.r.n. The patient was noted to have an elevated white count which decreased consistent with myocardial infarction. The patient was noted to have a low grade temperature to 101 which abated which was consistent with recent myocardial infarction. Amylase and lipase were sent when the patient complained of epigastric pain with back pain. Amylase and lipase were both noted to be within normal limits. The patient was discharged on , with the following medications: 1. Atenolol 50 milligrams p.o. q.d. 2. Zestril 2.5 milligrams p.o. q.d. 3. Nitroglycerin 0.4 milligrams sublingual q5minutes p.r.n. chest pain. 4. Prilosec 20 milligrams p.o. q.d. 5. Lipitor 10 milligrams p.o. q.d. 6. Aspirin 325 milligrams p.o. q.d. 7. Plavix 75 milligrams p.o. q.d. times twenty-eight days."},"extractive_notes_summ":{"kind":"string","value":"Mild (1+) mitral regurgitation is seen. Mild tricuspid [1+]regurgitation is seen. There is mild symmetric left ventricularhypertrophy. There is nomitral valve prolapse. There is nomitral valve prolapse. The right ventricleis not well seen.The aortic leaflets (3) appear structurally normal with goodleaflet excursion. Noaortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild regional left ventricularsystolic dysfunction.RIGHT VENTRICLE: The right ventricle is not well seen.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. There is systolic motion of the mitral chordae (normalvariant), but no resting outflow tract gradient. There is mild regional left ventricular systolic dysfunction withhypokinesis of the posterior wall and basal inferior wall. The pulmonary artery systolic pressure could not bedetermined.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation. There is nopericardial effusion. Lateral ST-T wave flattening persists.TRACING #2 There is nopulmonic valve stenosis.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: The patient is bradycardic (HR<60bpm).Conclusions:The left atrium is normal in size. Sinus rhythm with a single late cycle ventricular premature beat. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to the previous tracing of ST segmentelevations, consistent with acute infero-posterolateral myocardial infarction,have resolved. The leftventricular cavity size is normal. T wave inversions in leads III, aVF and V5-V6 consistent withevolution of the infero-posterolateral myocardial infarction. Since the previous tracing of ST-T wave changes inevolution persist.TRACING #1 Acute myocardial infarction.Height: (in) 71Weight (lb): 170BSA (m2): 1.97 m2Status: InpatientDate/Time: at 14:30Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Subcostal views are limited.LEFT ATRIUM: The left atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Since the previous tracing of T wave abnormalities areless marked.TRACING #2 Low limb lead voltage. The mitral leaflets are structurally normal. Compared to theprevious tracing of T wave inversions are new. There is now a prominentR wave in lead V2 and tall right precordial T waves which could be indicativeof posterior myocardial infarction.TRACING #3 Poor qualitytracing. There is no significant aortic valve stenosis. ST segment elevations in leads II, III, aVF and V4-V6 withST segment depressions in leads VI-V2 consistent with an acuteinfero-posterolateral myocardial infarction. Leftward axis. No previous tracing available forcomparison.TRACING #1 Clinical correlation is suggested. Increased mi-precordial leadvoltage."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2107-04-22 00:00:00.000","description":"Report","row_id":68989,"text":"PATIENT/TEST INFORMATION:\nIndication: Chest pain.\n? Acute myocardial infarction.\nHeight: (in) 71\nWeight (lb): 170\nBSA (m2): 1.97 m2\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSubcostal views are limited.\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction.\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no significant aortic valve stenosis. No\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. There is systolic motion of the mitral chordae (normal\nvariant), but no resting outflow tract gradient. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. There is no\npulmonic valve stenosis.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The patient is bradycardic (HR<60bpm).\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. There is mild regional left ventricular systolic dysfunction with\nhypokinesis of the posterior wall and basal inferior wall. The right ventricle\nis not well seen.The aortic leaflets (3) appear structurally normal with good\nleaflet excursion. The mitral leaflets are structurally normal. There is no\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2107-04-25 00:00:00.000","description":"Report","row_id":155257,"text":"Sinus rhythm. Since the previous tracing of T wave abnormalities are\nless marked.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2107-04-24 00:00:00.000","description":"Report","row_id":155258,"text":"Sinus rhythm. Since the previous tracing of ST-T wave changes in\nevolution persist.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2107-04-23 00:00:00.000","description":"Report","row_id":155259,"text":"Sinus rhythm. T wave inversions in leads III, aVF and V5-V6 consistent with\nevolution of the infero-posterolateral myocardial infarction. Compared to the\nprevious tracing of T wave inversions are new. There is now a prominent\nR wave in lead V2 and tall right precordial T waves which could be indicative\nof posterior myocardial infarction.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2107-04-22 00:00:00.000","description":"Report","row_id":155260,"text":"Sinus rhythm. Compared to the previous tracing of ST segment\nelevations, consistent with acute infero-posterolateral myocardial infarction,\nhave resolved. Lateral ST-T wave flattening persists.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2107-04-22 00:00:00.000","description":"Report","row_id":155261,"text":"Sinus rhythm. ST segment elevations in leads II, III, aVF and V4-V6 with\nST segment depressions in leads VI-V2 consistent with an acute\ninfero-posterolateral myocardial infarction. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2107-04-22 00:00:00.000","description":"Report","row_id":155262,"text":"Sinus rhythm with a single late cycle ventricular premature beat. Poor quality\ntracing. Low limb lead voltage. Leftward axis. Increased mi-precordial lead\nvoltage. Clinical correlation is suggested.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2107-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 68989,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chest pain.\\n? Acute myocardial infarction.\\nHeight: (in) 71\\nWeight (lb): 170\\nBSA (m2): 1.97 m2\\nStatus: Inpatient\\nDate/Time: at 14:30\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nSubcostal views are limited.\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal. There is mild regional left ventricular\\nsystolic dysfunction.\\n\\nRIGHT VENTRICLE: The right ventricle is not well seen.\\n\\nAORTA: The aortic root is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\\ngood leaflet excursion. There is no significant aortic valve stenosis. No\\naortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\\nmitral valve prolapse. There is systolic motion of the mitral chordae (normal\\nvariant), but no resting outflow tract gradient. Mild (1+) mitral\\nregurgitation is seen.\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\\nregurgitation is seen. The pulmonary artery systolic pressure could not be\\ndetermined.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal with physiologic pulmonic regurgitation. There is no\\npulmonic valve stenosis.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: The patient is bradycardic (HR<60bpm).\\n\\nConclusions:\\nThe left atrium is normal in size. There is mild symmetric left ventricular\\nhypertrophy. There is mild regional left ventricular systolic dysfunction with\\nhypokinesis of the posterior wall and basal inferior wall. The right ventricle\\nis not well seen.The aortic leaflets (3) appear structurally normal with good\\nleaflet excursion. The mitral leaflets are structurally normal. There is no\\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no\\npericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-04-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 155257,\n \"text\": \"Sinus rhythm. Since the previous tracing of T wave abnormalities are\\nless marked.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-04-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 155258,\n \"text\": \"Sinus rhythm. Since the previous tracing of ST-T wave changes in\\nevolution persist.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-04-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 155259,\n \"text\": \"Sinus rhythm. T wave inversions in leads III, aVF and V5-V6 consistent with\\nevolution of the infero-posterolateral myocardial infarction. Compared to the\\nprevious tracing of T wave inversions are new. There is now a prominent\\nR wave in lead V2 and tall right precordial T waves which could be indicative\\nof posterior myocardial infarction.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 155260,\n \"text\": \"Sinus rhythm. Compared to the previous tracing of ST segment\\nelevations, consistent with acute infero-posterolateral myocardial infarction,\\nhave resolved. Lateral ST-T wave flattening persists.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 155261,\n \"text\": \"Sinus rhythm. ST segment elevations in leads II, III, aVF and V4-V6 with\\nST segment depressions in leads VI-V2 consistent with an acute\\ninfero-posterolateral myocardial infarction. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-04-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 155262,\n \"text\": \"Sinus rhythm with a single late cycle ventricular premature beat. Poor quality\\ntracing. Low limb lead voltage. Leftward axis. Increased mi-precordial lead\\nvoltage. Clinical correlation is suggested.\\n\\n\"\n }\n]"}}},{"rowIdx":24299,"cells":{"subject_id":{"kind":"number","value":76658,"string":"76,658"},"hadm_id":{"kind":"number","value":123009,"string":"123,009"},"target_text":{"kind":"string","value":"This is a 77 year old female with past medical history significant for hypertension presenting in complete heart block s/p temporary pacemaker placement and kidney failure (acute vs. CKD). # Complete Heart Block - Etiology a recent MI given elevated trop to 8 with inferior q-waves on EKG leading to complete heart block. Dual chamber permanent pacer placed and set to 80 bpm. PA/LAT CXR showed appropriate positioning. Pt received 4 doses of prophylactic IV Vancomycin. No abx on discharge. Completed physical therapy that suggested home with PT. EP interrogated the pacer on discharge and was OK with discharge. . # Completed Inferior MI - Given q waves and lack of ST changes and elevated troponins, pt had MI in the near past, reports chest discomfort a week or so ago. ECHO showed EF 45%. We started medical management with , 325, Atorva 80, Metop XL 25, Echo showed inferior posterior wall hypokinesis, and EF 45%. Pt was without chest pain during her admission. . # Acute Kidney Injury with possible CKD - Cr 4.7 on admission. Cr 1.6 on Discharge. We treated her with gentle IVF, renally dosing meds, avoiding nephrotoxins, and fixing her conduction system allowing appropriate forward flow. The etiology is unclear given unknown baseline Cr, mostly like it is ATN to poor forward flow. On discharge we restarted . . # HTN - We initially held all home BP meds (Dilt, HCTZ, telmasartan) during the admission given her low BPs. Patient was instructed to restart telmasartan, and she was started on metoprolol. . ### Transitions of care: - BP has been low during hospital stay, consider starting ACEi for remodeling benefit as outpatient."},"extractive_notes_summ":{"kind":"string","value":"RV function depressed.PERICARDIUM: No pericardial effusion.Conclusions:The right ventricular cavity is dilated with depressed free wallcontractility. The right ventricular cavity is dilated with depressed free wallcontractility. The right ventricular free wall thickness isnormal. Abnormal septal motion/position consistent with RV pressure/volumeoverload.AORTA: Normal aortic diameter at the sinus level. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo;RIGHT VENTRICLE: Normal RV free wall thickness. Normal main PA. No Doppler evidence for PDAPERICARDIUM: Small pericardial effusion.Conclusions:A pacemaker wire is seen in the right atrium and right ventricle. FINDINGS: There is slight tortuosity and calcification along the thoracic aorta. The left ventricular cavity size isnormal. Moderate [2+] tricuspid regurgitation isseen. There is mild pulmonary artery systolichypertension. Mildlydepressed LVEF. Focal calcifications inascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Normal ascending aorta diameter. PATIENT/TEST INFORMATION:Indication: Pericardial effusionHeight: (in) 60Weight (lb): 175BSA (m2): 1.77 m2BP (mm Hg): 89/49HR (bpm): 70Status: InpatientDate/Time: at 12:54Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT VENTRICLE: Dilated RV cavity. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. There is no sign of cardiactamponade.Compared with the findings of the prior study (images reviewed) of , the following findings are new:(1) pacemaker wire now seen in RA/RV, entering and probably perforating RVfree wall(2) small pericardial effusion now seen subtending area where pacemaker wiretip seen (no sign of cardiac tamponade)(3) pacemaker-induced LV dyssynchrony is now present(4) inferior posterior wall hypokinesis now present(5) RV is now dilated and hypocontractilediscussed with Dr HblockHeight: (in) 60Weight (lb): 175BSA (m2): 1.77 m2BP (mm Hg): 105/68HR (bpm): 79Status: InpatientDate/Time: at 10:23Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. An eccentric, posteriorly directed jet of moderate (2+) mitralregurgitation is seen. Moderate (2+) MR. tothe eccentric MR jet, its severity may be underestimated (Coanda effect).TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. FINDINGS: Single frontal view of the chest was obtained. Cannot excludeold inferior and anterior myocardial infarctions. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Sinus bradycardia with occasional atrial premature beats and high grade,probably complete, A-V block with ventricular escape rhythm. There is abnormal septal motion/position consistent with rightventricular pressure/volume overload. Compared to the prior study the fluid status is slightly worse. [Due to acoustic shadowing, the severity of tricuspid regurgitation maybe significantly UNDERestimated.] There has been interval removal of a transvenous pacer. There is mild pulmonary vascular redistribution. Patchy retrocardiac opacity, probably in the left lower lobe, is most suggestive of minor atelectasis. [Due to acousticshadowing, the severity of tricuspid regurgitation may be significantlyUNDERestimated.] IMPRESSION: Status post removal of transvenous pacer. The right atrium is moderately dilated. There is vague patchy hilar opacification on each side, which may suggest slight congestion. There is volume loss at both bases and an early infiltrate cannot be excluded in either lower lobe. IMPRESSION: Suspicion for slight congestion, otherwise unremarkable. Focal calcifications inaortic root. FINDINGS: Left-sided battery pack with pacemaker lead wires terminating in the right atrium and right ventricle without change in position. The heart is probably at the upper limits of normal size. There is a small pericardial effusion subtending the epicardialsurface where the pacemaker wire tip emerges. Opacification at the right base could represent atelectasis and small effusion. FINDINGS: There is a right IJ pacer wire that extends to the region of the apex of the right ventricle, in similar location compared to prior. Overall left ventricular systolic function is mildly depressed (LVEF =45%) secondary to hypokinesis of the inferior and posterior walls, and topacemaker-induced dyssynchrony. Moderate [2+] TR. Mild pulmonary edema from is mostly resolved. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of , a pacemaker wire is no longer seen; no pericardial effusionseen. Normal tricuspidvalve supporting structures. Interval insertion of pacer has been made through the right internal jugular approach with its tip projecting at the expected location of right ventricle. Normal LV cavity size. RV functiondepressed. There is volume loss in both lower lungs and bilateral pleural effusions. No acute cardiopulmonary process. Cardiomediastinal silhouette is stable. No PS.Physiologic PR. FINDINGS: In comparison with study of earlier in this date, there has been placement of a right IJ pacer that extends to the region of the apex of the right ventricle. Due to the eccentric nature of the regurgitant jet, itsseverity may be significantly underestimated (Coanda effect). The cardiomediastinal silhouette is stable. Normal mitralvalve supporting structures. The tip ofthe pacemaker wire appears to penetrate the right ventricular free wall andmay protrude beyon the epicardial surface of the right ventricular free wall(through-and-through perforation).The left atrium is dilated. COMPARISONS: Multiple prior chest radiographs, most recently of . Portable AP radiograph of the chest was reviewed in comparison to , . Leftventricular wall thicknesses are normal. TECHNIQUE: Chest, portable AP upright. Bilateral pleural effusions are present. Compared to the study from the prior day, the appearance to the lower lungs is worse. Patient currently desaturating. A catheter or pacingwire is seen in the RA and extending into the RV.LEFT VENTRICLE: Normal LV wall thickness. PATIENT/TEST INFORMATION:Indication: Myocardial infarction. TECHNIQUE: AP and lateral views of the chest. 6:19 PM CHEST (PORTABLE AP) Clip # Reason: eval for cardiopulm process MEDICAL CONDITION: History: 78F with malaise, bradycardia REASON FOR THIS EXAMINATION: eval for cardiopulm process FINAL REPORT CHEST RADIOGRAPH HISTORY: Malaise and bradycardia."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2103-10-19 00:00:00.000","description":"Report","row_id":64161,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion\nHeight: (in) 60\nWeight (lb): 175\nBSA (m2): 1.77 m2\nBP (mm Hg): 89/49\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 12:54\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe right ventricular cavity is dilated with depressed free wall\ncontractility. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , a pacemaker wire is no longer seen; no pericardial effusion\nseen.\n\n\n"},{"category":"Echo","chartdate":"2103-10-19 00:00:00.000","description":"Report","row_id":64107,"text":"PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Hblock\nHeight: (in) 60\nWeight (lb): 175\nBSA (m2): 1.77 m2\nBP (mm Hg): 105/68\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:23\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly\ndepressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nRIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV cavity. RV function\ndepressed. Abnormal septal motion/position consistent with RV pressure/volume\noverload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. No MS. Eccentric MR jet. Moderate (2+) MR. to\nthe eccentric MR jet, its severity may be underestimated (Coanda effect).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. [Due to acoustic\nshadowing, the severity of tricuspid regurgitation may be significantly\nUNDERestimated.] Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nA pacemaker wire is seen in the right atrium and right ventricle. The tip of\nthe pacemaker wire appears to penetrate the right ventricular free wall and\nmay protrude beyon the epicardial surface of the right ventricular free wall\n(through-and-through perforation).\n\nThe left atrium is dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is mildly depressed (LVEF =\n45%) secondary to hypokinesis of the inferior and posterior walls, and to\npacemaker-induced dyssynchrony. The right ventricular free wall thickness is\nnormal. The right ventricular cavity is dilated with depressed free wall\ncontractility. There is abnormal septal motion/position consistent with right\nventricular pressure/volume overload. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral\nregurgitation is seen. Due to the eccentric nature of the regurgitant jet, its\nseverity may be significantly underestimated (Coanda effect). The tricuspid\nvalve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is\nseen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may\nbe significantly UNDERestimated.] There is mild pulmonary artery systolic\nhypertension. There is a small pericardial effusion subtending the epicardial\nsurface where the pacemaker wire tip emerges. There is no sign of cardiac\ntamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the following findings are new:\n\n(1) pacemaker wire now seen in RA/RV, entering and probably perforating RV\nfree wall\n\n(2) small pericardial effusion now seen subtending area where pacemaker wire\ntip seen (no sign of cardiac tamponade)\n\n(3) pacemaker-induced LV dyssynchrony is now present\n\n(4) inferior posterior wall hypokinesis now present\n\n(5) RV is now dilated and hypocontractile\n\ndiscussed with Dr \n\n\n"},{"category":"ECG","chartdate":"2103-10-18 00:00:00.000","description":"Report","row_id":125942,"text":"Sinus bradycardia with occasional atrial premature beats and high grade,\nprobably complete, A-V block with ventricular escape rhythm. Cannot exclude\nold inferior and anterior myocardial infarctions. No previous tracing\navailable for comparison.\n\n"},{"category":"Radiology","chartdate":"2103-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254231,"text":" 8:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ptx, line placement\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 78F with with cordis and pacer\n REASON FOR THIS EXAMINATION:\n eval for ptx, line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Line placement.\n\n Portable AP radiograph of the chest was reviewed in comparison to , .\n\n Interval insertion of pacer has been made through the right internal jugular\n approach with its tip projecting at the expected location of right ventricle.\n Cardiomediastinal silhouette is stable. No evidence of pneumothorax is\n present.\n\n"},{"category":"Radiology","chartdate":"2103-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254221,"text":" 6:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 78F with malaise, bradycardia\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Malaise and bradycardia.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, portable AP upright.\n\n FINDINGS: There is slight tortuosity and calcification along the thoracic\n aorta. The heart is probably at the upper limits of normal size. There is\n vague patchy hilar opacification on each side, which may suggest slight\n congestion. Patchy retrocardiac opacity, probably in the left lower lobe, is\n most suggestive of minor atelectasis.\n\n IMPRESSION: Suspicion for slight congestion, otherwise unremarkable.\n\n"},{"category":"Radiology","chartdate":"2103-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254328,"text":" 3:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluation of location of new temp pacer wire\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with HTN presented with recent MI c/b complete heart block\n now a new pacer wire\n REASON FOR THIS EXAMINATION:\n evaluation of location of new temp pacer wire\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pacer placement.\n\n FINDINGS: In comparison with study of earlier in this date, there has been\n placement of a right IJ pacer that extends to the region of the apex of the\n right ventricle. No evidence of pneumothorax. Opacification at the right\n base could represent atelectasis and small effusion. Somewhat similar but\n less prominent appearance is seen on the left. In the appropriate clinical\n setting, supervening pneumonia would have to be considered.\n\n\n"},{"category":"Radiology","chartdate":"2103-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254298,"text":" 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for any pulmonary process\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with HTN presented with recent MI c/b complete heart block\n now with pacer wire removed, pacer wire found to have gone through RV, now\n desatting\n REASON FOR THIS EXAMINATION:\n Evaluate for any pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with recent MI complicated by complete heart\n block, now with pacer wire removed. Patient currently desaturating. Evaluate\n for pulmonary process.\n\n COMPARISONS: Multiple prior chest radiographs, most recently of .\n\n FINDINGS: Single frontal view of the chest was obtained. There has been\n interval removal of a transvenous pacer. The cardiomediastinal silhouette is\n stable. No pneumothorax, focal consolidation, or pleural effusion.\n\n IMPRESSION: Status post removal of transvenous pacer. No acute\n cardiopulmonary process.\n\n"},{"category":"Radiology","chartdate":"2103-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254477,"text":" 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check position of temp pacing wire\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with complete heart block s/p temporary pacemaker placement\n and kidney failure\n REASON FOR THIS EXAMINATION:\n Check position of temp pacing wire\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Complete heart block with temporary pacer.\n\n FINDINGS: There is a right IJ pacer wire that extends to the region of the\n apex of the right ventricle, in similar location compared to prior. There is\n volume loss at both bases and an early infiltrate cannot be excluded in either\n lower lobe. Compared to the study from the prior day, the appearance to the\n lower lungs is worse.\n\n\n"},{"category":"Radiology","chartdate":"2103-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1254505,"text":" 1:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check pacer wire placement\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman p/w CHB s/p permanent pace maker placement.\n REASON FOR THIS EXAMINATION:\n check pacer wire placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Pacemaker.\n\n FINDINGS: There is a new dual-lead pacemaker with leads projecting over the\n expected locations. There is volume loss in both lower lungs and bilateral\n pleural effusions. There is mild pulmonary vascular redistribution. An\n underlying infectious infiltrate in the lower lobes cannot be excluded.\n Compared to the prior study the fluid status is slightly worse.\n\n\n"},{"category":"Radiology","chartdate":"2103-10-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1254603,"text":" 2:37 PM\n CHEST (PA & LAT) Clip # \n Reason: pacemaker placement, please do the PA/Lat instead of portabl\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with new AV pacer for heart block\n REASON FOR THIS EXAMINATION:\n pacemaker placement, please do the PA/Lat instead of portable\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old man with a new dual-lead pacer for heart rate.\n\n COMPARISON: .\n\n TECHNIQUE: AP and lateral views of the chest.\n\n FINDINGS: Left-sided battery pack with pacemaker lead wires terminating in\n the right atrium and right ventricle without change in position. Bilateral\n pleural effusions are present. Mild pulmonary edema from \n is mostly resolved.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2103-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 64161,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion\\nHeight: (in) 60\\nWeight (lb): 175\\nBSA (m2): 1.77 m2\\nBP (mm Hg): 89/49\\nHR (bpm): 70\\nStatus: Inpatient\\nDate/Time: at 12:54\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe right ventricular cavity is dilated with depressed free wall\\ncontractility. There is no pericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of , a pacemaker wire is no longer seen; no pericardial effusion\\nseen.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2103-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 64107,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Myocardial infarction. Hblock\\nHeight: (in) 60\\nWeight (lb): 175\\nBSA (m2): 1.77 m2\\nBP (mm Hg): 105/68\\nHR (bpm): 79\\nStatus: Inpatient\\nDate/Time: at 10:23\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Dilated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\\nwire is seen in the RA and extending into the RV.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly\\ndepressed LVEF. No resting LVOT gradient.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\\nhypo;\\n\\nRIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV cavity. RV function\\ndepressed. Abnormal septal motion/position consistent with RV pressure/volume\\noverload.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Normal ascending aorta diameter. Focal calcifications in\\nascending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\\nvalve supporting structures. No MS. Eccentric MR jet. Moderate (2+) MR. to\\nthe eccentric MR jet, its severity may be underestimated (Coanda effect).\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\\nvalve supporting structures. No TS. Moderate [2+] TR. [Due to acoustic\\nshadowing, the severity of tricuspid regurgitation may be significantly\\nUNDERestimated.] Mild PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: Small pericardial effusion.\\n\\nConclusions:\\nA pacemaker wire is seen in the right atrium and right ventricle. The tip of\\nthe pacemaker wire appears to penetrate the right ventricular free wall and\\nmay protrude beyon the epicardial surface of the right ventricular free wall\\n(through-and-through perforation).\\n\\nThe left atrium is dilated. The right atrium is moderately dilated. Left\\nventricular wall thicknesses are normal. The left ventricular cavity size is\\nnormal. Overall left ventricular systolic function is mildly depressed (LVEF =\\n45%) secondary to hypokinesis of the inferior and posterior walls, and to\\npacemaker-induced dyssynchrony. The right ventricular free wall thickness is\\nnormal. The right ventricular cavity is dilated with depressed free wall\\ncontractility. There is abnormal septal motion/position consistent with right\\nventricular pressure/volume overload. The aortic valve leaflets (3) are mildly\\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\\nprolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral\\nregurgitation is seen. Due to the eccentric nature of the regurgitant jet, its\\nseverity may be significantly underestimated (Coanda effect). The tricuspid\\nvalve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is\\nseen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may\\nbe significantly UNDERestimated.] There is mild pulmonary artery systolic\\nhypertension. There is a small pericardial effusion subtending the epicardial\\nsurface where the pacemaker wire tip emerges. There is no sign of cardiac\\ntamponade.\\n\\nCompared with the findings of the prior study (images reviewed) of , the following findings are new:\\n\\n(1) pacemaker wire now seen in RA/RV, entering and probably perforating RV\\nfree wall\\n\\n(2) small pericardial effusion now seen subtending area where pacemaker wire\\ntip seen (no sign of cardiac tamponade)\\n\\n(3) pacemaker-induced LV dyssynchrony is now present\\n\\n(4) inferior posterior wall hypokinesis now present\\n\\n(5) RV is now dilated and hypocontractile\\n\\ndiscussed with Dr \\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2103-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 125942,\n \"text\": \"Sinus bradycardia with occasional atrial premature beats and high grade,\\nprobably complete, A-V block with ventricular escape rhythm. Cannot exclude\\nold inferior and anterior myocardial infarctions. No previous tracing\\navailable for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254231,\n \"text\": \" 8:38 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for ptx, line placement\\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 78F with with cordis and pacer\\n REASON FOR THIS EXAMINATION:\\n eval for ptx, line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Line placement.\\n\\n Portable AP radiograph of the chest was reviewed in comparison to , .\\n\\n Interval insertion of pacer has been made through the right internal jugular\\n approach with its tip projecting at the expected location of right ventricle.\\n Cardiomediastinal silhouette is stable. No evidence of pneumothorax is\\n present.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254221,\n \"text\": \" 6:19 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for cardiopulm process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 78F with malaise, bradycardia\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulm process\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n HISTORY: Malaise and bradycardia.\\n\\n COMPARISONS: None.\\n\\n TECHNIQUE: Chest, portable AP upright.\\n\\n FINDINGS: There is slight tortuosity and calcification along the thoracic\\n aorta. The heart is probably at the upper limits of normal size. There is\\n vague patchy hilar opacification on each side, which may suggest slight\\n congestion. Patchy retrocardiac opacity, probably in the left lower lobe, is\\n most suggestive of minor atelectasis.\\n\\n IMPRESSION: Suspicion for slight congestion, otherwise unremarkable.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254328,\n \"text\": \" 3:06 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: evaluation of location of new temp pacer wire\\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with HTN presented with recent MI c/b complete heart block\\n now a new pacer wire\\n REASON FOR THIS EXAMINATION:\\n evaluation of location of new temp pacer wire\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Pacer placement.\\n\\n FINDINGS: In comparison with study of earlier in this date, there has been\\n placement of a right IJ pacer that extends to the region of the apex of the\\n right ventricle. No evidence of pneumothorax. Opacification at the right\\n base could represent atelectasis and small effusion. Somewhat similar but\\n less prominent appearance is seen on the left. In the appropriate clinical\\n setting, supervening pneumonia would have to be considered.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254298,\n \"text\": \" 11:44 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for any pulmonary process\\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with HTN presented with recent MI c/b complete heart block\\n now with pacer wire removed, pacer wire found to have gone through RV, now\\n desatting\\n REASON FOR THIS EXAMINATION:\\n Evaluate for any pulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 70-year-old female with recent MI complicated by complete heart\\n block, now with pacer wire removed. Patient currently desaturating. Evaluate\\n for pulmonary process.\\n\\n COMPARISONS: Multiple prior chest radiographs, most recently of .\\n\\n FINDINGS: Single frontal view of the chest was obtained. There has been\\n interval removal of a transvenous pacer. The cardiomediastinal silhouette is\\n stable. No pneumothorax, focal consolidation, or pleural effusion.\\n\\n IMPRESSION: Status post removal of transvenous pacer. No acute\\n cardiopulmonary process.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254477,\n \"text\": \" 7:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Check position of temp pacing wire\\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with complete heart block s/p temporary pacemaker placement\\n and kidney failure\\n REASON FOR THIS EXAMINATION:\\n Check position of temp pacing wire\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Complete heart block with temporary pacer.\\n\\n FINDINGS: There is a right IJ pacer wire that extends to the region of the\\n apex of the right ventricle, in similar location compared to prior. There is\\n volume loss at both bases and an early infiltrate cannot be excluded in either\\n lower lobe. Compared to the study from the prior day, the appearance to the\\n lower lungs is worse.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1254505,\n \"text\": \" 1:57 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: check pacer wire placement\\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman p/w CHB s/p permanent pace maker placement.\\n REASON FOR THIS EXAMINATION:\\n check pacer wire placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Pacemaker.\\n\\n FINDINGS: There is a new dual-lead pacemaker with leads projecting over the\\n expected locations. There is volume loss in both lower lungs and bilateral\\n pleural effusions. There is mild pulmonary vascular redistribution. An\\n underlying infectious infiltrate in the lower lobes cannot be excluded.\\n Compared to the prior study the fluid status is slightly worse.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2103-10-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1254603,\n \"text\": \" 2:37 PM\\n CHEST (PA & LAT) Clip # \\n Reason: pacemaker placement, please do the PA/Lat instead of portabl\\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old woman with new AV pacer for heart block\\n REASON FOR THIS EXAMINATION:\\n pacemaker placement, please do the PA/Lat instead of portable\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 70-year-old man with a new dual-lead pacer for heart rate.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: AP and lateral views of the chest.\\n\\n FINDINGS: Left-sided battery pack with pacemaker lead wires terminating in\\n the right atrium and right ventricle without change in position. Bilateral\\n pleural effusions are present. Mild pulmonary edema from \\n is mostly resolved.\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":242,"numItemsPerPage":100,"numTotalItems":24993,"offset":24200,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTg3NjUzNCwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTg4MDEzNCwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.-8aCqfjMxKW05JjfeKI_T5pY3CmwkuW4KwZwrt6qW5gobgRextmkZWtcflCCLZXmbm6AhVf04jg_pYKT2XklAg","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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30,183 | 115,246 | In the MICU: Pt continued his heparin gtt from the ED for his R IJ tunneled-cath clot. Blood pressure elevated to 205/144 and was controlled with a labetalol gtt and a nitro gtt. Pt presented in pulmonary edema and was subsequently taken to HD the night of admission - pt did not require additional intervention. Pt developed one episode of bloody emesis and was taken off of his heparin gtt. By the time of transfer the pt was weaned off of his labetalol/nitro gtt and was down to 4L of O2 with adequate sats. . On the general medicine floor: . Nonocclusive right IJ thrombus: Pt was treated with heparin to coumadin bridge. The plan was discussed with Vascular and Renal and it was decided that the R IJ tunneled-cath would be left in place. The catheter was accessed for HD throughout the pt's stay. Transplant surgery will evaluate the pt for placement of a fistula. Pt has missed last 5 appointments as an outpatient. Social work was contact and will help facilitate the outpatient appointment. Scheduled appointment with transplant surgery on with Dr. . The pt was treated with warfarin 5mg x 3 days, warfarin 7.5mg x 3 days and finally warfarin 10mg x 1 day to reach the target INR. On the day of discharge pt had been therapeutic on heparin for 7 days, had an INR of 1.9 and was given lovenox 30mg x 1 dose before leaving. This plan was discussed with renal and they approved the use of lovenox in the setting of this pt's end stage renal disease managed with dialysis. Pt will follow with Dr. in dialysis for coumadin management until he sees his PCP (pt never had a regular PCP, appointment) Dr. this Thursday for further management. . Bloody emesis: The pt had only 1 episode in the MICU . Heparin and coumadin were briefly held and restarted once the pt's HCT was stable. Pt was placed on pantoprazole and had no further issues on the floor. . Fluid overload: Pt initially presented with a BNP > and with pulmonary edema. Once stabilized in the MICU pt was able to maintain adequate O2 sats on the floor without supplemental O2 and demonstrated no clinical evidence of pulmonary congestion. . Hypertension: Pt was weaned off of nitro gtt and labetalol gtt in the MICU. Pt typically with BP 160s/100s on the floor with elevation to 180-200/110-120 in the early AM. Pt asymptomatic with these episodes. BP responded to hydralazine IV prn. Pt was initially treated with nifedipine 40mg q6h, labetalol 300mg and lisinopril 40mg . Given the pt's history of non-compliance and difficult to control BP within the hospital, the pt's nifedipine was switched to 90mg to facilitate compliance and minoxidil 5mg qdaily was added for better BP control. Renal doppler was ordered for RAS w/u and could not r/o RAS on the L. MRA was not pursued in the setting of ESRD the risk of NSF. Pt may continue w/u as an outpatient with renal. . ESRD: Pt tolerated HD throughout hospital stay without issues. Pt was maintained on nephrocaps and sevelamer. Pt required increased dosing of both nephrocaps and sevelamer. Appreciate input from Renal - no new recommendations. Pt will resume outpatient regimen of MWF at the Clinic. . FEN: Pt tolerated PO intake. Electrolytes managed with HD. . PPX: Maintained on heparin, coumadin (once HCT stabilized) and PPI. . # Access: PIV and tunneled R IJ for HD . # Code: FULL | IMPRESSION: Findings suggestive of a nonocclusive thrombus within the right internal jugular vein, immediately upstream from the expected location of the hemodialysis catheter. Again noted are diffuse bilateral perihilar opacities, which are largely unchanged from the prior study, and likely reflects pulmonary edema. The right internal jugular dialysis catheter tip terminates in the expected location of the distal SVC. Findings are suggestive of a non-occlusive thrombus. Large calcified right upper pole renal lesion, incompletely evaluated, and appears largely unchanged. IMPRESSION: Limited study with delayed systolic upstroke in the left parenchymal arteries. Heterogeneous and irregular echogenicity is seen within the right internal jugular vein, immediately upstream from the expected location of the hemodialysis catheter. ABDOMEN SOFT, BOWEL SOUNDS PRESENT, NO BM.RENAL: HD CATH IN RT SCL, A-V FISTULA IN LT ARM WHICH IS NOT BEING USED. FINDINGS: Grayscale and color Doppler son of the right IJ, right subclavian, right brachial, basilic, and cephalic veins were obtained. Clinical correlation is suggested.Since the previous tracing of the Q-T interval is shorter. 3:47 PM UNILAT UP EXT VEINS US RIGHT Clip # Reason: SOB RT ARM SWELLING EVAL FOR DVT MEDICAL CONDITION: 33 yo M ESRD on HD w/ port p/w R CP rad to RUE w/ RUE swelling and tenderness REASON FOR THIS EXAMINATION: eval for DVT WET READ: JXKc TUE 5:19 PM Heterogeneous echogenicity of the right IJ immediately upstream to the where the HD catheter courses, with decreased flow and decreased doppler signal, concerning for a non-occlusive thrombus. PFI REPORT Delayed systolic upstrokes in the left kidney parenchymal arteries. Of note, on a subsequent radiograph on , these opacities in bilateral lungs appear to have largely resolved, suggesting that these findings may represent pulmonary edema. Limited views of the upper abdomen again reveal a heavily calcified rounded lesion within the upper pole of the right kidney, unchanged. There is a large rim calcified lesion, stable, in the right upper quadrant. HEPARIN GTTS STOPPED S/P LG GUAIAC POS EMESIS, PTT 130.RESP: DESAT AT TIMES UPPER 80'S, WHEN OFF. Renal artery stenosis on this side cannot be excluded. Renal artery stenosis on this side cannot be excluded. IMPRESSION: Pulmonary edema without evidence of focal infiltrate. FINDINGS: There is bilateral perihilar opacity, and upper lobe redistribution consistent with pulmonary edema. IMPRESSION: No interval change in diffuse hazy opacities in bilateral lungs, likely reflecting pulmonary edema. The previously noted chronic submental pulmonary embolism in the right upper lobe is not fully assessed on this study, due to respiratory motion. Previously noted tiny chronic PE in the right upper lobe is not fully evaluated due to respiratory motion. 3:56 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: eval for PE MEDICAL CONDITION: 33 yo F ESRD on HD p/w R-sided CP and SOB acute onset, intermittent hypoxia now 100 on NC REASON FOR THIS EXAMINATION: eval for PE No contraindications for IV contrast WET READ: JXKc TUE 5:08 PM Diffuse ground glass nodular opacities bilaterally with interlobular septal thickening, likely reflecting pulmonary edema. RECEIVED FROM ED WITH HEPARIN GTTS @ 1150U/H AND NTG GTTS @ 1.5MCG/KG/MIN, BP UNCONTROLLED @ 220/140. FINDINGS: In comparison with study of , there is little change in the mild cardiomegaly and diffuse bilateral pulmonary opacifications consistent with pulmonary edema. Renal artery stenosis in the setting cannot be excluded. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The heart is enlarged, without evidence of a pericardial effusion. The descending aorta contour is not as sharply seen, raising the possibility of developing atelectasis or even consolidation at the left base posteriorly. Previously noted chronic segmental pulmonary embolism in the right upper lobe is not fully assessed on this study due to respiratory motion. Diffuse ground-glass opacities bilaterally, with intralobular septal thickening. COMPARISON: at 2:52 p.m. PORTABLE UPRIGHT CHEST, ONE VIEW: Right dialysis catheter tip terminates within the distal SVC, unchanged. Clinical correlation is suggested.TRACING #1 The right IJ more upstream appears patent with normal compression and flow. The waveforms are quite limited on this side, however, there do appear to be delayed upstrokes in the parenchymal arterial waveforms on the left compared to the right kidney. The main renal artery and vein are patent. HD DONE REMOVED 3.8L, PT STATES HE VOIDS X2-3/DAY, HAS NOT VOIDED. NURSING ADMISSIONCV: HR NSR, NO ECTOPY. There appears to be a relative peripheral sparing by the ground-glass opacities. N/PRONGS REAPPLIED AND O2 TITRATED. , B. MED CC7A 2:57 PM RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # DUPLEX DOP ABD/PEL LIMITED Reason: Please evaluate for RAS. Now with difficult to control hypertension. Otherwise, the mediastinal and hilar contours are normal. Increased QRS voltage with ST-T wave abnormalities. MODIFIED NEURO EXAM DONE DURING NOC DUE TO C/O HEADACHE AND PERSISTANT HTN IN ED AND THROUGH PM...EXAM WNL.GI: PT INITIALLY PERMITTED TO DRINK FLUIDS PER MICU TEAM. Coronal, sagittal, and oblique reformatted images were obtained. Given these time course of findings, as well as a history of end-stage renal disease on hemodialysis, these findings likely reflect pulmonary edema. | 11 | [
{
"category": "Radiology",
"chartdate": "2154-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019138,
"text": " 2:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with sob, hypoxia\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST\n\n INDICATION: 33-year-old man with shortness of breath, hypoxia, question\n infiltrate.\n\n COMPARISON: .\n\n FINDINGS: There is bilateral perihilar opacity, and upper lobe redistribution\n consistent with pulmonary edema. There is no pneumonia. There is no effusion\n or pneumothorax. The right internal jugular dialysis catheter tip terminates\n in the expected location of the distal SVC. There is cardiomegaly as on\n prior. There is a large rim calcified lesion, stable, in the right upper\n quadrant.\n\n IMPRESSION: Pulmonary edema without evidence of focal infiltrate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-05-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019208,
"text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: RIGHT INTERNAL JUGULAR THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with h/o flash pulmonary edema p/w HD line thrombosis, fluid\n overload, HTN\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pulmonary edema, to evaluate for change.\n\n FINDINGS: In comparison with study of , there is little change in the\n mild cardiomegaly and diffuse bilateral pulmonary opacifications consistent\n with pulmonary edema. No definite pleural effusion.\n\n The descending aorta contour is not as sharply seen, raising the possibility\n of developing atelectasis or even consolidation at the left base posteriorly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-05-21 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1019155,
"text": " 3:47 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: SOB RT ARM SWELLING EVAL FOR DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 yo M ESRD on HD w/ port p/w R CP rad to RUE w/ RUE swelling and tenderness\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: JXKc TUE 5:19 PM\n Heterogeneous echogenicity of the right IJ immediately upstream to the where\n the HD catheter courses, with decreased flow and decreased doppler signal,\n concerning for a non-occlusive thrombus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 32-year-old male with end-stage renal disease, on hemodialysis, with\n right upper extremity swelling and tenderness. Evaluate for DVT.\n\n No prior studies are available for comparison.\n\n FINDINGS: Grayscale and color Doppler son of the right IJ, right\n subclavian, right brachial, basilic, and cephalic veins were obtained.\n Heterogeneous and irregular echogenicity is seen within the right internal\n jugular vein, immediately upstream from the expected location of the\n hemodialysis catheter. There is also decreased color flow with decreased\n Doppler signal in this location. Findings are suggestive of a non-occlusive\n thrombus. The right IJ more upstream appears patent with normal compression\n and flow. The right subclavian, brachial, basilic, and cephalic veins\n demonstrated wall-to-wall color flow, with appropriate Doppler signal.\n\n IMPRESSION: Findings suggestive of a nonocclusive thrombus within the right\n internal jugular vein, immediately upstream from the expected location of the\n hemodialysis catheter.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-05-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1019157,
"text": " 3:56 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 yo F ESRD on HD p/w R-sided CP and SOB acute onset, intermittent hypoxia now\n 100 on NC\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc TUE 5:08 PM\n Diffuse ground glass nodular opacities bilaterally with interlobular septal\n thickening, likely reflecting pulmonary edema. Previously noted tiny chronic\n PE in the right upper lobe is not fully evaluated due to respiratory motion.\n No PE in the central or large segmental branches.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 32-year-old female with end-stage renal disease, on hemodialysis,\n short of breath.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n upper abdomen with the administration of IV contrast. Coronal, sagittal, and\n oblique reformatted images were obtained.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The heart is enlarged, without\n evidence of a pericardial effusion. The previously noted chronic submental\n pulmonary embolism in the right upper lobe is not fully assessed on this\n study, due to respiratory motion. There is no evidence for a central or large\n segmental pulmonary embolism on this study. There are no pathologically\n enlarged mediastinal, hilar, or axillary lymph nodes.\n\n There are diffuse ground-glass opacities throughout both lungs, with\n interlobular septal thickening. There appears to be a relative peripheral\n sparing by the ground-glass opacities. These findings are similar to prior\n study from . Of note, on a subsequent radiograph on , these opacities in bilateral lungs appear to have largely resolved,\n suggesting that these findings may represent pulmonary edema.\n\n Limited views of the upper abdomen again reveal a heavily calcified rounded\n lesion within the upper pole of the right kidney, unchanged. This is\n incompletely evaluated.\n\n Osseous structures reveal no suspicious lytic or sclerotic lesion.\n\n IMPRESSION:\n 1. Diffuse ground-glass opacities bilaterally, with intralobular septal\n thickening. These findings are similar to prior CT from , with\n marked improvement on subsequent radiograph of . Given these\n time course of findings, as well as a history of end-stage renal disease on\n hemodialysis, these findings likely reflect pulmonary edema.\n (Over)\n\n 3:56 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Previously noted chronic segmental pulmonary embolism in the right upper\n lobe is not fully assessed on this study due to respiratory motion. No large\n central or large segmental pulmonary embolism identified.\n\n 3. Large calcified right upper pole renal lesion, incompletely evaluated, and\n appears largely unchanged.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-05-23 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1019512,
"text": " 2:57 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please evaluate for RAS.\n Admitting Diagnosis: RIGHT INTERNAL JUGULAR THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with ESRD HTN admitted for RIJ thrombus and hypertensive\n urgency with pulmonary edema, now with difficult to control HTN.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RAS.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:05 PM\n Delayed systolic upstrokes in the left kidney parenchymal arteries. Renal\n artery stenosis on this side cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33-year-old man with end-stage renal disease secondary to\n hypertension admitted for a right internal jugular thrombosis and hypertensive\n urgency with pulmonary edema. Now with difficult to control hypertension.\n\n COMPARISON: CTA of the chest from , and renal ultrasound from\n .\n\n RENAL ULTRASOUND: The right kidney measures approximately 7.4 cm. In the\n upper pole as has been on prior imaging studies is a peripherally calcified\n cyst measuring approximately 3.5 cm. There is no evidence of hydronephrosis.\n The evaluation of the renal vasculature was limited due to patient's shortness\n of breath. On the right, the main renal artery demonstrates sharp\n acceleration time. The parenchymal waveforms are within normal limits.\n\n The left kidney measures 7.9 cm and is echogenic consistent with chronic renal\n disease. The waveforms are quite limited on this side, however, there do\n appear to be delayed upstrokes in the parenchymal arterial waveforms on the\n left compared to the right kidney. The main renal artery and vein are patent.\n\n IMPRESSION:\n\n Limited study with delayed systolic upstroke in the left parenchymal arteries.\n Renal artery stenosis in the setting cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-05-23 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1019513,
"text": ", B. MED CC7A 2:57 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please evaluate for RAS.\n Admitting Diagnosis: RIGHT INTERNAL JUGULAR THROMBUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with ESRD HTN admitted for RIJ thrombus and hypertensive\n urgency with pulmonary edema, now with difficult to control HTN.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RAS.\n ______________________________________________________________________________\n PFI REPORT\n Delayed systolic upstrokes in the left kidney parenchymal arteries. Renal\n artery stenosis on this side cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019170,
"text": " 6:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: worsening dyspnea\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old man with sob\n REASON FOR THIS EXAMINATION:\n worsening dyspnea\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 33-year-old male with shortness of breath, worsening dyspnea.\n\n COMPARISON: at 2:52 p.m.\n\n PORTABLE UPRIGHT CHEST, ONE VIEW: Right dialysis catheter tip terminates\n within the distal SVC, unchanged. There is cardiomegaly. Otherwise, the\n mediastinal and hilar contours are normal. Again noted are diffuse bilateral\n perihilar opacities, which are largely unchanged from the prior study, and\n likely reflects pulmonary edema. There is no pleural effusion. Osseous\n structures are unremarkable. Rounded calcific density in the right upper\n quadrant of the abdomen is consistent with the calcific lesion in the upper\n pole of the right kidney seen on CT.\n\n IMPRESSION: No interval change in diffuse hazy opacities in bilateral lungs,\n likely reflecting pulmonary edema.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-05-22 00:00:00.000",
"description": "Report",
"row_id": 1651502,
"text": "Please see transfer note for daily progress note\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-05-22 00:00:00.000",
"description": "Report",
"row_id": 1651501,
"text": "NURSING ADMISSION\nCV: HR NSR, NO ECTOPY. RECEIVED FROM ED WITH HEPARIN GTTS @ 1150U/H AND NTG GTTS @ 1.5MCG/KG/MIN, BP UNCONTROLLED @ 220/140. NTG DOSE MAXIMIZED AND LABETALOL GTTS ADDED, PO AGENTS LISINOPRIL AND NIFEDEPINE ALSO GIVEN. BP QUICKLY NORMALIZED AND GTTS WEANED RAPIDLY. BP NORMOTENSIVE SINCE. HEPARIN GTTS STOPPED S/P LG GUAIAC POS EMESIS, PTT 130.\n\nRESP: DESAT AT TIMES UPPER 80'S, WHEN OFF. ATTEMPTED FACE TENT BUT PT WOULD NOT TOLERATE MASK. N/PRONGS REAPPLIED AND O2 TITRATED. LUNG SOUNDS @ BIL BASES.\n\nNEURO: ALERT AND ORIENTED X3. C/O HEADACHE IN PM, TYLENOL 650MG WITH MOD EFFECT. MODIFIED NEURO EXAM DONE DURING NOC DUE TO C/O HEADACHE AND PERSISTANT HTN IN ED AND THROUGH PM...EXAM WNL.\n\nGI: PT INITIALLY PERMITTED TO DRINK FLUIDS PER MICU TEAM. EPISODE OF VOMITING LG AMOUNT OF BROWN FLECKED GUAIAC POS FOLLOWED. NOW NPO. ZOFRAN 4MG AND COMPAZINE 10MG GIVEN BEFORE NAUSEA COMPLETELY SUBSIDED. ABDOMEN SOFT, BOWEL SOUNDS PRESENT, NO BM.\n\nRENAL: HD CATH IN RT SCL, A-V FISTULA IN LT ARM WHICH IS NOT BEING USED. HD DONE REMOVED 3.8L, PT STATES HE VOIDS X2-3/DAY, HAS NOT VOIDED. AM LABS PENDING.\n\nPLAN: REASSESS COAGULATION STATUS.\nMAINTAIN SBP<=160.\n\nPT MONITORED CLOSELY.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "ECG",
"chartdate": "2154-05-21 00:00:00.000",
"description": "Report",
"row_id": 218861,
"text": "Sinus rhythm. Increased QRS voltage with ST-T wave abnormalities. Since the\nprevious tracing no significant change. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2154-05-21 00:00:00.000",
"description": "Report",
"row_id": 218862,
"text": "Sinus rhythm. Short P-R interval. Leftward axis. Increased QRS voltage\nwith ST-T wave abnormalities which meet criteria for left ventricular\nhypertrophy, but the patient is young. Clinical correlation is suggested.\nSince the previous tracing of the Q-T interval is shorter. ST segment\ndepression is more prominent. Clinical correlation is suggested.\nTRACING #1\n\n"
}
] |
25,870 | 139,818 | Given the patient's large anterior wall MI w/ VSD (wall rupture), she was admitted to the CCU in critical condition, still with an aortic balloon pump. Her condition was grave and her daughter was at her bedside, aware of her prognosis. Upon arrival to the CCU, the patient's pressors were turned off, the balloon pump was transitioned to 1:8 from 1:1, and morphine was ordered for comfort. She did not require any of this medication, as she was very comfortable. The CCU team was called to pronounce the patient just before 8 pm on . She had no corneal reflex, dilated pupils, no respiratory effort, no pulse, and was pronounced dead at 8:00 pm. Patient's daughter declined autopsy. Cause of death was cardiac arrest, secondary to VSD and myocardial infarction. Dr , the attending, was notified. Medical examiner's office was also notified, given patient's death within 24 hours of admission. They declined autopsy as well. | IABP off. IVGtts d/c'd. on iabp, levo. bp 60s/40s via art line.resp: off o2. arrangements made. Daughter present. support to pt and family. states she understands pt's current state and anticipates her passing shortly. rr 12-18.social: dtr at bedside. CCU note 8pmPt expired at 8pm. unable to follow sat d/t poor circulation. ccu nursing progress noteadm from lab s/p lrg ant mi and vsd. tx w mso4 gtt w good effect.cv: hr now in the 60s. d/t high risk of surgery and after discussion with pt's dtr pt is now comfort measures only.neuro: arouses at times stating needs to urinate. CCU team called, assessed pt and talked with daughter. levo dc'd and iabp weaned to 1:8 in order to avoid pulling iabp at this time. c/o some chest pressure. nonlabored. | 2 | [
{
"category": "Nursing/other",
"chartdate": "2133-10-15 00:00:00.000",
"description": "Report",
"row_id": 1599539,
"text": "ccu nursing progress note\nadm from lab s/p lrg ant mi and vsd. on iabp, levo. d/t high risk of surgery and after discussion with pt's dtr pt is now comfort measures only.\n\nneuro: arouses at times stating needs to urinate. c/o some chest pressure. tx w mso4 gtt w good effect.\ncv: hr now in the 60s. levo dc'd and iabp weaned to 1:8 in order to avoid pulling iabp at this time. bp 60s/40s via art line.\nresp: off o2. unable to follow sat d/t poor circulation. nonlabored. rr 12-18.\nsocial: dtr at bedside. states she understands pt's current state and anticipates her passing shortly. other family members are aware but she does not wish for them to travel in from the .\na: s/p lrg ami c/b vsd\np: mso4 for comfort. support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-10-15 00:00:00.000",
"description": "Report",
"row_id": 1599540,
"text": "CCU note 8pm\n\nPt expired at 8pm. Daughter present. CCU team called, assessed pt and talked with daughter. arrangements made. IVGtts d/c'd. IABP off.\n"
}
] |
2,784 | 148,747 | Pt was admitted to MICU intubated after resp arrest at Rehab facility. Thought to be r/t plugging from granulation tissue. Flex bronch showed patent T-tube w/o granulation tissue above or below the T-tube. Etiology of resp arrest then thought to be from secretion plugging. Rec'd supporttive pulmonary/cardiac care in MICU w/ good recovery. Intubation via stoma w/ ETT was converted back to trach as prior to event. On HD #3 pt transferred from ICU to floor for ongoing pul rahab. Noted to be having runs of non-sustained, asymptomatic bigeminy and trigeminy. Cardiology was consulted and echo was performed (see report section )w/o etiology of ectopy; thought to be related to CPR given during arrest. Currently on betablocker and can be titrated up for HR control if BP allows. Treated w/ linezolid and levoflox for MRSA PNA which will stop on . Rec'ing bactrim for UTI until . On steriod taper for edmea noted on bronch. glucoses controlled w/ NPH and SSRI. Kept NPO w/ tube feeds via J-tube until able to perform video swallow study. Swallow study done on HD#7 and pt passed for ground diet and nectar thick liquids; no thin liquids. capping trial initiated on HD#7- capping x 4 hrs but became anxious. Sats were mid-high 90's however, pt was uncapped d/t anxiety. Remained uncapped over noc w/ hunidified oxygen. | Palatal elevation and, laryngeal valve closure, and epiglottic deflection were within functional limits. HAVE LIDOCAINE NEB PRN.ABD SOFT POS BS/NO BM. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Pt was brought to their EW from today with c/o difficulty ventillating. administered one neb of lidocaine with improved patient comfort post rx. ?repeat study since t-tube placement.GI/GU: Abdomen soft, BS present. Mild spillover was noted before each swallow. POST OP, PT SOMNOLENT, EASILY AROUSABLE WITH VOICE STIMULI, PROCEDURE DONE UNDER GENERAL ANESTHESIA, NOT REVERSED. Normal regional LV systolic function. Trach does become disconneted but easily reconnected and breathing returns to normal.GI - Abd soft with positive BS but no stool. Trace aortic regurgitation is seen. Mild mitralannular calcification. Left ventricular function.Height: (in) 56Weight (lb): 154BSA (m2): 1.59 m2BP (mm Hg): 100/46HR (bpm): 77Status: InpatientDate/Time: at 12:05Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Tracheostomy tube in standard position. INDICATION: Tracheostomy and shortness of breath. IMPRESSION: Airway narrowing proximal to tracheostomy entry site without change. Am labs as noted in carevue.Resp)Ls remains sl coarse to upper resp area and with clear bases. LAST SWALLOW EVAL REVEALS INEFFECTIVE COUGH CLEARANCE /TRACE-MILD ASPIRATION. Patient is s/p median sternotomy. BRONCH POST PROCEDURE REVEALS TRACHEAL EDEMA/ NOT TO BE CAPPED TODAY. S/P TRACHEAL DILATATION AND TTUBE PLACEMENT .RECEIVED PT /UNABLE TO ASSESS ORIENT LANGUE BARRIER, SPONTENEOUS, FOLLOWS COMMANDS, ABLE TO MAKE NEEDS KNOWN. RIGID BRONCH REVEALS TRACHEAL MALACIA/ SUBGLOTIC STENOSIS/ ADMITTED TO MICU FOR FURTHER MANAGEMENT. HR 80-110 sinus rhythm.Resp: Pt difficult to beg upon arrival. Shift NoteCV: HR 90-102, NSR with rare PVC's (slightly tachy with exertion). Sinus rhythmNormal ECGSince previous tracing, atrial fibrillation, and T wave changes absent * cont ABX as noted. Position okay but some tracheal stenosis and and mucosal edema were noted. Trivial mitralregurgitation is seen. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Frequent ventricular premature beats.Conclusions:The left atrium is mildly dilated. Rhythm returned after trach was able to be changed. Positive bowel sounds.GU: Foley is in place draining clear urine in adequate amts.ID: Afebrile at present with WBC 7.3. Put on PSV with slight improvement in airway pressures. Foley cath draining adequate UO; light yellow/clear. need for new speech and swollow eval now that t-tube has been placed.GU)Good U/O via foley.Plan: * ? There is narrowing of the airway proximal to the level of the tube without change. Mild valleculae residue was noted, cleared with frequent swallowing. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV systolic function.AORTA: Normal aortic root diameter. Pt is to be NPO except for meds. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , the LVEF is nolonger hyperdynamic, but remains normal. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cricolaryngeal excursion was normal. REASON FOR THIS EXAMINATION: PTX FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Question pneumothorax s/p right subclavian line attempt. A tracheostomy tube remains in place. PEG intact and patent. K LEVEL THIS 3.4/REPLETED WITH KCL 40MEQ IV. Please eval for PTX. 24 HR FLUID STATUS 754/870. now w/ fair video swallow- needs video REASON FOR THIS EXAMINATION: aspiration w/ po's FINAL REPORT PROCEDURE: Video oropharyngeal swallow. PRESENTLY PT IS AWAKE AND .HEART RYTHM SINUS, HR 90S-100S/ TACHY IN 100-105 AT TIMES. BP stable. MDI's administered as ordered. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Pt had one episode of discomfort after coughing last night,- which was relieved by Lidocaine 1% neb treatment.GI)Abd soft with + BS. Pt has PEG in place which is being used for meds only at present. Regional left ventricularwall motion is normal. Care NotePt adm from OSH with #6 portex trache and placed on Vent with PSV settings as charted on resp flowsheet. TMAX: 98.3/ REMAINS ON LEVO/LINEZOLID/ SPUTUM CX ON POS FOR PSEUDOMONAS, GRAM NEG RODS. Did require suctioning x2 for mod amt bld tinged secretions. The left ventricular inflow pattern suggests impairedrelaxation. Sinus rhythm with occasional ventricular premature beats. PEG IN PLACE, PATENT.FOLEY PATENT DRAINING CLEAR URINE/ UOP 100-120CC/HR.SKIN WARM/DRY. Able to wean dopamine off with MAP staying greater than 64. Min IVF.Resp - BS course bilat and decreased at bases. STOOL NEG FOR CDIFF.RECEIVED PT / TAKEN TO OR AT 0930 FOR TRACH DILATATION/ RIGIG BRONCH AND TTUBE PLACEMENT. Trach site slightly reddened but otherwise clean. With thin liquids, mild aspiration was noted without cough reflex initiated. Bronched at bedside to eval t-tube, some edema noted above proximal end. pt was bronched today see bronch sheet in chart for more information. MICU NPN Admit to MICU 6:69y.o. Plan is to bronch to eval airway placement as trache placed at OSH. Pt currently has #6 portex in place. Probalance TF's with goal 65ml/hr with Q6hr H2O flushes since Na 148. IMPRESSION: Before swallowing patient develops mild spillover into the valleculae cleared with frequent swallows. Mild to moderate[+] TR. Currently stable on PSV 10 with 5cm peep. Plan is to cap t-tube this am and possible c/o to floors. Right ventricular systolic function is normal. Nsg Progress Note 2300-0700CV - Pt afebrile. patient remained afebrile this shift. Mild aspiration upon thin liquids without initiating cough reflex. Sputum from + pseudomonas, GNR. | 18 | [
{
"category": "Echo",
"chartdate": "2173-09-22 00:00:00.000",
"description": "Report",
"row_id": 81745,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function.\nHeight: (in) 56\nWeight (lb): 154\nBSA (m2): 1.59 m2\nBP (mm Hg): 100/46\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 12:05\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent ventricular premature beats.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular systolic function is normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation. The tricuspid valve leaflets are mildly thickened. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the LVEF is no\nlonger hyperdynamic, but remains normal. Otherwise, no change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-09-23 00:00:00.000",
"description": "Report",
"row_id": 201436,
"text": "Sinus rhythm and frequent ventricular ectopy. Compared to the previous tracing\nof no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-09-17 00:00:00.000",
"description": "Report",
"row_id": 201437,
"text": "Sinus rhythm with occasional ventricular premature beats. Compared to the\nprevious tracing of ectopy is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-09-15 00:00:00.000",
"description": "Report",
"row_id": 201438,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing, atrial fibrillation, and T wave changes absent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-14 00:00:00.000",
"description": "Report",
"row_id": 1298518,
"text": "BRIEF UPDATE TO NPN ADMISSION:\nPt seen by IP who bronched her and found severe stenosis and edema below the level of the trach. Team will plan to take her to OR tomorrow for tracheal dilitation. In the meantime pt will be getting steroids IV and a dose of racemic epi is ordered. Pt is not to be suctioned via trach if possible tonight. She may need heliox also. Pt is to be NPO except for meds. In an emergency the plan will be to intubate her using a 5.5 ETT in her tracheal stoma. Attending on call aware of the plan.\n\nBlood sugars are to be checked Q4hrs and covered with sliding scale as ordered. She may need IV insulin drip if this is not enough.\n\nPt is still on small dose of dopamine 2.2mcg/kg/min.and our team is in the process of putting in central line at this time.\n\nShe can have morphine 1-2mg IV as needed for comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-16 00:00:00.000",
"description": "Report",
"row_id": 1298526,
"text": "Shift Note\nCV: HR 90-102, NSR with rare PVC's (slightly tachy with exertion). NIBP 113-120/40-50's. Na elevated and ?reason PTT elevated. coags and Na sent at 1700.\n\nAccess: PIV x2; femoral line to be d/c\n\nResp: 35% trach collar via t-tube. Patient bronch around 1600 to assess placement of t-tube; edema noted. ?starting patient on IV steriods and racemic epi. BBS coarse/diminished bases. Pt has strong cough and expectorating thick creamy sputum. Trach was capped yesterday and patient was able to talk. IP does not want trach capped at this time since no audible air leak.\n\nNeuro: Pt and will attempt to sign for things she needs since cambodian speaking only. Daughter called and spoke with patient to inform her of bronch, transfer and reasons for NPO status since patient continually requesting a drink of water. Speech/swallow showed signs of aspiration. ?repeat study since t-tube placement.\n\nGI/GU: Abdomen soft, BS present. Probalance TF's with goal 65ml/hr with Q6hr H2O flushes since Na 148. Foley cath draining adequate UO; light yellow/clear. No BM\n\nEndo: SSC. Pt only received 1/2 dose of NPH this am on prior shift since BS on low side and TF's just started.\n\nID: Pt on linezolid and levofloxcin for pseudomonas, MRSA and enterococcus. afebrile.\n\nSocial: Daughter spoke to patient to provide updates twice today. Aware of pending transfer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-15 00:00:00.000",
"description": "Report",
"row_id": 1298522,
"text": "Resp. Care Note\nPt received trached with #6 portex and vented on PSV settings as charted on flowsheet. Pt to OR today for tracheal dilatation and placement of T-tube. Placed on 40% trache mask post procedure and is doing well. Bronched at bedside to eval t-tube, some edema noted above proximal end. Able to speak when t-tube covered, initially some stridor noted with this but appeared improved in afternoon with much clearer voice. MDI's as ordered, lido/ codiene as ordered for coughing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-16 00:00:00.000",
"description": "Report",
"row_id": 1298523,
"text": "Respiratory Care Note:\n received patient this shift with a t-tube in place and cool mist at 40%. BS are coarse throughout. patient able to raise secretions most of the time, often small amounts of blood tinged thick secretions. patient remained afebrile this shift. administered one neb of lidocaine with improved patient comfort post rx. MDI's administered as ordered. SPO2 remains 100%. patient weaned to 35% cool mist. Plan is to cap t-tube this am and possible c/o to floors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-16 00:00:00.000",
"description": "Report",
"row_id": 1298524,
"text": "7pm to 7am:\n\nPt had a ridgit bronch done , which showed critical tracheal stenosis and edema. Pt had a balloon dilatation, stent placement and a t-tube placement. Pt had an uneventful night.\n\nNeuro)\nPt has been awake and . Unable to assess orientation D/T trached and language barrier. Pt is appropriate and able to make her needs known. Pt will follow very simple commands.\n\nCV)\nPt remains in NSR without any ectopy noted. HR in the 90's upon rest and increases to 100-120 with activity. No edema noted. Am labs as noted in carevue.\n\nResp)\nLs remains sl coarse to upper resp area and with clear bases. No SOB/DOE noted. Pt has been on TC 35% fio2 with an o2sat of 98-100%. Trach was capped off last night x 1hr without any complications. Pt was able to speak with family members. to cap trach this am at 8am. Sputum from + pseudomonas, GNR. No new changes made to ABX. Pt has had strong prod cough for pale blood tinged secretions. Pt had one episode of discomfort after coughing last night,- which was relieved by Lidocaine 1% neb treatment.\n\nGI)\nAbd soft with + BS. TF started at midnight and is now up to 20cc/hr as of 4am. increase to 30 cc/hr at 8am. Goal for TF is 50cc/hr. No BM. ? need for new speech and swollow eval now that t-tube has been placed.\n\nGU)\nGood U/O via foley.\n\nPlan: * ? speech and swollow eval.\n * ?transfer to floor.\n * cont ABX as noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-16 00:00:00.000",
"description": "Report",
"row_id": 1298525,
"text": "respiratory care\npt on 35% cool mist via trach and T-tube tol well. pt was bronched today see bronch sheet in chart for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-15 00:00:00.000",
"description": "Report",
"row_id": 1298519,
"text": "Nsg Progress Note 2300-0700\n\nCV - Pt afebrile. HR increases with agitation and epi treatments but has been mainly in the 90's with no ectopy. BP stable. Able to wean dopamine off with MAP staying greater than 64. Min IVF.\n\nResp - BS course bilat and decreased at bases. Able to stay on PSV and PEEP throughout the night without problem. Did require suctioning x2 for mod amt bld tinged secretions. Trach site slightly reddened but otherwise clean. Trach does become disconneted but easily reconnected and breathing returns to normal.\n\nGI - Abd soft with positive BS but no stool. PEG intact and patent. No TF's as pt is going to OR today.\n\nGU - Foley cath draining adequate amt cl yellow urine.\n\nEndocrine- BS 172 at 2am - covered with SS reg insulin.\n\nNeuro - Pt awake or easily arousible. Follows commands but language barrier makes it unable to assess orientation. She is able to let most of her needs be known. MAE and can turn to side by self.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-15 00:00:00.000",
"description": "Report",
"row_id": 1298520,
"text": "resp care note\n\nPt was bronched last night to assure proper position of # 6 Portex blue line trach which had been emergently inserted @ OSH. Position okay but some tracheal stenosis and and mucosal edema were noted. Plan for today is to go to OR for dialation or placement of stint. Pt did well overnight and did not has dyspnea. SpO2 remained in high 90's. She is on PSV 10/+5, 50% FiO2. Pt was not sx by RT but did cough to clear x 1.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-15 00:00:00.000",
"description": "Report",
"row_id": 1298521,
"text": "NSG 7AM-7PM\nPLEASE REFER TO CAREVIEW FOR LABS, I/OS, V/S.\n\n69 YR OLD CAMBODIAN WOMAN WITH HX OF PAPILLARY THYROID CA, S/P SUBTOTAL THYROIDECTOMY AND TRACHEOSTOMY,PRESENTING FROM OSH AFTER CARDIAC AND RESP ARREST. RIGID BRONCH REVEALS TRACHEAL MALACIA/ SUBGLOTIC STENOSIS/ ADMITTED TO MICU FOR FURTHER MANAGEMENT. S/P TRACHEAL DILATATION AND TTUBE PLACEMENT .\n\nRECEIVED PT /UNABLE TO ASSESS ORIENT LANGUE BARRIER, SPONTENEOUS, FOLLOWS COMMANDS, ABLE TO MAKE NEEDS KNOWN. POST OP, PT SOMNOLENT, EASILY AROUSABLE WITH VOICE STIMULI, PROCEDURE DONE UNDER GENERAL ANESTHESIA, NOT REVERSED. PRESENTLY PT IS AWAKE AND .\n\nHEART RYTHM SINUS, HR 90S-100S/ TACHY IN 100-105 AT TIMES. BP 90S-120S/40S-50S, MAP 60S-80S. OFF PRESSOR SINCE AT 0200. NO EPISODE OF HYPOTENSION. K LEVEL THIS 3.4/REPLETED WITH KCL 40MEQ IV. 24 HR FLUID STATUS 754/870. TMAX: 98.3/ REMAINS ON LEVO/LINEZOLID/ SPUTUM CX ON POS FOR PSEUDOMONAS, GRAM NEG RODS. STOOL NEG FOR CDIFF.\n\nRECEIVED PT / TAKEN TO OR AT 0930 FOR TRACH DILATATION/ RIGIG BRONCH AND TTUBE PLACEMENT. BRONCH POST PROCEDURE REVEALS TRACHEAL EDEMA/ NOT TO BE CAPPED TODAY. WILL REATTEMPT IN AM. CURRENTLY, TTUBE IN PLACE, NO BLEED, 40% HUMIDIFIED O2/SATO2 100%, LUNG SOUNDS COARSE THROUGHOUT, STRONG COUGH TIMES, EXPECTORATES MODERATE AMOUNT OF THICK BLOOD TINGED SPUTUM. CODEINE 15MG GIVEN WITH POS EFFECT/COUGHS LESS OFTEN. HAVE LIDOCAINE NEB PRN.\n\nABD SOFT POS BS/NO BM. REMAINS NPO. LAST SWALLOW EVAL REVEALS INEFFECTIVE COUGH CLEARANCE /TRACE-MILD ASPIRATION. TF TO START ON MN. PEG IN PLACE, PATENT.\n\nFOLEY PATENT DRAINING CLEAR URINE/ UOP 100-120CC/HR.\n\nSKIN WARM/DRY. SKIN CARE DONE.\n\nDAUGHTER CALLED SEVERAL TIMES/UPDATE GIVEN RE: PT'S CONDITION.\n\nMONITOR RESP STATUS/ TITRATE O2/ CAP WHEN ABLE.\nMONITOR BP\nPOSS C/O IN AM.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-14 00:00:00.000",
"description": "Report",
"row_id": 1298516,
"text": "MICU NPN Admit to MICU 6:\n69y.o. cantonese speaking female transferred from EW s/p cardiopulmonary Arrest. Pt was brought to their EW from today with c/o difficulty ventillating. Pt was difficult to bag with increased airway resistance and eventually coded and required fluids, atropine, epi. Rhythm returned after trach was able to be changed. Pt currently has #6 portex in place. Pt required dopamine drip for hypotension. Arrived via ambulance with this running in peripherally. Pt needs central access due to pressors and poor IV access.\n\nPMH: Thyroid CA, s/p thyroidectomy with sternotomy , s/p trach and PEG also , s/p B- cell lymphoma, s/p chemo, hiatal hernia, MRSA, A-flutter, Vitamin B12 deficiency, CVA, HTN, IDDM\n\nAllergies: NKA\n\nNeuro: Arrived via ambulance, lethargic. Trach in place. Unable to speak with her due to language barrier. Daughter plans to visit at 7PM this evening so we can ask questions to pt at that time and see if she is at her baseline mental status. Cooperative with care, not restrained at present but arrived via ambulance with restaints in place. Will assess closely. She has not been given any sedation and seems comfortable at present.\n\nCV: BP 90's on dopamine at 5mcg/kg/min. Getting 500cc fluid bolus at present. HR 80-110 sinus rhythm.\n\nResp: Pt difficult to beg upon arrival. Put on PSV with slight improvement in airway pressures. Currently stable on PSV 10 with 5cm peep. SRR 12 and good sat. Lungs coarse with insp/exp wheezes. Awaiting for her to be seen by IP.\n\nGI: NPO for now. Pt has PEG in place which is being used for meds only at present. Abdomen soft non-tender. Positive bowel sounds.\n\nGU: Foley is in place draining clear urine in adequate amts.\n\nID: Afebrile at present with WBC 7.3. Pt has had positive wound culture from rehab and is on IV antibiotics.\n\nEndo: Pt's blood glucose was 299 at 6PM and pt treated with sliding scale coverage as well as half her normal dinner dose of nPH. Pt given 6u regular with 12 units NPH. team aware and I will follow glucose again this evening.\n\nAccess: Team is aware pt is receiving peripheral dopamine infusion. Access is poor. VERY DIFFICULT TIME GETTING LABS UPOB ARRIVAL. Team is aware. Team is holding off on inserting central line until she is seen by IP and plan is made for possible intervention. Team will plan to get blood gas on pt later this evening.\n\nSocial: Daughter is spokesperson and will plan to visit pt this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-09-14 00:00:00.000",
"description": "Report",
"row_id": 1298517,
"text": "Resp. Care Note\nPt adm from OSH with #6 portex trache and placed on Vent with PSV settings as charted on resp flowsheet. PSV 10 peep 5 and 50% with TV 350-400 range and RR 12-16. Plan is to bronch to eval airway placement as trache placed at OSH.\n"
},
{
"category": "Radiology",
"chartdate": "2173-09-22 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 924245,
"text": " 1:10 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: aspiration w/ po's\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with s/p tracheostomy, s/p thryoidectomy. now w/ fair video\n swallow- needs video\n REASON FOR THIS EXAMINATION:\n aspiration w/ po's\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Video oropharyngeal swallow.\n\n INDICATION: 69-year-old woman status post tracheostomy, status post\n thyroidectomy. Please evaluate swallowing function.\n\n VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal swallowing\n video fluoroscopy was performed today in collaboration with the speech and\n language pathology division. Various consistencies of barium including thin\n liquid, nectar thickened liquid, puree, and a half cookie coated with barium\n were administered.\n\n FINDINGS: The oral phase was unremarkable for pathology. Mild valleculae\n residue was noted, cleared with frequent swallowing. Mild spillover was noted\n before each swallow. With thin liquids, mild aspiration was noted without\n cough reflex initiated. Cricolaryngeal excursion was normal. Palatal\n elevation and, laryngeal valve closure, and epiglottic deflection were within\n functional limits.\n\n IMPRESSION: Before swallowing patient develops mild spillover into the\n valleculae cleared with frequent swallows. No aspiration with thick liquids.\n Mild aspiration upon thin liquids without initiating cough reflex.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-09-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 923975,
"text": " 11:17 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change s/p bronch\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with tracheostomy and shortness of breath\n\n REASON FOR THIS EXAMINATION:\n interval change s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY DATED \n\n COMPARISON: .\n\n INDICATION: Tracheostomy and shortness of breath.\n\n A tracheostomy tube remains in place. There is narrowing of the airway\n proximal to the level of the tube without change. Heart size is normal. The\n aorta is tortuous. The lungs are clear, and there are no pleural effusions.\n\n IMPRESSION:\n\n Airway narrowing proximal to tracheostomy entry site without change.\n\n No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 923321,
"text": " 11:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: RESPIRATORY DISTRESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman s/p failed right subclavian line attempt, now with right\n femoral line. Please eval for PTX. Thank you.\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Question pneumothorax s/p right subclavian line attempt.\n\n Comparison is made with prior study performed the same day in the morning.\n\n FINDINGS: There is no pneumothorax. Tracheostomy tube in standard position.\n There is no pleural effusion. The lungs are clear. Heart size is normal.\n Patient is s/p median sternotomy.\n\n IMPRESSION: No pneumothorax.\n\n"
}
] |
29,487 | 116,532 | 86 y/o F with PMHx of severe AS & CHF admitted with urosepsis, s/p extubation on , had recurrent A.fib with RVR & hypotension that responded to repeat IV fluid boluses, made DNR/DNI on with continued delirium. . # A.Fib/CV: Pt with severe AS & CHF with EF 50%. Pt developped Afib with RVR c/b hypotension that responded to repeated IVF boluses. Concern for aggressive fluid resuscitation sending pt into pulm edema, likely to compromise resp status. Per family meeting, pt was made DNR/DNI, no lines, no pressors. Pt had intermittent episodes of hypotension requiring further fluid boluses. Avoiding aggressive volume boluses due to tenous volume status. Was on Digoxin 0.125mg every other day to help control rate. . #UTI/Septic Shock: Pt recently completed a 10 day course of Zosyn for pseudomonas urosepsis, successfully extubated on . WBC had trended down, afebrile. However, pt developed recurrent hypotension likely cardiogenic etiology but was restarted on empiric ABx prior to leaving the ICU (Zosyn/Vancomycin). Upon arrival to the floor, the patient remained afebrile with WBC trending down. Culture data was also negative. Therefore, antibiotics were stopped and the patient was monitored. . # RENAL FAILURE, ACUTE on chronic: Pt initially with oliguric renal failure likely hypoperfusion vs ATN in setting of shock. Pt began to naturally diurese on , then UOP dropped in setting of hypotension on . Currently, avoiding volume overload with gentle IVF boluses. Creatinine gradually increasing after transfer from ICU to medicine floor. Urine output decreased and urine studies consistent with pre-renal picture. Patient given intermittent IVF given poor PO intake. . # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS changes. CXR with bilateral pleural effusions R>L & pulm edema. CT on showed possible airspace disease in RLL vs chronic changes to right sided pleurodeisis. Pt extubated successfully on and has been maintaining sats on 2-3LNC. Was given nebulizer treatments as needed. . # MS CHANGES: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. Sleep/wake cycles now very disturbed. Pt has been pulling out lines overnight, had to place restraints temporary. Was started on Zyprexa (initially 5mg , then 2.5/5mg, then 2.5mg w/ PRN doses). . # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious source. CT neg for joint effusion, bone scan neg for pathologic fracture/metastatic lesion. PT consulted to assist with getting OOB. Initially received Dilaudid in the ICU, however that was stopped due to worry for hypotension and clouding mental status. On transfer to the floor, patient still with significant pain. In discussing with family, decision made to re-start Dilaudid (however in PO form) to control pain, with the understanding that this may cloud mental status. . #Thrombocytopenia ?????? pt has baseline plt ct 50-70s, trended down to 40 & heparin products held . Plts have been stable. Suspician of HIT very low and HIT Ab never sent from lab. Heparin products were held. . #Sacral Decub/intertriguinous rash - was seen by the wound care nurse implemented for wound care. Also placed on kinair mattress with regular position changes. Was given antifungal cream as well. . #Nutrition Pleasure feeds with pureed nectar thickened feeds (maintained on aspiration precautions). . Code status: DNR/DNI, no lines, no pressors . On , patient rapidly became hypotensive and unresponsive and expired. Family was notified. | # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant & delicate fluid balance. Sinus rhythmAtrial premature complexesRight bundle branch blockDiffuse ST-T wave abnormalities - are in part primary and nonspecific butclinical correlation is suggestedSince previous tracing of , atrial fibrillation absent and ST-T wavechanges decreased SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Pt presented with positive UA, hypotension and presumed urosepsis, but was covered with Vanc/Zosyn for 48hrs unable to wean from pressors. Atrial fibrillation with rapid ventricular responseRight bundle branch blockDiffuse ST-T wave abnormalities - are in part primary and nonspecific butclinical correlation is suggestedSince previous tracing of the same date, atrial fibrillation bnow present PATIENT/TEST INFORMATION:Indication: r/o Pericardial effusion.Height: (in) 61Weight (lb): 120BSA (m2): 1.52 m2BP (mm Hg): 89/34HR (bpm): 65Status: InpatientDate/Time: at 12:28Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Moderate symmetric LVH. While in the ED became hypotensive to 70s systolic in the setting of a positive U/A and elevated WBC code sepsis called, central line placed, levophed initiated and was transferred to the M/SICU for further management of ? CXR with effusions R>L & pulm edema. was given Zosyn and IVF in ED. was given Zosyn and IVF in ED. was given Zosyn and IVF in ED. septic brusitis, ortho following and await additonal recs continue zosynm f/u cx's SHOCK, CARDIOGENIC--cardiogenic in setting of afib with RVR and hypotension, now rate controlled BP improved, sdtable and off of pressors, cvp difficult to follow given severe AS, lactates normalized RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) renal follwoing, atn from sepsis hypotension, cr seems to have peaked, phos binder started, all meds renally dosed thrombocytopenia--on review of records baseline thromnbocytopenia in 50-70 range, with intial elevation here likely from hemoconcentration, dic labs negative and HUS/TTP unlikely, check smear, component of hemoconcetration likely though HIT possibiloty but given that plt is now at baseline--follow for further reduction from baseline, continue heparin products for now given low suspicion for HIT ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, limited given her severe af, respnsive to IVFs but would avoid calcium channel blockers, given new drop in hct and plts Leukocytosis--improving toward normal, check dc diff, continue vacno X 24 more hrs given catheter, clinically improving and highest suspicion is of urosepsis, though with line in plae would check ultrasound of porta cath and await new cx gram stain and result to show no GPs AORTIC STENOSIS--severem, preload depedent, URINARY TRACT INFECTION (UTI)--pseudomonas, pan senstivie--continue zosyn CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL) PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed for sedartion L hip pain--follow up ortho, pain control with fentanyl EKG - At 10:18 AM BLOOD CULTURED - At 12:40 PM BLOOD CULTURED - At 12:50 PM EKG - At 02:10 PM INVASIVE VENTILATION - START 03:00 PM URINE CULTURE - At 03:39 PM Assessment and Plan SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): GU likely source, but continued elevated WBC and pressor requirement despite broad spectrum abx suggest either inadequate coverage of Pseudomonas, or other source such as infected hip, c. diff, line infection (portacath), acalculous cholecystitis, etc. CXR with effusions R>L & pulm edema. Action: Medicated with Dilaudid x2 this shift. Action: Medicated with Dilaudid x2 this shift. Vasopressin gtt and eventually both levophed and vasopressin weaned to off. Vasopressin gtt and eventually both levophed and vasopressin weaned to off. septic brusitis, ortho following and await additonal recs continue zosynm f/u cx's SHOCK, CARDIOGENIC--cardiogenic in setting of afib with RVR and hypotension, now rate controlled BP improved, sdtable and off of pressors, cvp difficult to follow given severe AS, lactates normalized RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) renal follwoing, atn from sepsis hypotension, cr seems to have peaked, phos binder started, all meds renally dosed thrombocytopenia--on review of records baseline thromnbocytopenia in 50-70 range, with intial elevation here likely from hemoconcentration, dic labs negative and HUS/TTP unlikely, check smear, component of hemoconcetration likely though HIT possibiloty but given that plt is now at baseline--follow for further reduction from baseline, continue heparin products for now given low suspicion for HIT ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, limited given her severe af, respnsive to IVFs but would avoid calcium channel blockers, given new drop in hct and plts Leukocytosis--improving toward normal, check dc diff, continue vacno X 24 more hrs given catheter, clinically improving and highest suspicion is of urosepsis, though with line in plae would check ultrasound of porta cath and await new cx gram stain and result to show no GPs AORTIC STENOSIS--severem, preload depedent, URINARY TRACT INFECTION (UTI)--pseudomonas, pan senstivie--continue zosyn CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE, CERVICAL, ENDOMETRIAL) PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed for sedartion L hip pain--follow up ortho, pain control with fentanyl EKG - At 10:18 AM BLOOD CULTURED - At 12:40 PM BLOOD CULTURED - At 12:50 PM EKG - At 02:10 PM INVASIVE VENTILATION - START 03:00 PM URINE CULTURE - At 03:39 PM Assessment and Plan SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): GU likely source, but continued elevated WBC and pressor requirement despite broad spectrum abx suggest either inadequate coverage of Pseudomonas, or other source such as infected hip, c. diff, line infection (portacath), acalculous cholecystitis, etc. -continue holding heparin products and f/u HIT Ab ICU Care Nutrition: NPO for now, pending s/s eval Glycemic Control: ISS Lines: Indwelling Port (PortaCath) - 07:04 PM Prophylaxis: DVT: pneumoboots Stress ulcer: H2 blocker Code status: DNR (do not resuscitate) Disposition: possible out to floor - Will get repeat cultures - Check LFTs - CT chest and CT hip - Redose vanco according to levels - Consult ID re: antibiotic coverage SHOCK, SEPTIC/CARDIOGENIC: Continues to need pressors, with slow escalation. Pt with massive extravasc volume overload, will need to be slowly diuresed as pt is very preload dependant & tends to develop A.Fib with RVR when preload drops. While in the ED became hypotensive to 70s systolic in the setting of a positive U/A and elevated WBC code sepsis called, central line placed, levophed initiated and was transferred to the M/SICU for further management of ? While in the ED became hypotensive to 70s systolic in the setting of a positive U/A and elevated WBC code sepsis called, central line placed, levophed initiated and was transferred to the M/SICU for further management of ? While in the ED became hypotensive to 70s systolic in the setting of a positive U/A and elevated WBC code sepsis called, central line placed, levophed initiated and was transferred to the M/SICU for further management of ? While in the ED became hypotensive to 70s systolic in the setting of a positive U/A and elevated WBC code sepsis called, central line placed, levophed initiated and was transferred to the M/SICU for further management of ? Not concerned - continue to f/u blood & urine cultures - bolus prn to maintain Maps>65 SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib with RVR and became hypotensive on . Assessment and Plan 86 y/o F with PMHx of severe AS & CHF admitted with urosepsis, s/p extubation on , had recurrent A.fib with RVR & hypotension that responded to repeat IV fluid boluses, made DNR/DNI on with continued delirium. Assessment and Plan 86 y/o F with PMHx of severe AS & CHF admitted with urosepsis, s/p extubation on , had recurrent A.fib with RVR & hypotension that responded to repeat IV fluid boluses, made DNR/DNI on with continued delirium. 86 yo F with severe AS, h/o renal cell and ovarian ca who presented with L hip pain and hypotension, with resolved pseudomonal urosepsis c/b Afib/RVR, ARF (ATN) and respiratory failure stable since extubation Atrial fibrillation (Afib) Assessment: Action: Response: Plan: Delirium / confusion Assessment: Action: Response: Plan: # MS changes: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. # MS CHANGES: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. # MS CHANGES: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. # MS CHANGES: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. # MS CHANGES: Pt with delirium likely secondary to intubation, polypharmacy & prolonged ICU stay. CXR with effusions R>L & pulm edema. CXR with effusions R>L & pulm edema. CXR with effusions R>L & pulm edema. CXR with effusions R>L & pulm edema. CXR with effusions R>L & pulm edema. CXR with effusions R>L & pulm edema. | 158 | [
{
"category": "Physician ",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318601,
"text": "Chief Complaint: urpsepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n afib with rvr given BB (metoprolol)\n delirius\n metoprolol 12.5 started\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:30 PM\n Furosemide (Lasix) - 10:59 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:32 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 74 (63 - 124) bpm\n BP: 144/35(61) {101/19(41) - 144/70(78)} mmHg\n RR: 28 (16 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 1,577 mL\n 182 mL\n PO:\n 240 mL\n 60 mL\n TF:\n IVF:\n 1,337 mL\n 122 mL\n Blood products:\n Total out:\n 2,240 mL\n 1,800 mL\n Urine:\n 2,240 mL\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -663 mL\n -1,619 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin, elderly\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Oriented (to): confused, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 8.5 g/dL\n 60 K/uL\n 95 mg/dL\n 2.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 67 mg/dL\n 107 mEq/L\n 148 mEq/L\n 25.9 %\n 7.0 K/uL\n [image002.jpg]\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n WBC\n 6.1\n 5.7\n 7.0\n Hct\n 25.4\n 25.8\n 25.9\n Plt\n 42\n 40\n 58\n 60\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Imaging: no new imaging\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, stable\n since extubation\n Active issues remains:\n ATRIAL FIBRILLATION (AFIB)- recurrent afib overnight\n Continue dig, started BB, monitor u/o and give lasix prn\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > Delirium\ncontinues to be main issue, large component of sundowning\n at night and altered sleep schedule icu,\n continue zyprexa, reorient, optimize sleep cycle at night\n limit narcotics, consult--delirium w/u if not yet performed\n > hypoxemia--stable on minimal o2, recheck cxr\n > Hypernatremia--maintenance with D 5 --follow sodium\n > Sacral abrasions--wound care following, matress\n > Nutrition--aspiration risk and agitated so will hold on placing NGT\n > Thrombocytopenia--\n slow drop,--though now at baseline and stable, though low\n suspicion of hit, heparin products stopped and Hit panel sent, Now\n improved and at prior baseline.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Auto-diureses phase of atn, creatinine improving, holding on\n diuresis\n Stop phoslo\n Renal dosing of meds pending further improvement\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n Completed zosyn course X 10 days\n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BB\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, tylenol\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318606,
"text": "Chief Complaint: urpsepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca who\n presented with L hip pain and hypotension, with resolved pseudomonal\n urosepsis c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure,\n stable since extubation\n 24 Hour Events:\n a-fib with rvr to 140\n, given BB (metoprolol)\n very confused, awake all night\n metoprolol 12.5 started\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:30 PM\n Furosemide (Lasix) - 10:59 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:32 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 74 (63 - 124) bpm\n BP: 144/35(61) {101/19(41) - 144/70(78)} mmHg\n RR: 28 (16 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 1,577 mL\n 182 mL\n PO:\n 240 mL\n 60 mL\n TF:\n IVF:\n 1,337 mL\n 122 mL\n Blood products:\n Total out:\n 2,240 mL\n 1,800 mL\n Urine:\n 2,240 mL\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -663 mL\n -1,619 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin, elderly\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric)\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Oriented (to): confused, Movement: Purposeful, Tone: Not\n assessed\n Labs / Radiology\n 8.5 g/dL\n 60 K/uL\n 95 mg/dL\n 2.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 67 mg/dL\n 107 mEq/L\n 148 mEq/L\n 25.9 %\n 7.0 K/uL\n [image002.jpg]\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n WBC\n 6.1\n 5.7\n 7.0\n Hct\n 25.4\n 25.8\n 25.9\n Plt\n 42\n 40\n 58\n 60\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n Imaging: no new imaging\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, stable\n since extubation\n Active issues remains:\n ATRIAL FIBRILLATION (AFIB)- recurrent afib overnight\n Continue dig, started BB\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > Delirium\ncontinues to be main issue, large component of sundowning\n at night and altered sleep schedule icu,\n continue zyprexa, re-orient, optimize sleep cycle at night\n limit narcotics, head ct, consult--delirium w/u (RPR,\n folate, tsh, b12) if not yet performed\n > hypoxemia--stable on minimal NC o2, recheck cxr\n > Hypernatremia\nfree water deficit in setting of NPO and diuresis,\n maintenance with D 5 --follow sodium\n > Sacral abrasions--wound care following, mattress\n > Nutrition--aspiration risk and agitated so will hold on placing NGT,\n and start maintenance ivf\n > Thrombocytopenia--\n Low ate baseline, though low suspicion of hit, heparin products\n stopped and Hit panel sent, Now improved and at prior baseline.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Auto-diureses phase of atn, creatinine improving, holding on\n diuresis\n d/c phoslo\n Renal dosing of meds pending further improvement\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n Completed zosyn course X 10 days\n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BB\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, tylenol\n ICU Care\n Nutrition: NPO for aspiration risk, failed swallow study, maintenance\n IVF\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318283,
"text": "Chief Complaint:\n 24 Hour Events:\n - BP stable off pressors, no bolus requirement\n - UOP adequate, still net positive\n - tolerated for 5 hrs, ABGs improved\n - admin Lasix 40mg IV this am\n Pt intubated, sedated, opening eyes but only intermittently responding\n to commands.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.9\nC (96.6\n HR: 74 (67 - 92) bpm\n BP: 132/39(69) {96/32(53) - 154/58(90)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 9 (2 - 12)mmHg\n Total In:\n 1,068 mL\n 306 mL\n PO:\n TF:\n 470 mL\n 220 mL\n IVF:\n 258 mL\n 66 mL\n Blood products:\n Total out:\n 510 mL\n 45 mL\n Urine:\n 510 mL\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 558 mL\n 261 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 363 (363 - 405) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.37/37/136/22/-3\n Ve: 7.7 L/min\n PaO2 / FiO2: 453\n Physical Examination\n GEN: NAD, intubated, opening eyes to commands\n HEENT: swollen, edematous face\n CV: irreg/irreg gr 3 SEM over LSB\n RESP: crackles bilaterally at bases, no w/r\n ABD: soft,NT/ND/NABS\n Extr: 2+ pitting edema bilaterally\n Labs / Radiology\n BONE\n SCAN: No scintigraphic evidence of hip metastasis or pathologic fractur\n e.\n Portable CXR:\n FINDINGS: In comparison with study of , there is no change in the\n appearance of the endotracheal and nasogastric tubes and central venous\n catheter and Port-A-Cath. No change in the appearance of the\n cardiomediastinal silhouette. Large right and smaller left pleural eff\n usions\n persist. No evidence of acute focal pneumonia.\n IMPRESSION: Little change.\n 51 K/uL\n 8.7 g/dL\n 132 mg/dL\n 2.9 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 65 mg/dL\n 111 mEq/L\n 140 mEq/L\n 27.4 %\n 7.8 K/uL\n [image002.jpg]\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n WBC\n 14.7\n 7.8\n Hct\n 28.9\n 27.4\n Plt\n 72\n 51\n Cr\n 3.0\n 3.1\n 2.9\n TCO2\n 21\n 22\n 21\n 21\n 22\n 24\n 22\n Glucose\n 127\n 161\n 132\n Other labs: PT / PTT / INR:12.9/33.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n C Diff negative x 4, Blood Cx NGTD\n Urine Culture + Pseudomonas pan sensitive\n Sputum Culture + yeast\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis and\n MS changes.\n .\n #SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): etiology presumed urosepsis\n with positive UA growing out pan sensitive Pseudomonas, now day 7 of\n Zosyn. Pt is s/p Intubation on for worsening acidosis/MS\n changes. Pt had transient hypotensive episode with worsening acidosis\n on -intermittently requiring pressors. WBC now trending down,\n afebrile, no recurrence of hypotension. Further infectious work up neg\n to date, L chest U/S neg for abscess,Bone scan negative.\n - apprec ID consult, continue Zosyn day \n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n - gentle bolus of 250 LR prn to maintain Maps>65\n - will repeat cultures if any recurrence of hypotension\n .\n #SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib\n with RVR and became hypotensive on . Pressure responded to IVF &\n pressors. Pt was intubated and pressors weaned. Pt has been in/out of\n Afib but HR better controlled on digoxin. Transiently hypotensive on\n , required pressors approx 5hrs, likely due to severe AS and\n preload dependence. Pt with extravasc volume overload and complicated\n fluid balance.\n - continue Digoxing 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - attempt aggressive diuresis today, goal -500cc\n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation.\n WBC ct down, it is unlikely that this due to a new PNA, but will\n reculture and broaden Abx if pt clinically deteriorates. Pulm edema\n and extravascular volume overload may be a barrier to extubation. Goal\n to run i/os negative 500cc today\n - tolerated well for 5hrs o/n. ABGs show normal acid base status,\n oxygenating & ventilating well.\n - f/u RSBI in am, possible extubation over weekend\n .\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Creatinine improved & having increased UOP. Acidosis improved on vent\n with AC, unclear etiology of metabolic acidosis leading to intubation.\n Apprec renal recs, will admin Lasix & Metolazone this am to attempt\n diuresis\n - monitor i/os, goal net negative 500cc\n - renally dose all meds\n - continue phoslo TID\n .\n # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant\n & delicate fluid balance. Gentle bolus with 250cc LR prn to maintain\n MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n .\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n # LEFT HIP PAIN: Etiology unclear but not an infectious source. Not a\n septic joint on admission, but clearly painful on manipulation now. CT\n neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n - continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:51 AM 35 mL/hour\n Glycemic Control:\n Lines: Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin sc TID\n Stress ulcer: H2 blocker\n VAP: Chlorhexidine\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Echo",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Report",
"row_id": 95989,
"text": "PATIENT/TEST INFORMATION:\nIndication: r/o Pericardial effusion.\nHeight: (in) 61\nWeight (lb): 120\nBSA (m2): 1.52 m2\nBP (mm Hg): 89/34\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 12:28\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Low normal\nLVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Moderately dilated ascending aorta. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets.\nModerate-severe AS (area 0.8-1.0cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate (2+) MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.] Prolonged (>250ms)\ntransmitral E-wave decel time. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is mildly dilated. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Overall\nleft ventricular systolic function is low normal (LVEF 50%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The ascending aorta is moderately dilated. The aortic valve\nleaflets are severely thickened/deformed. There is moderate to severe aortic\nvalve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Moderate\n(2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The left\nventricular inflow pattern suggests impaired relaxation. The tricuspid valve\nleaflets are mildly thickened. The supporting structures of the tricuspid\nvalve are thickened/fibrotic. There is a small pericardial effusion. The\neffusion appears circumferential. There are no echocardiographic signs of\ntamponade.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , the findings are similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Report",
"row_id": 259936,
"text": "Multifocal atrial tachycardia. Right bundle-branch block. Compared to the\nprevious tracing of the rate has increased and there is multifocal\natrial tachycardia. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Report",
"row_id": 259937,
"text": "Sinus arrhythmia with PVCs\nLeftward axis\nRight bundle branch block\nPossible inferior infarct - age undetermined\nLateral T wave changes\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Report",
"row_id": 259938,
"text": "Sinus rhythm\nAtrial premature complexes\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\nclinical correlation is suggested\nSince previous tracing of , atrial fibrillation absent and ST-T wave\nchanges decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Report",
"row_id": 259939,
"text": "Atrial fibrillation with rapid ventricular response\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\nclinical correlation is suggested\nSince previous tracing of the same date, atrial fibrillation bnow present\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Report",
"row_id": 259940,
"text": "Sinus rhythm\nAtrial premature complexes\nLeft atrial abnormality\nRight bundle branch block\nDiffuse ST-T wave abnormalities - are in part primary and nonspecific but\nclinical correlation is suggested\nSince previous tracing of , ST-T wave changes appear slightly more\nprominent\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Report",
"row_id": 259941,
"text": "Baseline artifact. Sinus rhythm with frequent atrial premature beats and\npossible multifocal atrial rhythm. Occasional ventricular premature beats.\nP-R interval about 160 milliseconds. Left atrial abnormality. Borderline\nleft axis deviation. Right bundle-branch block. Possible prior inferior wall\nmyocardial infarction. Non-specific Inferior ST-T wave changes with mild\nQTc interval prolongation. Compared to the previous tracing of \nventricular ectopy is now seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Report",
"row_id": 259942,
"text": "Sinus rhythm. Occasional atrial premature beats. Compared to the previous\ntracing ectopy has diminished. Tachycardia is no longer present. Right\nbundle-branch block persists.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2163-01-16 00:00:00.000",
"description": "Report",
"row_id": 259943,
"text": "Sinus tachycardia. Frequent atrial premature beats. Right bundle-branch block.\nCompared to the previous tracing of a rare atrial premature beat was\npreviously present. Tachycardia has appeared.\nTRACING #1\n\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317845,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:30 AM- Afib, RBBB, no acute ST-T waves changes\n ARTERIAL LINE - START 04:15 PM\n - CE negative\n - vanc added\n - urine grew out pseudomonas, did not double cover per ID\n - MRI hip ordered, not performed\n - uable to wean pressors overnight\n Pt doing okay this am, still some L hip pain, but otherwise, breathing\n comfortably, no CP/SOB/Abd pain.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 09:45 AM\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Infusions:\n Other ICU medications:\n Heparin TID, Allopurinol,\n Famotidine, Tamoxifen,\n Dilaudid, Zofran, Insulin,\n Bisacodyl, Colace\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 90 (84 - 101) bpm\n BP: 94/40(60) {90/37(-17) - 109/44(66)} mmHg\n RR: 16 (9 - 23) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 13 (13 - 27)mmHg\n SvO2: 75%\n Total In:\n 6,279 mL\n 214 mL\n PO:\n 1,020 mL\n TF:\n IVF:\n 5,259 mL\n 214 mL\n Blood products:\n Total out:\n 159 mL\n 20 mL\n Urine:\n 159 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,120 mL\n 194 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n GEN: NAD, comfortable, HOH\n HEENT: RIJ in place, NCAT, unable to visualize JVP\n CV: irreg/irreg, gr early peaking SEM over LSB, prominent S2\n Resp: CTAB ant lung fields, BS over LLL, no w/r\n ABD: soft/NT/ND/NABS\n EXTR: 2+ pitting edema bilaterally\n Neuro: AXO, HOH\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 88 mg/dL\n 2.9 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 60 mg/dL\n 101 mEq/L\n 133 mEq/L\n 32.9 %\n 28.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n 02:04 PM\n 05:30 AM\n WBC\n 20.6\n 24.5\n 33.3\n 28.6\n Hct\n 30\n 31.6\n 32.9\n 31.6\n 32.9\n Plt\n 83\n 121\n 114\n 114\n Cr\n 2.3\n 2.4\n 2.4\n 2.9\n TropT\n 0.11\n 0.12\n 0.11\n TCO2\n 25\n Glucose\n 147\n 89\n 74\n 88\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:6.0 mg/dL\n Assessment and Plan:\n 86 y/o F with PMHx of severe AS with EF of 45%, Renal Cell Ca and\n Ovarian Ca who presented with L hip pain and presumed urosepsis,\n clinical status deteriorated this afternoon with oliguria & acidosis,\n increased pressor requirement & MS changes. Pt was intubated and ABG\n improving on vent.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Pt presented with positive\n UA, hypotension and presumed urosepsis, but was covered with Vanc/Zosyn\n for 48hrs unable to wean from pressors. WBC ct rising, worsening\n acidosis and developped Afib with RVR & hypotension requiring addl\n pressors. Pt was bolused 2.5L and converted, but MS deteriorated & pt\n was intubated for airway protection and acidosis. Post intubation, pt\n was able to wean from pressors. ABG 7.29/38/252\n - will FiO2 and repeat ABG\n - apprec ID consult, will monitor BPs overnight, if clinically\n deteriorates, will broaden coverage to Meropenem/Vanc\n - bolus IVF prn, no pressor requirement currently\n - follow CT chest/abd/pelv read, ruling out abscess, septic joint or\n infected hardware\n - consider d/c portocath in am\n - f/u blood & urine cultures, Urine +pseudomonas\nsensitivities pending\n SHOCK, CARDIOGENIC: Pt developped Afib with RVR and became\n hypotensive. Responded to fluid boluses, then post-intubation, all\n pressors weaned and BP stable. Pt was loaded with digoxin\n - f/u am digoxin level on \n - fluid bolus prn A.fib & consider amiodarone vs cardioversion if\n uncontrolled RVR\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Apprec renal consult\n for pt with oliguric renal failure likely due to ATN but urine sediment\n revealed sheets of WBCs, unable to further assess sediment.\n - currently oliguric and extravascularly volume overloaded\n - resp status stable on vent, no acute indication for dialysis\n - renally dose meds, starting phoslo & monitor lytes \n AORTIC STENOSIS: AS with valve area 0.7cm, very preload dependant,\n bolus fluid prn and avoid BB/CCBs.\n - continue digoxin, monitor for worsening CHF\n URINARY TRACT INFECTION (UTI): presumed source of sepsis, currently\n in oliguric RF, foley in place\n - continue Vanc/Zosyn for coverage of pseudomonas species, waiting on\n sensitivities\nLEFT HIP PAIN: unknown etiology, concern for fluid collection/septic\n joint. Apprec ortho consult\n - f/u CT pelvis and continue Vanc/Zosyn. Intubated with fentanyl for\n sedation & pain control.\n ICU Care\n Nutrition: NPO with OG in place for meds\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin 5000 TID\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 317944,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318002,
"text": "No significant events overnight\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely low ~ 10 cc/hr, total body overloaded w/ 4+\n pitting edema x all 4 extremities\n Action:\n All meds renally dosed, no fluid boluses overnight\n Response:\n Plan:\n Cont to trend changes in BUN/CR, renally dose all meds, nephrology may\n need to re evaluate if urine output does not improve.\n Pain control (acute pain, chronic pain)\n Assessment:\n Sedated on fent/midaz grimaces during turns/repositioning\n Action:\n Fent boluses prior to turning, lido patch off @ 00:00\n Response:\n Continues to experience pain\n Plan:\n Continue w/ current pain/sedation regimen, ortho consult to evaluate\n for septic L hip.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318003,
"text": "No significant events overnight\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely low ~ 10 cc/hr, total body overloaded w/ 4+\n pitting edema x all 4 extremities\n Action:\n All meds renally dosed, no fluid boluses overnight\n Response:\n Plan:\n Cont to trend changes in BUN/CR, renally dose all meds, nephrology may\n need to re evaluate if urine output does not improve.\n Pain control (acute pain, chronic pain)\n Assessment:\n Sedated on fent/midaz grimaces during turns/repositioning\n Action:\n Fent boluses prior to turning, lido patch off @ 00:00\n Response:\n Continues to experience pain\n Plan:\n Continue w/ current pain/sedation regimen, ortho consult to evaluate\n for septic L hip.\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 317832,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Vol/Press:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1800\n Bedside Procedures:\n Comments:\n Intubated without complication electively by anesthesia\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318149,
"text": "Chief Complaint: urosepsis, erspiratory failure, afib with rvr\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n hypotensive overnight without response to 500 cc IVF bolus and levophed\n restarted then off this am,\n increasingly acidemic on PS so replaced to ACV\n History obtained from house staff\n Patient unable to provide history: Sedated\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:51 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (96.9\n HR: 80 (66 - 99) bpm\n BP: 149/58(83) {82/34(50) - 149/58(83)} mmHg\n RR: 17 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 8 (-1 - 10)mmHg\n Total In:\n 1,501 mL\n 445 mL\n PO:\n TF:\n 497 mL\n 67 mL\n IVF:\n 734 mL\n 179 mL\n Blood products:\n Total out:\n 620 mL\n 240 mL\n Urine:\n 570 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 881 mL\n 205 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 351 (305 - 387) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/36/150/19/-4\n Ve: 8.4 L/min\n PaO2 / FiO2: 500\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), a-fib\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n b/l bases, No(t) Wheezes : , Diminished: )\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, Sedated, Tone:\n Normal\n Labs / Radiology\n 9.3 g/dL\n 72 K/uL\n 161 mg/dL\n 3.1 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 65 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.9 %\n 14.7 K/uL\n [image002.jpg]\n 06:59 PM\n 05:17 AM\n 05:39 AM\n 10:07 AM\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n WBC\n 10.9\n 14.7\n Hct\n 26.7\n 28.9\n Plt\n 56\n 72\n Cr\n 2.9\n 3.0\n 3.1\n TCO2\n 21\n 20\n 25\n 21\n 22\n 21\n 21\n Glucose\n 99\n 127\n 161\n Other labs: PT / PTT / INR:12.9/33.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Imaging: et ok, underpentrated\n Microbiology: urine cx --2 pan sensitive pseudomonas\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n SHOCK, CARDIOGENIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ATRIAL FIBRILLATION (AFIB)\n AORTIC STENOSIS\n URINARY TRACT INFECTION (UTI)\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n abg and change back to PS after road trip....feel that fatigue is\n likely from volume, needs to mobilize fluid\n making increased urine output,\n no urine eos and compelemnts low,\n zosyn for uti\n bone scan today for hip pain\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hyptotesnion, in ICU with pseudomal urosepsis c/b\n Afib/RVR, hypotension, ARF and respiratory failure\n > Respiratory failure\ndoing well on vent with improved acidosis but\n is total body volume up and will need to diurese prior to extubation,\n given some improved urine output today will likely begin auto-diuresis\n phase of ATN, will follow u/o and consider gentle diuresis later today\n with goal even to negative 500 today prior to extubation\n continue PS and lighten sedation with SBT in am\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis,\n improving\n WBC trending down, hemodynamically stable, porta cath without\n fluid by u/s and low suspicion of seeding given GNRs rather than GPCs\n L hip pain remains problem for possible met/lytic lesion or\n fx, no evidence of fluid for tap to suggest septic bursitis/source for\n infection\n Continue zosyn X 14 day course and f/u cx results\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension, now rate controlled and stable hemodynamically off of\n pressors\n suspect that the dopr in BP secondary to preload dependance\n With severe AS rather than persistent spesis, now starting to\n autodiurese, would match i/o's as is very preload dependant also in\n setting of positive pressure, would allow autodiuresis and consider\n diruestics later, for goal even to negative fluid balnace\n cvp difficult to follow given severe AS\n lactates normalized\n follow MAPs and u/o\n ATRIAL FIBRILLATION (AFIB)- reverted back to NSR with ectopy and\n paroxysmal---now rate controlled, on dig, responsive to IVFs but would\n avoid calcium channel blockers in setting of RVR given severe AS, Daily\n stoke risk low and would not anticoagulate at this time given low plts\n at baseline, though would reassess as clinical picture improves as may\n remain in chronic a- fib,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n atn from sepsis and hypotension\n cr appears to have peaked and now with increasing u/o--will likely\n start to auto-diurese\n continue phos binder\n all meds renally dosed\n urine eos neg, complement pending and renal service recs\n appreciated\n > Leukocytosis\nnormalizing\n check C diff cx\n d/c vanco as no GPs from cx data and given clinical\n improvement\n continue zosyn for pseudomonas\n clinically improving and highest suspicion remains of\n urosepsis\n > thrombocytopenia--on review of records, baseline thrombocytopenia in\n 50-70 range, with initial elevation here likely from hemoconcentration\n and now likely at baseline, dic labs negative and HUS/TTP unlikely,\n check smear\n follow for further reduction from baseline, continue heparin products\n for now given low suspicion for HIT\n > anemia- h/h now stable, likely component of hemodilution,\n transfuse for < 21 or active bleed or if hypotension\n AORTIC STENOSIS--severe, preload dependent as above\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan sensitive--continue\n zosyn as above X 14 day course\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed while on\n vent\n > Hip pain--dose not seem source of infection but given her significant\n pain concern for some lytic lesion/fx or micro fx or bony mets-- bone\n scan to assess\n > Diarrhea--wbc trending down, c diff neg X 2 with third pending\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 09:15 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318164,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hypotensive to 70s, not resposive to 500cc bolus, re-started levophed\n with good response\n - ABGs progressively more acidemic, switched back to AC following\n midnight ABG with good response\n - d/c'd vanc\n Pt intubated/sedated, not responding to commands. Still on Levophed\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 66 (66 - 99) bpm\n BP: 133/43(73) {82/34(50) - 133/49(78)} mmHg\n RR: 14 (9 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 7 (-1 - 10)mmHg\n Total In:\n 1,656 mL\n 434 mL\n PO:\n TF:\n 653 mL\n 259 mL\n IVF:\n 734 mL\n 115 mL\n Blood products:\n Total out:\n 620 mL\n 152 mL\n Urine:\n 570 mL\n 152 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,036 mL\n 282 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 351 (271 - 387) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n SpO2: 98%\n ABG: 7.35/36/150/19/-4\n Ve: 7 L/min\n PaO2 / FiO2: 500\n Physical Examination\n GEN: NAD, intubated, comfortable on vent\n CV: RRR gr 3 SEM over LSB, does not radiate\n RESP: CTAB, BS over bases\n ABD: ND, mildly tense, no grimacing to palp,NABS\n EXTR: 2+pitting edema bilaterally\n Labs / Radiology\n 72 K/uL\n 9.3 g/dL\n 161 mg/dL\n 3.1 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 65 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.9 %\n 14.7 K/uL\n [image002.jpg]\n 06:59 PM\n 05:17 AM\n 05:39 AM\n 10:07 AM\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n WBC\n 10.9\n 14.7\n Hct\n 26.7\n 28.9\n Plt\n 56\n 72\n Cr\n 2.9\n 3.0\n 3.1\n TCO2\n 21\n 20\n 25\n 21\n 22\n 21\n 21\n Glucose\n 99\n 127\n 161\n Other labs: PT / PTT / INR:12.9/33.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan: 86 y/o F with PMHx of severe AS & CHF p/w Left hip\n pain, adm to for presumed urosepsis, intubated on for\n worsening acidosis and MS changes.\n #SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): presumed to be urosepsis with\n positive UA growing out pan sensitive Pseudomonas, now day 4 of Zosyn.\n Pt is s/p Intubation of for worsening acidosis/MS changes, pt\n developped a worsening mixed acidosis & hypotension with minimal\n vent support, switch to AC overnight & pH improved. Hypotension did\n not resolve with 500cc bolus, required Levophed for apporx 5 hrs.\n Etiology of acidosis/hypotension unclear, possibly due to uremia, NS\n resussitation and preload dependance given severe AS. Ruling out\n ongoing sepsis, further infectious work up neg to date, L chest U/S neg\n for abscess, CT unrevealing. Bone scan pending today.\n - ID consult, continue Zosyn for coverage of pseudomonas in\n urine, Vanc was d/c\nd \n - ortho consult for L hip pain, bone scan pending today for ?mets\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n - gentle bolus of 250 LR prn to maintain Maps>65\n - will repeat cultures if any recurrence of hypotension\n #SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib\n with RVR and became hypotensive on . Pressure responded to IVF &\n pressors. Pt was intubated and pressors weaned. Pt has been in/out of\n Afib but HR better controlled on digoxin. BP dropped overnight, did\n not respond to IV bolus, required pressors approx 5hrs. This was\n likely due to severe AS and preload dependance but concern for ongoing\n sepsis. Extravascular volume overload and complicated fluid balance,\n goal of net even i/os.\n - continue Digoxing 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA low\n - fluid bolus 250cc LR prn to maintain maps>60\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR shows bilateral effusions & pulm edema. CT showed\n possible airspace disease in , have been aspiration\n peri-intubation. WBC ct increased at 14 today. It is unlikely that\n this due to a new PNA, but will reculture and broaden Abx if pt\n clinically deteriorates. Pulm edema and extravascular volume overload\n will likely be a barrier to extubation. Goal to run i/os even, waiting\n on spontaneous diuresis.\n - repeat ABG in pm, consider weaning to this evening\n - f/u RSBI in am, possible extubation over weekend\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Urine sediment filled with WBCs, no e/o casts. Creatinine increased\n slightly overnight, likely contraction, having increased UOP.\n Renal recs, there is no acute indication for dialysis. Acidosis\n improved on vent with AC, unclear if metabolic acidosis leading to\n intubation was uremia vs NS resussitation. renal recs, waiting\n on natruriesis\n - monitor i/os, goal net even\n - renally dose all meds\n - continue phoslo TID\n # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant\n & delicate fluid balance. Gentle bolus with 250cc LR prn to maintain\n MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn renally dosed for coverage\n # LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation. CT neg for joint effusion, bone scan pending today\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition: Nutren Pulmonary (Full) - 07:33 PM 35 mL/hour\n Glycemic Control: Insulin SS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin sc\n Stress ulcer: H2 blocker\n VAP: chlorhexidine\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318145,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318172,
"text": "Chief Complaint: urosepsis, erspiratory failure, afib with rvr\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca who\n presented with L hip pain and hyptotension, in ICU with pseudomonal\n urosepsis c/b Afib/RVR, ARF (ATN) and respiratory failure\n 24 Hour Events:\n increasingly acidemic on PS\nchanged back to ACV\n Hypotensive (70;s systolic) overnight without response to 500 cc IVF\n bolus and levophed restarted\nnow off with stable BPs and MAPs\n History obtained from house staff\n Patient unable to provide history: Sedated\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 11:51 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 01:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.1\nC (96.9\n HR: 80 (66 - 99) bpm\n BP: 149/58(83) {82/34(50) - 149/58(83)} mmHg\n RR: 17 (10 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 8 (-1 - 10)mmHg\n Total In:\n 1,501 mL\n 445 mL\n PO:\n TF:\n 497 mL\n 67 mL\n IVF:\n 734 mL\n 179 mL\n Blood products:\n Total out:\n 620 mL\n 240 mL\n Urine:\n 570 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 881 mL\n 205 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 351 (305 - 387) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/36/150/19/-4\n Ve: 8.4 L/min\n PaO2 / FiO2: 500\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), a-fib\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n b/l bases, No(t) Wheezes : , Diminished: )\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Not assessed, Sedated, Tone:\n Normal\n Labs / Radiology\n 9.3 g/dL\n 72 K/uL\n 161 mg/dL\n 3.1 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 65 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.9 %\n 14.7 K/uL\n [image002.jpg]\n 06:59 PM\n 05:17 AM\n 05:39 AM\n 10:07 AM\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n WBC\n 10.9\n 14.7\n Hct\n 26.7\n 28.9\n Plt\n 56\n 72\n Cr\n 2.9\n 3.0\n 3.1\n TCO2\n 21\n 20\n 25\n 21\n 22\n 21\n 21\n Glucose\n 99\n 127\n 161\n Other labs: PT / PTT / INR:12.9/33.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Imaging: et ok, underpentrated\n Microbiology: urine cx --2 pan sensitive pseudomonas\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, in ICU with pseudomonal urosepsis c/b\n Afib/RVR, ARF (ATN) and respiratory failure\n Overall improving, volume status and underlying severe AS complicating\n wean\n Active issues remains:\n Respiratory failure\ndoing well on vent with improved acidosis\n but is total body volume up and will need to diurese prior to\n extubation, urine output continues to improve and will likely begin\n auto-diuresis phase of ATN, is likely somewhat preload dependant and in\n setting of positive pressure though at risk for significant flash pulm\n edema post extubation and resultant ischemia\n follow u/o and consider gentle diuresis later today (lasix,\n thiazide)\n would change back to PS later and follow abg though\n not ready for extubation\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis,\n improving, suspect recurrent hypotensive episode overnight may have\n been secondary to volume shifts, though WBC elevated, all counts are up\n and would trend\n Infection work up as previously noted, following all cx\n Continue zosyn X 14 day course\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, needs to mobilize fluids prior to extubation\n though recently hypotensive as has preload dependence from AS also in\n setting of positive pressure\n Starting to autodiurese,\n follow MAPs and u/o and consider gentle diuretics later\n ATRIAL FIBRILLATION (AFIB)- reverted back to NSR, with ectopy\n Continue dig\n Daily stoke risk low and would not anticoagulate at this time given\n low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n atn from sepsis and hypotension\n cr appears to have peaked and now with increasing u/o--will likely\n start to auto-diurese\n continue phos binder\n all meds renally dosed\n > Leukocytosis\nup slightly along with all cell counts\ntrend, no\n diarrhea and c diff neg and appropriate antibx coverage in place,\n follow and continue zosyn for pseudomonas\n > thrombocytopenia--on review of records, baseline thrombocytopenia in\n 50-70 range, with initial elevation here likely from hemoconcentration\n and now likely at baseline, dic labs negative and HUS/TTP unlikely\n follow for further reduction from baseline, continue heparin\n products for now given low suspicion for HIT\n > anemia- h/h now stable, likely component of hemodilution,\n transfuse for < 21 or active bleed or if hypotension\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan sensitive--continue\n zosyn as above X 14 day course\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n > Hip pain--dose not seem source of infection but given her significant\n pain concern for some lytic lesion/fx or micro fx or bony mets-- bone\n scan to assess\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 09:15 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318305,
"text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: continue to wean psv as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318306,
"text": "Pt is a 86 y/o woman with history of severe AS, cervical and ovarian\n CA,and CRF with baseline Creat 2,, presented to the EW with c/o L hip\n pain, leukocyctosis, fever, found to have UTI , hypotensive to SBP70/\n treated with fluid boluses for total of 7liters, then on pressors.\n Admit to MICU for urospesis. Urine cultures +pseudomonas, Pt developed\n new AFib . Worsening metabolic acidosis requiring intubation on \n with worsening mental status changes. Currently is 8kg over admit\n weight.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Was on A/C overnight placed back on PS this morning 12cm with PEEP 5cm,\n maintaining TV of 330-400cc with minute vent 6-8 liters/min. suctioning\n for min secretions. Dropped PS to 10cm at 1800.\n Action:\n Cont with PS as tolerated. Check ABG\n Response:\n Pt will maintain good ABg while on PS\n Plan:\n Cont PS ventilation, attempting to diuresis with goal of -500cc to a\n 1000cc. follow ABG\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Urine output averaging 20-30cc/hr with lasix has averaged 60-70cc/hr.\n giving diurel 500mg with 120mg of lasix at 1800\n Action:\n Good diuresis with goal being 500or greater.\n Response:\n Maintain good urine output\n Plan:\n Follow I&O\ns closely.\n Urinary tract infection (UTI)\n Assessment:\n Cont on Zosyn day 6. urine cultures still positive for pseudomonas\n afebrile with WBC s down to 7 this am.\n Action:\n Cont to follow temps, antibx as ordered. Re culture if spikes temp.\n Response:\n Pt will cont to be afebrile.\n Plan:\n Administer antibx as ordered.\n Pain control (acute pain, chronic pain)\n Assessment:\n Sleeping between daily care activites. Able to tolerate turning but\n grimaced with movement of L leg.\n Action:\n Cont on IV fentanyl at 20mcg/hr and lido patche applied to l hip area.\n Response:\n Pt will be pain free\n Plan:\n Cont with meds. Assessment ,\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318388,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on 50% cool neb,was stable during night.\n Action:\n Cool neb weaned off to NC 2L\n Response:\n O2 sats maintained 100% on NC 2L, after weaning,ABG -WNL\n Plan:\n Can be weaned off to RA.\n ed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Diuresis for fluid overload\n Action:\n Chlorothiazide and Lasix at AM\n Response:\n Diuresing well with previous diuretics on negative balance now.\n Plan:\n Continue diuresing as pt tolerates\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt looks comfortable unless otherwise stimulated for position,personal\n care etc\n Action:\n Reposition as needed,Lidocaine patch on lt hip,Dilaudid prn\n Response:\n Better with repositioning\n Plan:\n Dilaudid prn,Lidocaine patch off at midnight,to be put on at 1200.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318389,
"text": "Chief Complaint: Urosepsis\n 24 Hour Events:\n -- given diuril + lasix w/ good response, repeated at 4am\n -- ABG unchanged\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:02 PM\n Infusions:\n Fentanyl - 20 mcg/hour\n Other ICU medications:\n Heparin Sodium - 12:13 PM\n Furosemide (Lasix) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36\nC (96.8\n HR: 74 (68 - 114) bpm\n BP: 147/41(72) {96/32(53) - 174/62(101)} mmHg\n RR: 18 (8 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 15 (4 - 15)mmHg\n Total In:\n 1,203 mL\n 308 mL\n PO:\n TF:\n 841 mL\n 293 mL\n IVF:\n 252 mL\n 14 mL\n Blood products:\n Total out:\n 1,532 mL\n 900 mL\n Urine:\n 1,532 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -329 mL\n -592 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 369 (363 - 428) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 53\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.37/45/129/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 47 K/uL\n 8.6 g/dL\n 144 mg/dL\n 3.1 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 69 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n WBC\n 14.7\n 7.8\n 7.4\n Hct\n 28.9\n 27.4\n 26.6\n Plt\n 72\n 51\n 47\n Cr\n 3.1\n 2.9\n 3.1\n TCO2\n 21\n 21\n 22\n 24\n 22\n 25\n 27\n Glucose\n 161\n 132\n 144\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis and\n MS changes.\n .\n #SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): etiology presumed urosepsis\n with positive UA growing out pan sensitive Pseudomonas, now day 7 of\n Zosyn. Pt is s/p Intubation on for worsening acidosis/MS\n changes. Pt had transient hypotensive episode with worsening acidosis\n on -intermittently requiring pressors. WBC now trending down,\n afebrile, no recurrence of hypotension. Further infectious work up neg\n to date, L chest U/S neg for abscess,Bone scan negative.\n - apprec ID consult, continue Zosyn day \n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n - gentle bolus of 250 LR prn to maintain Maps>65\n - will repeat cultures if any recurrence of hypotension\n .\n #SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib\n with RVR and became hypotensive on . Pressure responded to IVF &\n pressors. Pt was intubated and pressors weaned. Pt has been in/out of\n Afib but HR better controlled on digoxin. Transiently hypotensive on\n , required pressors approx 5hrs, likely due to severe AS and\n preload dependence. Pt with extravasc volume overload and complicated\n fluid balance.\n - continue Digoxin 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - schedule metolazone and lasix daily, repeat in pm if volume up\n - EKG today\n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation.\n WBC ct down, it is unlikely that this due to a new PNA, but will\n reculture and broaden Abx if pt clinically deteriorates. Pulm edema\n and extravascular volume overload may be a barrier to extubation.\n - tolerated well. ABGs show normal acid base status, oxygenating &\n ventilating well.\n - RSBI 53, will attempt extubation today\n .\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Creatinine improved & having increased UOP. Acidosis improved on vent\n with AC, unclear etiology of metabolic acidosis leading to intubation.\n Apprec renal recs, will admin Lasix & Metolazone this am to attempt\n diuresis. Improved urine output but Cr still well above baseline.\n - monitor i/os, goal net negative\n - renally dose all meds\n - continue phoslo TID\n .\n # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant\n & delicate fluid balance. Gentle bolus with 250cc LR prn to maintain\n MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n .\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n - repeat UA\n test of cure\n # LEFT HIP PAIN: Etiology unclear but not an infectious source. Not a\n septic joint on admission, but clearly painful on manipulation now. CT\n neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n - continue Fentanyl for pain control\n - Tylenol and dilaudid for pain prn\n Thrombocytopenia\n baseline 50-70s, 47 this am\n - re-check pm plts\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 AM 35 mL/hour\n NPO for\n extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318381,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Doing well on PSV 5/5.\n Action:\n Extub and placed on 50% CN.\n Response:\n Gd ABGs. Gd O2sats. No tachypnea.\n Plan:\n Cont to follow.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Gd UO from diuresis on previus shift.\n Action:\n Cont to follow UO.\n Response:\n Currently > 1L neg.\n Plan:\n Re-dose Lasix and Chlorothiazide in a.m.\n Urinary tract infection (UTI)\n Assessment:\n Afebrile.\n Action:\n Continues on Zosyn. Repeat U/A C/S sent.\n Response:\n Afebrile.\n Plan:\n Follow urines tests. Cont current mgmt.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Comfortable on 20 mics/hr Fent\n Action:\n DC\nd fent gtt prior to extub. Lido patch applied as ordered to L hip.\n Response:\n Groggy still. Attempting to speak but unable to understand. Seems\n somewhat confused. Sleeping when undisturbed. Not able to take Pos at\n present d/t MS.\n :\n Cont to assess for pain. PRN dilaudid. RE-orient and cont to assess MS.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317656,
"text": "86 yo female admitted to ED after 3 days of new onset left hip pain.\n She is s/p right hip replacement. Pt also has chronic UTI\ns and was on\n keflex at home. She presented to ED for evaluation of hip pain and\n work up for possible pathological fracture. Pt was noted to by\n hypotensive to the 70\ns systolic. Her WBC was elevated and her U/A was\n positive. CXR was negative for PNA. Her initial lactate was 2.1. A\n central line was placed and pt started on antibiotics for infection and\n levophed for BP support.\n She was transferred to MICU for further evlauation and treatment of\n urosepsis.\n Upon arrival to MICU\n pt stated she was comfortable and felt much\n better. Pt received 1 mg dilaudid IV in the ED. SVO2 set up and pt\n continued on levophed for BP support.\n .H/O hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-16 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 317643,
"text": "Chief Complaint: Left hip pain admitted to MICU with likely urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yr old woman, hx of RCC and ovarian ca, OA s/p right THR, and severe\n AS with 0.7,\n here with new left sided hip pain x 3d with difficulty ambulating due\n to severe pain. Has hx of recurrent UTIs on cephalexin prophylaxis\n which was recently increased on from 250mg to 500mg .\n During ED work up for hip fracture, BP dropped to 70s systolic. Also\n found to have leukocytosis and positive u/a. Also had increased\n creatinine from baseline 1.6 to 2.4. Lactate 2.1.\n CXR appeared unchanged from but persistent bilat R>L effusions.\n Central line placed in ED (RIJ), tx with Zosyn, 3-4 liters of IV fluids\n and started on Levophed. Transferred to MICU.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Lasix ? dose 80-160 daily, allopurinol, colace, Keflex, hydralazine 100\n TID, isordil 20 TID, omeprazole, MVI, microK, tamoxifen\n Past medical history:\n Family history:\n Social History:\n Occupation: retired, owned drapery business\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, No(t) Myalgias, left hip, see HPI\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 11:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,600 mL\n PO:\n TF:\n IVF:\n 1,600 mL\n Blood products:\n Total out:\n 0 mL\n 383 mL\n Urine:\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,217 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No audible murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Surgical scars\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 83 K/uL\n 31.6 %\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 20.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Fluid analysis / Other labs: Creatinine was 2.4 at 11am.\n Troponin-T 0.06 at 11am to 0.11 at 20:30 with normal CK.\n Lactate decreased from 2.1 to 1.1.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 317647,
"text": "Chief Complaint: Left hip pain admitted to MICU with likely urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yr old woman, hx of RCC and ovarian ca, OA s/p right THR, and severe\n AS with 0.7,\n here with new left sided hip pain x 3d with difficulty ambulating due\n to severe pain. Has hx of recurrent UTIs on cephalexin prophylaxis\n which was recently increased on from 250mg to 500mg .\n During ED work up for hip fracture, BP dropped to 70s systolic. Also\n found to have leukocytosis and positive u/a. Also had increased\n creatinine from baseline 1.6 to 2.4. Lactate 2.1.\n CXR appeared unchanged from but persistent bilat R>L effusions.\n Central line placed in ED (RIJ), tx with Zosyn, 3-4 liters of IV fluids\n and started on Levophed. Transferred to MICU.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Lasix ? dose 80-160 daily, allopurinol, colace, Keflex, hydralazine 100\n TID, isordil 20 TID, omeprazole, MVI, microK, tamoxifen\n Past medical history:\n Family history:\n Social History:\n Occupation: retired, owned drapery business\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, No(t) Myalgias, left hip, see HPI\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 11:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,600 mL\n PO:\n TF:\n IVF:\n 1,600 mL\n Blood products:\n Total out:\n 0 mL\n 383 mL\n Urine:\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,217 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No audible murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Surgical scars\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 83 K/uL\n 31.6 %\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 20.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Fluid analysis / Other labs: Creatinine was 2.4 at 11am.\n Troponin-T 0.06 at 11am to 0.11 at 20:30 with normal CK.\n Lactate decreased from 2.1 to 1.1.\n Assessment and Plan\n 86 yr old, hx of ovarian ca and RCC, presented with left sided hip\n pain, in ED had hypotension, likely due to urosepsis.\n 1. Likely septic shock exacerbated by Dilaudid in setting of\n severe AS. Source of infection likely GU, with positive u/a,\n leukocytosis, acidosis, recent cultures positive for pseudomonas. Given\n pansensitivity of pseudomonas, agree with Pip-Tazo. On Levophed 0.1\n mcg/kg\n will try to wean. CVP of 18 likely due to severe AS. SvO2\n >70%. Received ~4 L of IV fluids. Will treat with maintenance fluids\n for now given risk of CHF with her severe AS. Follow up cultures.\n 2. Severe AS: followed by Dr. . At risk for CHF. Hold\n hydralazine, lasix\n 3. Lactic acidosis: likely due to sepsis, resolving\n 4. Acute on CRF: worse in setting of probable urosepsis. Renal\n ultrasound showed no hydronephrosis. Dose meds renally.\n 5. Hip pain: no fracture or dislocation found on plain\n radiographs. MRI abdomen did not show new concerning lesions.\n Pain control, consider repeat MRI to r/o occult fracture.\n 6. Hx of cdiff: not acute\n 7. Hx of ovarian ca\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 317648,
"text": "Chief Complaint: hypotension\n HPI: 86 yo F with hx RCC, ovarian CA, arthritis, s/p right hip\n replacement with new onset L hip pain for 3 days. pt has had difficulty\n ambulating, endorses pain with any movements at all. Pt has chronic UTI\n on keflex at home. She presented to the ED for evaluation of L hip\n pain. during w/u for possible pathologic Fx pat was noted to be\n hypotensive to 70s. She was found to have a WBC of 14K, a positive U/A,\n as well as an elevated creatinine of 2.4 (baseline 1.6-1.8). Her\n initial lactate was 2.1. CXR was negative for PNA. She was ordered for\n hip/pelvis plain films. A central line was placed, pat was given zosyn\n and 3-4L IVF. Started on levophed.\n Admitted to ICU for urosepsis.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Left renal tumor x2, status post CyberKnife radioablation in \n .\n h/o ovarian cancer with peritoneal metastases (followed by Dr\n \n h/o recurrent partial small bowel obstructions\n CRI (1.3 to 1.6)\n CHF (EF 50% with mod AS, +AR, 2+MR)\n h/o PAD\n h/o C. difficile infections\n HTN\n h/o diverticulitis,\n h/o recurrent UTIs\n s/p left CEA,\n h/o talc pleurodesis\n TAH/BSO 19 years ago\n Gout\n h/o Collagenous colitis\n NC\n Lives by herself; close relatives live . No tobacco,\n EtOH, or IV drug use.\n Husband died in .\n Review of systems:\n Flowsheet Data as of 12:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 45 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 45 mL\n Blood products:\n Total out:\n 383 mL\n 35 mL\n Urine:\n 83 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 10 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n Labs / Radiology\n 83 K/uL\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 31.6 %\n 20.6 K/uL\n [image002.jpg]\n \n 2:33 A2/24/ 05:23 PM\n \n 10:20 P2/24/ 08:30 PM\n \n 1:20 P2/24/ 10:15 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 86F w/ h/o RCC, ovarian CA, multiple UTIs on chronic prophylaxis,\n presenting w/ L hip pain and found to be hypotensive, with ED w/u\n indicating urosepsis.\n .\n #) Urosepsis: pat has + U/A, elevated WBC, and was hypotensive to\n systolic 70s in the ED. most recent UCx positive for pseudomonas, but\n had E.coli in prior UCx. was given Zosyn and IVF in ED. lactate\n initially 2.1, trended down to 0.7.hypotension likely exacerbated by\n dilaudid in setting of severe AS, perhaps in addition to increased\n lasix dose.\n - zosyn for gram-negative coverage\n - f/u UCx, BCx\n - IVF fluids cautiously given severe AS\n - if needed start levophed for UOP>30cc/h, MAP>60\n - transfuse PRBC as needed for SVO2>70%\n .\n #) Hip pain: arthritis vs infection vs mets (pathologic fracture); CT\n not possible given renal function. plain films done in ED. PE not\n indicatve of abscess (no swelling/erythema)\n - f/u pelvis/hip films\n - pain control w/ dilaudid prn\n - MRI for occult fracture\n .\n #) acute on chronic renal failure: likley in setting of infection.\n - check renal U/S to r/o obstruction/abscess\n - check ulytes\n - monitor UOP, Crea\n - dose meds renally\n .\n #) CHF/severe AS: in the setting of worsening AS, systolic dysfuction\n w/ EF of 45%. Pat on home lasix, hydralazine, nitrates. will for now\n hold all three meds until BP stable, will then restart as tolerated.\n .\n #) HTN: hold home meds in setting of urosepsis.\n .\n #) gout: renally dose allopurinol\n .\n #) h/o ovarian CA, RCC: not currently active\n - cont tamoxifen\n .\n #) FEN: NPO for now, IVF, replete lytes\n #) PPx: H2 blocker, MV, fishoil, bowel regimen, hep SQ, boots\n #) Code: presumed full\n #) Dispo: pending\n #) Communication:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 317649,
"text": "Chief Complaint: hypotension\n HPI: 86 yo F with hx RCC, ovarian CA, arthritis, s/p right hip\n replacement with new onset L hip pain for 3 days. pt has had difficulty\n ambulating, endorses pain with any movements at all. Pt has chronic UTI\n on keflex at home. She presented to the ED for evaluation of L hip\n pain. during w/u for possible pathologic Fx pat was noted to be\n hypotensive to 70s. She was found to have a WBC of 14K, a positive U/A,\n as well as an elevated creatinine of 2.4 (baseline 1.6-1.8). Her\n initial lactate was 2.1. CXR was negative for PNA. She was ordered for\n hip/pelvis plain films. A central line was placed, pat was given zosyn\n and 3-4L IVF. Started on levophed.\n Admitted to ICU for urosepsis.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Left renal tumor x2, status post CyberKnife radioablation in \n .\n h/o ovarian cancer with peritoneal metastases (followed by Dr\n \n h/o recurrent partial small bowel obstructions\n CRI (1.3 to 1.6)\n CHF (EF 50% with mod AS, +AR, 2+MR)\n h/o PAD\n h/o C. difficile infections\n HTN\n h/o diverticulitis,\n h/o recurrent UTIs\n s/p left CEA,\n h/o talc pleurodesis\n TAH/BSO 19 years ago\n Gout\n h/o Collagenous colitis\n NC\n Lives by herself; close relatives live . No tobacco,\n EtOH, or IV drug use.\n Husband died in .\n Review of systems:\n Flowsheet Data as of 12:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 45 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 45 mL\n Blood products:\n Total out:\n 383 mL\n 35 mL\n Urine:\n 83 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 10 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No audible murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Surgical scars\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 83 K/uL\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 31.6 %\n 20.6 K/uL\n [image002.jpg]\n \n 2:33 A2/24/ 05:23 PM\n \n 10:20 P2/24/ 08:30 PM\n \n 1:20 P2/24/ 10:15 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 86F w/ h/o RCC, ovarian CA, multiple UTIs on chronic prophylaxis,\n presenting w/ L hip pain and found to be hypotensive, with ED w/u\n indicating urosepsis.\n .\n #) Urosepsis: pat has + U/A, elevated WBC, and was hypotensive to\n systolic 70s in the ED. most recent UCx positive for pseudomonas, but\n had E.coli in prior UCx. was given Zosyn and IVF in ED. lactate\n initially 2.1, trended down to 0.7.hypotension likely exacerbated by\n dilaudid in setting of severe AS, perhaps in addition to increased\n lasix dose.\n - zosyn for gram-negative coverage\n - f/u UCx, BCx\n - IVF fluids cautiously given severe AS\n - if needed start levophed for UOP>30cc/h, MAP>60\n - transfuse PRBC as needed for SVO2>70%\n .\n #) Hip pain: arthritis vs infection vs mets (pathologic fracture); CT\n not possible given renal function. plain films done in ED. PE not\n indicatve of abscess (no swelling/erythema)\n - f/u pelvis/hip films\n - pain control w/ dilaudid prn\n - MRI for occult fracture\n .\n #) acute on chronic renal failure: likley in setting of infection.\n - check renal U/S to r/o obstruction/abscess\n - check ulytes\n - monitor UOP, Crea\n - dose meds renally\n .\n #) CHF/severe AS: in the setting of worsening AS, systolic dysfuction\n w/ EF of 45%. Pat on home lasix, hydralazine, nitrates. will for now\n hold all three meds until BP stable, will then restart as tolerated.\n .\n #) HTN: hold home meds in setting of urosepsis.\n .\n #) gout: renally dose allopurinol\n .\n #) h/o ovarian CA, RCC: not currently active\n - cont tamoxifen\n .\n #) FEN: NPO for now, IVF, replete lytes\n #) PPx: H2 blocker, MV, fishoil, bowel regimen, hep SQ, boots\n #) Code: presumed full\n #) Dispo: pending\n #) Communication:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 317650,
"text": "Chief Complaint: hypotension\n HPI: 86 yo F with hx RCC, ovarian CA, arthritis, s/p right hip\n replacement with new onset L hip pain for 3 days. pt has had difficulty\n ambulating, endorses pain with any movements at all. Pt has chronic UTI\n on keflex at home. She presented to the ED for evaluation of L hip\n pain. during w/u for possible pathologic Fx pat was noted to be\n hypotensive to 70s. She was found to have a WBC of 14K, a positive U/A,\n as well as an elevated creatinine of 2.4 (baseline 1.6-1.8). Her\n initial lactate was 2.1. CXR was negative for PNA. She was ordered for\n hip/pelvis plain films. A central line was placed, pat was given zosyn\n and 3-4L IVF. Started on levophed.\n Admitted to ICU for urosepsis.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Left renal tumor x2, status post CyberKnife radioablation in \n .\n h/o ovarian cancer with peritoneal metastases (followed by Dr\n \n h/o recurrent partial small bowel obstructions\n CRI (1.3 to 1.6)\n CHF (EF 50% with mod AS, +AR, 2+MR)\n h/o PAD\n h/o C. difficile infections\n HTN\n h/o diverticulitis,\n h/o recurrent UTIs\n s/p left CEA,\n h/o talc pleurodesis\n TAH/BSO 19 years ago\n Gout\n h/o Collagenous colitis\n NC\n Lives by herself; close relatives live . No tobacco,\n EtOH, or IV drug use.\n Husband died in .\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, No(t) Myalgias, left hip, see HPI\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 12:14 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 45 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 45 mL\n Blood products:\n Total out:\n 383 mL\n 35 mL\n Urine:\n 83 mL\n 35 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 10 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No audible murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Surgical scars\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 83 K/uL\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 31.6 %\n 20.6 K/uL\n [image002.jpg]\n \n 2:33 A2/24/ 05:23 PM\n \n 10:20 P2/24/ 08:30 PM\n \n 1:20 P2/24/ 10:15 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 86F w/ h/o RCC, ovarian CA, multiple UTIs on chronic prophylaxis,\n presenting w/ L hip pain and found to be hypotensive, with ED w/u\n indicating urosepsis.\n .\n #) Urosepsis: pat has + U/A, elevated WBC, and was hypotensive to\n systolic 70s in the ED. most recent UCx positive for pseudomonas, but\n had E.coli in prior UCx. was given Zosyn and IVF in ED. lactate\n initially 2.1, trended down to 0.7.hypotension likely exacerbated by\n dilaudid in setting of severe AS, perhaps in addition to increased\n lasix dose.\n - zosyn for gram-negative coverage\n - f/u UCx, BCx\n - IVF fluids cautiously given severe AS\n - if needed start levophed for UOP>30cc/h, MAP>60\n - transfuse PRBC as needed for SVO2>70%\n .\n #) Hip pain: arthritis vs infection vs mets (pathologic fracture); CT\n not possible given renal function. plain films done in ED. PE not\n indicatve of abscess (no swelling/erythema)\n - f/u pelvis/hip films\n - pain control w/ dilaudid prn\n - MRI for occult fracture\n .\n #) acute on chronic renal failure: likley in setting of infection.\n - check renal U/S to r/o obstruction/abscess\n - check ulytes\n - monitor UOP, Crea\n - dose meds renally\n .\n #) CHF/severe AS: in the setting of worsening AS, systolic dysfuction\n w/ EF of 45%. Pat on home lasix, hydralazine, nitrates. will for now\n hold all three meds until BP stable, will then restart as tolerated.\n .\n #) HTN: hold home meds in setting of urosepsis.\n .\n #) gout: renally dose allopurinol\n .\n #) h/o ovarian CA, RCC: not currently active\n - cont tamoxifen\n .\n #) FEN: NPO for now, IVF, replete lytes\n #) PPx: H2 blocker, MV, fishoil, bowel regimen, hep SQ, boots\n #) Code: presumed full\n #) Dispo: pending\n #) Communication:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 317651,
"text": "Chief Complaint: Left hip pain admitted to MICU with likely urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yr old woman, hx of RCC and ovarian ca, OA s/p right THR, and severe\n AS with 0.7,\n here with new left sided hip pain x 3d with difficulty ambulating due\n to severe pain. Has hx of recurrent UTIs on cephalexin prophylaxis\n which was recently increased on from 250mg to 500mg .\n During ED work up for hip fracture, BP dropped to 70s systolic. Also\n found to have leukocytosis and positive u/a. Also had increased\n creatinine from baseline 1.6 to 2.4. Lactate 2.1.\n CXR appeared unchanged from but persistent bilat R>L effusions.\n Central line placed in ED (RIJ), tx with Zosyn, 3-4 liters of IV fluids\n and started on Levophed. Transferred to MICU.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Lasix ? dose 80-160 daily, allopurinol, colace, Keflex, hydralazine 100\n TID, isordil 20 TID, omeprazole, MVI, microK, tamoxifen\n Past medical history:\n Family history:\n Social History:\n Occupation: retired, owned drapery business\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, No(t) Myalgias, left hip, see HPI\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 11:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,600 mL\n PO:\n TF:\n IVF:\n 1,600 mL\n Blood products:\n Total out:\n 0 mL\n 383 mL\n Urine:\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,217 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No audible murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Surgical scars\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 83 K/uL\n 31.6 %\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 20.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Fluid analysis / Other labs: Creatinine was 2.4 at 11am.\n Troponin-T 0.06 at 11am to 0.11 at 20:30 with normal CK.\n Lactate decreased from 2.1 to 1.1.\n Assessment and Plan\n 86 yr old, hx of ovarian ca and RCC, presented with left sided hip\n pain, in ED had hypotension, likely due to urosepsis.\n 1. Likely septic shock exacerbated by Dilaudid in setting of\n severe AS. Source of infection likely GU, with positive u/a,\n leukocytosis, acidosis, recent cultures positive for pseudomonas. Given\n pansensitivity of pseudomonas, agree with Pip-Tazo. On Levophed 0.1\n mcg/kg\n will try to wean. CVP of 18 likely due to severe AS. SvO2\n >70%. Received ~4 L of IV fluids. Will treat with maintenance fluids\n for now given risk of CHF with her severe AS. Follow up cultures.\n 2. Severe AS: followed by Dr. . At risk for CHF. Hold\n hydralazine, lasix\n 3. Lactic acidosis: likely due to sepsis, resolving\n 4. Acute on CRF: worse in setting of probable urosepsis. Renal\n ultrasound showed no hydronephrosis. Dose meds renally.\n 5. Hip pain: no fracture or dislocation found on plain\n radiographs. MRI abdomen did not show new concerning lesions.\n Pain control, consider repeat MRI to r/o occult fracture.\n 6. Hx of cdiff: not acute\n 7. Hx of ovarian ca\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , MD\n on: 00:26 ------\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 317652,
"text": "Chief Complaint: Left hip pain admitted to MICU with likely urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yr old woman, hx of RCC and ovarian ca, OA s/p right THR, and severe\n AS with 0.7,\n here with new left sided hip pain x 3d with difficulty ambulating due\n to severe pain. Has hx of recurrent UTIs on cephalexin prophylaxis\n which was recently increased on from 250mg to 500mg .\n During ED work up for hip fracture, BP dropped to 70s systolic. Also\n found to have leukocytosis and positive u/a. Also had increased\n creatinine from baseline 1.6 to 2.4. Lactate 2.1.\n CXR appeared unchanged from but persistent bilat R>L effusions.\n Central line placed in ED (RIJ), tx with Zosyn, 3-4 liters of IV fluids\n and started on Levophed. Transferred to MICU.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:45 PM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Lasix ? dose 80-160 daily, allopurinol, colace, Keflex, hydralazine 100\n TID, isordil 20 TID, omeprazole, MVI, microK, tamoxifen\n Past medical history:\n Family history:\n Social History:\n Occupation: retired, owned drapery business\n Drugs: none\n Tobacco: none\n Alcohol: social\n Other:\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain, No(t) Myalgias, left hip, see HPI\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Flowsheet Data as of 11:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.3\nC (95.6\n HR: 77 (77 - 86) bpm\n BP: 104/40(54) {80/38(54) - 125/57(70)} mmHg\n RR: 10 (9 - 16) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 16 (0 - 16)mmHg\n SvO2: 72%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,600 mL\n PO:\n TF:\n IVF:\n 1,600 mL\n Blood products:\n Total out:\n 0 mL\n 383 mL\n Urine:\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,217 mL\n Respiratory\n SpO2: 90%\n ABG: 7.24/55/139/24/-4\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No audible murmurs\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Surgical scars\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 83 K/uL\n 31.6 %\n 9.8 g/dL\n 147 mg/dL\n 24 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 20.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n WBC\n 20.6\n Hct\n 30\n 31.6\n Plt\n 83\n TropT\n 0.11\n TC02\n 25\n Glucose\n 147\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:47/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:7.8\n mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Fluid analysis / Other labs: Creatinine was 2.4 at 11am.\n Troponin-T 0.06 at 11am to 0.11 at 20:30 with normal CK.\n Lactate decreased from 2.1 to 1.1.\n Assessment and Plan\n 86 yr old, hx of ovarian ca and RCC, presented with left sided hip\n pain, in ED had hypotension, likely due to urosepsis.\n 1. Likely septic shock exacerbated by Dilaudid in setting of\n severe AS. Source of infection likely GU, with positive u/a,\n leukocytosis, acidosis, recent cultures positive for pseudomonas. Given\n pansensitivity of pseudomonas, agree with Pip-Tazo. On Levophed 0.1\n mcg/kg\n will try to wean. CVP of 18 likely due to severe AS. SvO2\n >70%. Received ~4 L of IV fluids. Will treat with maintenance fluids\n for now given risk of CHF with her severe AS. Follow up cultures.\n 2. Severe AS: followed by Dr. . At risk for CHF. Hold\n hydralazine, lasix\n 3. Lactic acidosis: likely due to sepsis, resolving\n 4. Acute on CRF: worse in setting of probable urosepsis. Renal\n ultrasound showed no hydronephrosis. Dose meds renally.\n 5. Hip pain: no fracture or dislocation found on plain\n radiographs. MRI abdomen did not show new concerning lesions.\n Pain control, consider repeat MRI to r/o occult fracture.\n 6. Hx of cdiff: not acute\n 7. Hx of ovarian ca\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Comments:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , MD\n on: 00:26 ------\n PMH:\n Left renal tumor x2, status post CyberKnife radioablation in \n .\n h/o ovarian cancer with peritoneal metastases (followed by Dr ,\n TAH/BSO 19 years ago\n h/o recurrent partial small bowel obstructions\n CRI (1.3 to 1.6)\n CHF (EF 50% with mod AS, +AR, 2+MR), h/o PVD\n h/o C. difficile infections\n HTN\n h/o diverticulitis, h/o recurrent UTIs\n s/p left CEA,\n h/o talc pleurodesis, Gout, h/o Collagenous colitis\n ------ Protected Section Addendum Entered By: , MD\n on: 00:29 ------\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317639,
"text": "Pt. with chronic UTIs on standing meds at home. Presented to MD office\n last week with UTI. Standing dose increased. Presented to ED today with\n severe L hip pain. Temp 100.1. Recived 1 mg of IV Dilaudid and became\n hypotensive not improving with IVF. Lactate 2.1. Code sepsis called and\n R IJ line placed. CVP 16 after 5L IVF. Started on low dose Levophed.\n Recived dose of IV Zosyn and Tylenol. CXR. Neg. Blood and urien cx.\n sent from ED. L hip films done with no significant findings per\n preliminary read.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317836,
"text": "Briefly this is an 86 y/o F w/ PMH significant for ovarian CA,CRI\n (baseline CR 1.8) chronic UTI (on keflex @ home), R hip replacement,\n who presented to the ED on complaining of new onset L hip pain x 3\n days. While in the ED became hypotensive to 70s systolic in the\n setting of a positive U/A and elevated WBC code sepsis called, central\n line placed, levophed initiated and was transferred to the M/SICU for\n further management of ? urosepsis.\n Urine output remains extremely low overnight, team is aware, became\n hypotensive to 80 systolic s/p .5mg IVP dilaudid for L hip pain. Unable\n to wean levophed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Cr continues to trend up, urine output extremely low\n Action:\n Foley irrigated easily, no evidence of obstruction found, Renal U/S\n from unremarkable\n Response:\n U/O remains <5cc/hr\n Plan:\n ? ATN from hypotensive episode, cont to monitor, renal consult may be\n beneficial.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n On levophed gtt @ .1mcg/kg/min, SVO monitor setup however SQI is 4,AM\n labs pending however WBC was 33 on . remains afebrile\n Action:\n Multiple attempts to wean levophed gtt were unsuccessful, Abx per\n orders\n Response:\n Remains on .1mcg/kg/min\n Plan:\n Titrate levophed gtt, trend WBC, broaden Abx coverage as necessary\n Urinary tract infection (UTI)\n Assessment:\n Culture from pos for pseudomonas\n Action:\n Cont on zosyn, vanco not recommended @ this time as pt remains in renal\n failure\n Response:\n Plan:\n Cont to monitor\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Moderate to severe L hip pain, exacerbated by repositioning\n Action:\n .5mg IVP dilaudid q 4hrs\n Response:\n Became hypotensive to 80 systolic immediately after administration,\n however pain relieved for approx 4 hours and was able to rest\n comfortably.\n Plan:\n MRI of L hip planned for this AM however pt remains on levophed so\n imaging remains unlikely, cont to medicate prn.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317924,
"text": "Chief Complaint: urosepsis, respiratory failure, a fib, acute renal\n failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yo F with severe AS, h/o renal cell and ovarian ca in ICU for\n urosepsis with Afib/RVR, hypotension, ARF and delirium, intubated for\n worsening acidosis and delirium\n 24 Hour Events:\n Afib with RVR and hypotension yesterday with response to IVF bolus\n worsening delirium and agitation\n Intubated for worsening acidosis (mixed metabolic and respiratory),\n confusion\n pressors weaned off\n Consult ID re: antibiotic coverage/double coverage of pseudomonas\n History obtained from Medical records, house staff\n Patient unable to provide history: intubated\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 03:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:30 PM\n Midazolam (Versed) - 05:20 PM\n Fentanyl - 08:22 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: intubated\n Flowsheet Data as of 09:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.6\nC (96.1\n HR: 80 (71 - 151) bpm\n BP: 101/36(57) {70/33(47) - 145/61(95)} mmHg\n RR: 16 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 264 (10 - 266)mmHg\n SvO2: 79%\n Total In:\n 4,373 mL\n 904 mL\n PO:\n TF:\n IVF:\n 3,573 mL\n 904 mL\n Blood products:\n Total out:\n 105 mL\n 133 mL\n Urine:\n 105 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 771 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/35/119/19/-5\n Ve: 7.2 L/min\n PaO2 / FiO2: 397\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing,\n dependent edema\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Verbal stimuli, , Sedated, Tone: Normal\n Labs / Radiology\n 8.1 g/dL\n 56 K/uL\n 106 mg/dL\n 2.8 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 107 mEq/L\n 137 mEq/L\n 25.1 %\n 12.7 K/uL\n [image002.jpg]\n 05:30 AM\n 12:52 PM\n 02:33 PM\n 03:20 PM\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n WBC\n 28.6\n 12.8\n 10.6\n 12.7\n Hct\n 32.9\n 27.7\n 26.2\n 25.1\n Plt\n 114\n 76\n 66\n 56\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n TCO2\n 22\n 19\n 21\n 19\n 21\n 20\n Glucose\n 88\n 133\n 104\n 106\n Other labs: PT / PTT / INR:14.8/42.3/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:4.7 mg/dL\n Imaging: effusions, L > R but with no evidence of loculated effusions,\n RLL airspace disease, ? aspiration\n no fluid collection, stranding at L hip\n chest xray pending from this am\n Microbiology: urine cx + psuedomonas, pan sensitive\n blood no growth to date c dff neg\n new cx's (blood and urine pending)\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)- psuedomonal urospesis also\n likely with asp pna--improving --off pressors with additional fluid\n resuscitation, wbc trending down\n L hip pain remains problem though no obvious fluid collection on\n imaging, pain with touch, motion on exam--? septic brusitis, ortho\n following and await additonal recs\n continue zosynm f/u cx's\n SHOCK, CARDIOGENIC--cardiogenic in setting of afib with RVR and\n hypotension, now rate controlled\n BP improved, sdtable and off of pressors, cvp difficult to follow given\n severe AS, lactates normalized\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n renal follwoing, atn from sepsis hypotension, cr seems to have peaked,\n phos binder started, all meds renally dosed\n thrombocytopenia--on review of records baseline thromnbocytopenia in\n 50-70 range, with intial elevation here likely from hemoconcentration,\n dic labs negative and HUS/TTP unlikely, check smear, component of\n hemoconcetration likely though HIT possibiloty but given that plt is\n now at baseline--follow for further reduction from baseline, continue\n heparin products for now given low suspicion for HIT\n ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, limited\n given her severe af, respnsive to IVFs but would avoid calcium channel\n blockers, given new drop in hct and plts\n Leukocytosis--improving toward normal, check dc diff, continue vacno\n X 24 more hrs given catheter, clinically improving and highest\n suspicion is of urosepsis, though with line in plae would check\n ultrasound of porta cath and await new cx gram stain and result to show\n no GPs\n AORTIC STENOSIS--severem, preload depedent,\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan senstivie--continue\n zosyn\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed for sedartion\n L hip pain--follow up ortho, pain control with fentanyl\n EKG - At 10:18 AM\n BLOOD CULTURED - At 12:40 PM\n BLOOD CULTURED - At 12:50 PM\n EKG - At 02:10 PM\n INVASIVE VENTILATION - START 03:00 PM\n URINE CULTURE - At 03:39 PM\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): GU likely source, but\n continued elevated WBC and pressor requirement despite broad spectrum\n abx suggest either inadequate coverage of Pseudomonas, or other source\n such as infected hip, c. diff, line infection (portacath), acalculous\n cholecystitis, etc. though she has a benign abd exam and negative\n cultures from her indwelling line.\n - Send repeat cultures\n - Check LFTs\n - CT chest (eval for loculated effusions/empyema as possible source,\n though low suspicion, may have seeded) and CT hip\n\n SHOCK, SEPTIC/CARDIOGENIC: Continues pressor needs, with slow\n escalation. SVO2 is adequate. AS complicates management and assessment\n of volume/cvp\n - Continue fluid boluses and vasopressor with goal to taper off as BP\n allows, carefully monitor oxygen/resp status\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): essentially\n anuric--Likely ATN, though creatinine also increasing slowly.\n - Continue fluid boluses to keep preload elevated, monitor lytes\n - Consult renal\nno acute HD needs\n ATRIAL FIBRILLATION (AFIB): Well rate controlled at present\n AORTIC STENOSIS: Continue boluses.\n URINARY TRACT INFECTION (UTI): Pseudomonas, awaiting sensitivities.\n Renal U/S without perinephric abscess or Hydro\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Showing signs of delirium on\n dilaudid, but she has multiple allergies.\n - Will continue dilaudid at low dose.\n - Add lidocaine patch, standing tylenol\n * DELERIUM: Related to age, ICU, meds.\n - Will begin haldol at low dose\n - Attempt to orient, minimize psychotropic meds.\n ICU Care\n Nutrition:\n Comments: begin TF's via OG tube\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments: upate family\n Code status: DNR (do not resuscitate)\n Disposition :\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317925,
"text": "Chief Complaint: urosepsis, respiratory failure, a fib, acute renal\n failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yo F with severe AS, h/o renal cell and ovarian ca in ICU for\n urosepsis with Afib/RVR, hypotension, ARF and delirium, intubated for\n worsening acidosis and delirium\n 24 Hour Events:\n Afib with RVR and hypotension yesterday with response to IVF bolus\n worsening delirium and agitation\n Intubated for worsening acidosis (mixed metabolic and respiratory),\n confusion\n pressors weaned off\n Consult ID re: antibiotic coverage/double coverage of pseudomonas\n History obtained from Medical records, house staff\n Patient unable to provide history: intubated\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 03:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:30 PM\n Midazolam (Versed) - 05:20 PM\n Fentanyl - 08:22 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: intubated\n Flowsheet Data as of 09:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.6\nC (96.1\n HR: 80 (71 - 151) bpm\n BP: 101/36(57) {70/33(47) - 145/61(95)} mmHg\n RR: 16 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 264 (10 - 266)mmHg\n SvO2: 79%\n Total In:\n 4,373 mL\n 904 mL\n PO:\n TF:\n IVF:\n 3,573 mL\n 904 mL\n Blood products:\n Total out:\n 105 mL\n 133 mL\n Urine:\n 105 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 771 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/35/119/19/-5\n Ve: 7.2 L/min\n PaO2 / FiO2: 397\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing,\n dependent edema\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Verbal stimuli, , Sedated, Tone: Normal\n Labs / Radiology\n 8.1 g/dL\n 56 K/uL\n 106 mg/dL\n 2.8 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 107 mEq/L\n 137 mEq/L\n 25.1 %\n 12.7 K/uL\n [image002.jpg]\n 05:30 AM\n 12:52 PM\n 02:33 PM\n 03:20 PM\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n WBC\n 28.6\n 12.8\n 10.6\n 12.7\n Hct\n 32.9\n 27.7\n 26.2\n 25.1\n Plt\n 114\n 76\n 66\n 56\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n TCO2\n 22\n 19\n 21\n 19\n 21\n 20\n Glucose\n 88\n 133\n 104\n 106\n Other labs: PT / PTT / INR:14.8/42.3/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:4.7 mg/dL\n Imaging: Chest CT:\n limited without intravenous contrast.\n right upper lobe, concerning for pneumonia, possibly related to aspirat\n ion.\n bowel. No specific evidence of bowel obstruction.\n peritoneum and abdomen, limited evaluation without intravenous contrast\n , but\n suspicious for metastatic foci.\n chest xray pending from this am\n Microbiology: urine cx + psuedomonas, pan sensitive\n blood no growth to date c dff neg\n new cx's (blood and urine pending)\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca in ICU for\n urosepsis with Afib/RVR, hypotension, ARF and delirium, intubated for\n worsening acidosis and airway protection\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)- pseudomonas urosepsis also\n likely with asp pna\n improving --off pressors after additional fluid resuscitation,\n wbc trending down\n L hip pain remains problem though no obvious fluid\n collection on imaging, has significant pain with touch,/motion\n ?septic bursitis, ortho following and await additonal\n recs\n Given no gram positives in blood and current clinical\n improvement, lower suspicion of seeded portacath\nwill check u/s for\n fluid collection\n Continue zosyn and f/u cx results\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension, now rate controlled\n BP improved and stable off of pressors, cvp difficult to follow given\n severe AS, lactates normalized\n Treating underlying infection as above\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n atn from sepsis and hypotension\n cr appears to have peaked and may see recover/autodiuresis in next\n few days\n renal following, no acute indication for HD, continue phos binder\n started, all meds renally dosed\n > Leukocytosis\nnormalizing\n check C diff,\n continue vanco X 24 more hrs given porta cath\nf/u on cx\n for GPs, check ultrasound of line\n zosyn for pseudomonas\n clinically improving and highest suspicion is of urosepsis\n > thrombocytopenia--on review of records baseline thrombocytopenia in\n 50-70 range, with initial elevation here likely from hemoconcentration,\n dic labs negative and HUS/TTP unlikely, check smear, component of\n hemodilution likely with aggressive fluids and now at baseline--follow\n for further reduction from baseline, continue heparin products for now\n given low suspicion for HIT\n anemia- follow, likely hemodilution, transfuse for < 21 or\n active bleed or if hypotension\n ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, responsive\n to IVFs but would avoid calcium channel blockers in setting of RVR\n given severe AS,\n Would not anticoagulate at this time given new drop in hct and\n plts (suspect hemodilution)\n AORTIC STENOSIS--severe, preload dependent,\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan sensitive--continue\n zosyn as above\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed for sedation\n on vent\n ICU Care\n Nutrition:\n Comments: begin TF's via OG tube\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Boots, sc hep\n Stress ulcer: HSB\nstart TFs\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments: upate family\n Code status: DNR (do not resuscitate)\n Disposition : ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 317928,
"text": "Subjective\n Patient is intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 62 kg\n 70 kg ( 09:00 AM)\n 26.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 137\n 50\n Diagnosis: UTI, Pyelonephritis\n PMH : ovarian A, RC CA, L renal tumor s/p XRT , afib, aortic\n stenosis, thrombocytopenia, recurrent PSBO, CRI(base creat 1.3-1.6),\n CHF, HTN, diverticulitis, Cdiff colitis, TAH/BSO.\n Food allergies and intolerances: none noted.\n Pertinent medications: fentanyl, midazolam, HISS, colace, tamoxifen\n citrate, pepcid, CaAc.\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 05:07 AM\n Glucose Finger Stick\n 128\n 12:00 PM\n BUN\n 60 mg/dL\n 05:07 AM\n Creatinine\n 2.8 mg/dL\n 05:07 AM\n Sodium\n 137 mEq/L\n 05:07 AM\n Potassium\n 3.5 mEq/L\n 05:07 AM\n Chloride\n 107 mEq/L\n 05:07 AM\n TCO2\n 19 mEq/L\n 05:07 AM\n PO2 (arterial)\n 119 mm Hg\n 05:21 AM\n PCO2 (arterial)\n 35 mm Hg\n 05:21 AM\n pH (arterial)\n 7.35 units\n 05:21 AM\n pH (urine)\n 5.5 units\n 08:23 PM\n CO2 (Calc) arterial\n 20 mEq/L\n 05:21 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:07 AM\n Phosphorus\n 4.7 mg/dL\n 05:07 AM\n Ionized Calcium\n 1.11 mmol/L\n 10:15 PM\n Magnesium\n 1.7 mg/dL\n 05:07 AM\n ALT\n 20 IU/L\n 05:30 AM\n Alkaline Phosphate\n 54 IU/L\n 05:30 AM\n AST\n 25 IU/L\n 05:30 AM\n Total Bilirubin\n 0.5 mg/dL\n 09:15 PM\n WBC\n 12.7 K/uL\n 05:07 AM\n Hgb\n 8.1 g/dL\n 05:07 AM\n Hematocrit\n 25.1 %\n 05:07 AM\n Current diet order / nutrition support: Clear Liquids\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Age, hx CA, hx CHF\n Estimated Nutritional Needs\n Calories: 1250 - 1500 (BEE x or / 25-30 cal/kg)\n Protein: 50 - 65 (1-1.3 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate\n Specifics:\n 86 YO female w/ hx ovarian CA/RCC, CRI & CHF. Currently intubated d/t\n worsening acidosis & MS changes. Consulted for TF recs\nagree w/ plan\n for now. Noted patient is fluid overloaded; Recommend volume/protein\n restricted formula given levated BUN/Creat\nFS Nutren Pulmonary at goal\n 35mL/hr, providing 1260kcal/57g protein (25kcal/kg 7 1.1g pro/kg ABW).\n Monitor hydration.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Change diet to: NPO\n 2. Start TF: FS Nutren Pulmonary; start at 10mL/hr, adv by 10mL\n Q4-6hrs or astolerated to goal 35mL/hr via OGT\n 3. Monitor TF tolerance; Check residuals Q 4hrs & hold X1hr if\n >150mL\n 4. Adjust free water flushes per hydration status\n 5. Will receive adequate MVI/Minerals once receiving goal rate\n TF\n 6. Possibly at risk for refeeding syndrome; monitor lytes closely\n & replete as needed\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318334,
"text": "Pain control (acute pain, chronic pain)\n Assessment:\n Pt mildly sedated,on mechanincal ventilation.\n Action:\n On fentanyl gtt 20 mcg/hr\n Response:\n Pt comfortable required small dose of bolus prior positioning,personal\n care etc.\n Plan:\n Continue with same\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vented on CPAP+PS 30/5/10 ABG on this settings are 7.36/42/12\n Action:\n Continued with above settings overnight.\n Response:\n Remained stable on vent with previous settings.\n Plan:\n RSBI at AM,SBT if tolerates,monitor ABG.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Anasarca,Urine output improved with diuresis but pt\ns wt remains same\n 78.6kg,planning to diures more.\n Action:\n Cholorothiazide 500mg and Lasix 120mg IV given at 0400\n Response:\n Planning to keep her negative side to achieve goal of fluid reduction\n Plan:\n Continue diuresing as needed,follow up AM labs please.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317717,
"text": "Pt. with chronic UTIs on standing meds at home. Presented to MD office\n last week with UTI. Standing dose increased. Presented to ED today with\n severe L hip pain. Temp 100.1. Recived 1 mg of IV Dilaudid and became\n hypotensive not improving with IVF. Lactate 2.1. Code sepsis called and\n R IJ line placed. CVP 16 after 5L IVF. Started on low dose Levophed.\n Recived dose of IV Zosyn and Tylenol. CXR. Neg. Blood and urien cx.\n sent from ED. L hip films done with no significant findings per\n preliminary read.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317721,
"text": "Pt. with chronic UTIs on standing meds at home. Presented to MD office\n last week with UTI. Standing dose increased. Presented to ED today with\n severe L hip pain. Temp 100.1. Recived 1 mg of IV Dilaudid and became\n hypotensive not improving with IVF. Lactate 2.1. Code sepsis called and\n R IJ line placed. CVP 16 after 5L IVF. Started on low dose Levophed.\n Recived dose of IV Zosyn and Tylenol. CXR. Neg. Blood and urien cx.\n sent from ED. L hip films done with no significant findings per\n preliminary read.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt. with new onset L hip pain prior to admission. Pain only with\n movement. Xrays neg. Ordered for MRI.\n Action:\n Medicated with Dilaudid x2 this shift. MRI on hold as Pt. with new\n onset A-fib and unstable BP requiring A-line insertion.\n Response:\n Pt. rested comfortably after each dose of pain med.\n Plan:\n Cont. to medicate for pain as needed. MRI in AM if remains stable.\n Urinary tract infection (UTI)\n Assessment:\n Pt. with rising WBC. Ucx. From + for pseudomonas. Ucx. Collected\n in ED and in ICU pending. Afebrile.\n Action:\n Cont. on Zosyn and Vanco added this AM. ID consulted for double\n coverage but not recommended at this time due to Pt.\ns renal failure\n and multiple allergies.\n Response:\n No new abx. At this time.\n Plan:\n Cont. to monitor.\n Atrial fibrillation (Afib)\n Assessment:\n New onset A-fib this AM with HR 90\ns-110\nsw with frequent PACs., ? if\n it is due to sepsis.\n Action:\n EKG done. Cardiac enzymes done.\n Response:\n CE flat. No anticoagulation at this time. Can\nt use BB due to sepsis\n and pressor requirements.\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt. with rising WBC up to 33.3 this afternoon. Afebrile. On cont. SVO2\n monitoring. Cont. on Levophed.\n Action:\n IV Abx. As ordered.\n Response:\n Cont. to require pressor at this time. Unable to wean but no higher\n requirements either. SVO2 70\ns-80\n Plan:\n Cont. to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317722,
"text": "Pt. with chronic UTIs on standing meds at home. Presented to MD office\n last week with UTI. Standing dose increased. Presented to ED today with\n severe L hip pain. Temp 100.1. Recived 1 mg of IV Dilaudid and became\n hypotensive not improving with IVF. Lactate 2.1. Code sepsis called and\n R IJ line placed. CVP 16 after 5L IVF. Started on low dose Levophed.\n Recived dose of IV Zosyn and Tylenol. CXR. Neg. Blood and urien cx.\n sent from ED. L hip films done with no significant findings per\n preliminary read.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt. with new onset L hip pain prior to admission. Pain only with\n movement. Xrays neg. Ordered for MRI.\n Action:\n Medicated with Dilaudid x2 this shift. MRI on hold as Pt. with new\n onset A-fib and unstable BP requiring A-line insertion.\n Response:\n Pt. rested comfortably after each dose of pain med.\n Plan:\n Cont. to medicate for pain as needed. MRI in AM if remains stable.\n Urinary tract infection (UTI)\n Assessment:\n Pt. with rising WBC. Ucx. From + for pseudomonas. Ucx. Collected\n in ED and in ICU pending. Afebrile.\n Action:\n Cont. on Zosyn and Vanco added this AM. ID consulted for double\n coverage but not recommended at this time due to Pt.\ns renal failure\n and multiple allergies.\n Response:\n No new abx. At this time.\n Plan:\n Cont. to monitor.\n Atrial fibrillation (Afib)\n Assessment:\n New onset A-fib this AM with HR 90\ns-110\nsw with frequent PACs., ? if\n it is due to sepsis.\n Action:\n EKG done. Cardiac enzymes done.\n Response:\n CE flat. No anticoagulation at this time. Can\nt use BB due to sepsis\n and pressor requirements.\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt. with rising WBC up to 33.3 this afternoon. Afebrile. On cont. SVO2\n monitoring. Cont. on Levophed.\n Action:\n IV Abx. As ordered.\n Response:\n Cont. to require pressor at this time. Unable to wean but no higher\n requirements either. SVO2 70\ns-80\n Plan:\n Cont. to monitor.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt. with minimal u/o this shift despite 1.5L fluid bolus. Creatnine 2.4\n up from baseline(1.8). Renal us done last night. With no abscess or\n hydronephrosis.\n Action:\n Foley cath irrigated with clear return and minimal sluge.\n Response:\n Plan:\n Cont. to monitor u/o and fb as per team orders.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317817,
"text": "86 yo F with severe AS admitted with urosepsis and L hip pain, with\n persistent vasopressor requirements, leukocytosis, and anuric ARF. Pt\n intub for worsening ms . Vasopressin gtt and eventually\n both levophed and vasopressin weaned to off. Pt reveived ns total\n 2500cc in bolus. Plan for CT scan of chest/abd/pelvis at 1800.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib, occass having sinus beats. 12 lead x2 done this\n shift. Pt with episode of raf with hr up to 160. Hr broke on own aftwer\n ivf bolus, hr [resenly well controlled. Digoxin load started, pt\n received .25mg iv dose, and will need repeat dose at 2100.\n Action:\n Digoxin load\n Response:\n good\n Plan:\n Dog load, next dose at 2100\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/o remains poor, ~!300cc this shift, team aware. Urine cx sent.\n Action:\n Renal consult\n Response:\n Awaiting recs\n Plan:\n Follow u/o, and cx data\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt conts with worsening hypotension hypotension\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317818,
"text": "86 yo F with severe AS admitted with urosepsis and L hip pain, with\n persistent vasopressor requirements, leukocytosis, and anuric ARF. Pt\n intub for worsening ms . Vasopressin gtt and eventually\n both levophed and vasopressin weaned to off. Pt reveived ns total\n 2500cc in bolus. Plan for CT scan of chest/abd/pelvis at 1800.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib, occas having sinus beats. 12 lead x2 done this\n shift. Pt with episode of raf with hr up to 160. Hr broke on own after\n ivf bolus, hr presenly well controlled. Digoxin load started, pt\n received .25mg iv dose, and will need repeat dose at 2100.\n Action:\n Digoxin load\n Response:\n good\n Plan:\n Dog load, next dose at 2100\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/o remains poor, ~!300cc this shift, team aware. Urine cx sent.\n Action:\n Renal consult\n Response:\n Awaiting recs\n Plan:\n Follow u/o, and cx data\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt conts with worsening hypotension in setting of new , pH\n 7.16. Pt received 1 dose 50meq nahco3. After total 2500cc in ns bolus,\n was able to wean off vasopressin and levophed gtts. Pt inutb at ~1500\n for decreasing MS, and worsening aciodsis, vent setting ac 16 peep 5\n 450 50%. Pt occas breathing over set rate.\n Action:\n Inutb and ivf bolus, weaning pressors\n Response:\n good\n Plan:\n Wean from vent as tol\n"
},
{
"category": "Nutrition",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 317910,
"text": "Subjective\n Patient is intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 62 kg\n 70 kg ( 09:00 AM)\n 26.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 137\n 50\n Diagnosis: UTI, Pyelonephritis\n PMH : ovarian A, RCC CA, L renal tumor s/p XRT , afib, aortic\n stenosis, thrombocytopenia, recurrent PSBO, CRI(base creat 1.3-1.6),\n CHF, HTN, diverticulitis, Cdiff colitis, TAH/BSO.\n Food allergies and intolerances: none noted.\n Pertinent medications: fentanyl, midazolam, HISS, colace, tamoxifen\n citrate, pepcid, CaAc.\n Labs:\n Value\n Date\n Glucose\n 106 mg/dL\n 05:07 AM\n Glucose Finger Stick\n 128\n 12:00 PM\n BUN\n 60 mg/dL\n 05:07 AM\n Creatinine\n 2.8 mg/dL\n 05:07 AM\n Sodium\n 137 mEq/L\n 05:07 AM\n Potassium\n 3.5 mEq/L\n 05:07 AM\n Chloride\n 107 mEq/L\n 05:07 AM\n TCO2\n 19 mEq/L\n 05:07 AM\n PO2 (arterial)\n 119 mm Hg\n 05:21 AM\n PCO2 (arterial)\n 35 mm Hg\n 05:21 AM\n pH (arterial)\n 7.35 units\n 05:21 AM\n pH (urine)\n 5.5 units\n 08:23 PM\n CO2 (Calc) arterial\n 20 mEq/L\n 05:21 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:07 AM\n Phosphorus\n 4.7 mg/dL\n 05:07 AM\n Ionized Calcium\n 1.11 mmol/L\n 10:15 PM\n Magnesium\n 1.7 mg/dL\n 05:07 AM\n ALT\n 20 IU/L\n 05:30 AM\n Alkaline Phosphate\n 54 IU/L\n 05:30 AM\n AST\n 25 IU/L\n 05:30 AM\n Total Bilirubin\n 0.5 mg/dL\n 09:15 PM\n WBC\n 12.7 K/uL\n 05:07 AM\n Hgb\n 8.1 g/dL\n 05:07 AM\n Hematocrit\n 25.1 %\n 05:07 AM\n Current diet order / nutrition support: Clear Liquids\n GI:\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Age, hx CA, hx CHF\n Estimated Nutritional Needs\n Calories: 1250 (BEE x or / 25 cal/kg)\n Protein: 50-65 (1-1.3 g/kg)\n Fluid: per team\n Estimation of previous intake:\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Change diet to: NPO\n Multivitamin / Mineral supplement:\n At risk for refeeding syndrome (monitor K / PO4 / Magnesium and repeat\n as needed):\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318328,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n .\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: tolerating psv with volumes of 350-400cc and rr 15-25\n .\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n .\n .\n .\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317809,
"text": "Chief Complaint: Urosepsis\n I saw and examined the patient, and was physically present with the for\n key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI: 86 yo F with severe AS admitted with urosepsis and L hip pain,\n with persistent vasopressor requirements, leukocytosis, and anuric ARF\n 24 Hour Events:\n EKG - At 11:30 AM: afib, no ischemic change\n ARTERIAL LINE - START 04:15 PM\n * U cx with pseudomonas\n * Oliguric\n * Remains on levophed\n * MRI deferred instability\n Subj: Continues to complain of L hip pain\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 09:45 AM\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Famotidine (Pepcid) - 11:00 PM\n Hydromorphone (Dilaudid) - 08:00 AM\n Other medications:\n allopurinol, SQ heparin, tamoxifen, ISS\n Changes to medical and family history:\n PMH, FH, SH unchanged from admission note\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 89 (84 - 100) bpm\n BP: 109/48(70) {88/37(-17) - 109/48(70)} mmHg\n RR: 9 (9 - 23) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 15 (12 - 21)mmHg\n SvO2: 83%\n Total In:\n 6,297 mL\n 447 mL\n PO:\n 1,020 mL\n TF:\n IVF:\n 5,277 mL\n 447 mL\n Blood products:\n Total out:\n 159 mL\n 30 mL\n Urine:\n 159 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,138 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Thin elderly F\n Harsh systolic m, irreg\n Coarse BS, symmetric chest wall excursion, diminshed at bases\n Soft abd, NT + BS\n Trace peripheral edema, L hip pain to touch, no erythema, warmth, +\n ROM though limited, unable to cooperate with exam\n Peripheral Vascular: (Right radial pulse:present), (Left radial\n pulse:present), (Right DP pulse:present), (Left DP pulse: present)\n Skin: Not assessed\n Neurologic: confused and agitated\n Labs / Radiology\n 9.9 g/dL\n 114 K/uL\n 88 mg/dL\n 2.9 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 60 mg/dL\n 101 mEq/L\n 133 mEq/L\n 32.9 %\n 28.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n 02:04 PM\n 05:30 AM\n WBC\n 20.6\n 24.5\n 33.3\n 28.6\n Hct\n 30\n 31.6\n 32.9\n 31.6\n 32.9\n Plt\n 83\n 121\n 114\n 114\n Cr\n 2.3\n 2.4\n 2.4\n 2.9\n TropT\n 0.11\n 0.12\n 0.11\n TCO2\n 25\n Glucose\n 147\n 89\n 74\n 88\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2\n %, Mono:4.5 %, Eos:0.1 %, Lactic Acid:1.1 mmol/L, LDH:145 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: FENA 1, U NA 30\n Imaging: : R > L pleural effusion slight increase from .\n Possible bibasilar opacities.\n Microbiology: Urine cx - pseudomonas, no sensi\n Blood cx - NGTD\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): GU likely source, but\n continued elevated WBC and pressor requirement despite broad spectrum\n abx suggest either inadequate coverage of Pseudomonas, or other source\n such as infected hip, c. diff, line infection (portacath), acalculous\n cholecystitis, etc. though she has a benign abd exam and negative\n cultures from her indwelling line.\n - Send repeat cultures\n - Check LFTs\n - CT chest (eval for loculated effusions/empyema as possible source,\n though low suspicion, may have seeded) and CT hip\n - Redose vanco according to levels\n - Consult ID re: antibiotic coverage/double coverage of pseudomonas\n Recheck abg for Ph/CO2 and lactate\n SHOCK, SEPTIC/CARDIOGENIC: Continues pressor needs, with slow\n escalation. SVO2 is adequate. AS complicates management and assessment\n of volume/cvp\n - Continue fluid boluses and vasopressor with goal to taper off as BP\n allows, carefully monitor oxygen/resp status\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): essentially\n anuric--Likely ATN, though creatinine also increasing slowly.\n - Continue fluid boluses to keep preload elevated, monitor lytes\n - Consult renal\nno acute HD needs\n ATRIAL FIBRILLATION (AFIB): Well rate controlled at present\n AORTIC STENOSIS: Continue boluses.\n URINARY TRACT INFECTION (UTI): Pseudomonas, awaiting sensitivities.\n Renal U/S without perinephric abscess or Hydro\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Showing signs of delirium on\n dilaudid, but she has multiple allergies.\n - Will continue dilaudid at low dose.\n - Add lidocaine patch, standing tylenol\n * DELERIUM: Related to age, ICU, meds.\n - Will begin haldol at low dose\n - Attempt to orient, minimize psychotropic meds.\n ICU Care\n Nutrition:\n Comments: Start clear liquids\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317889,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:18 AM- A.fib with no acute ST-T wave changes\n INVASIVE VENTILATION - START 03:00 PM\n URINE & BLOOD CULTUREs - At 03:39 PM\n - Intubated for worsening acidosis, MS changes. ID consulted\n - Afib with RVR & hypotension, resolved with fluid boluses, loaded\n digoxin\n - Urine Cx pan sensitive pseudomonas\n - oliguric renal failure, Renal consulted\n - CT- no e/o fluid collections, ortho consulted for L hip pain\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 03:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:30 PM\n Midazolam (Versed) - 05:20 PM\n Fentanyl - 08:22 PM\n Other medications:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.7\nC (96.2\n HR: 73 (71 - 151) bpm\n BP: 103/36(58) {70/33(47) - 145/61(95)} mmHg\n RR: 9 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 264 (10 - 266)mmHg\n SvO2: 79%\n Total In:\n 4,373 mL\n 745 mL\n PO:\n TF:\n IVF:\n 3,573 mL\n 745 mL\n Blood products:\n Total out:\n 105 mL\n 83 mL\n Urine:\n 105 mL\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 662 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/35/119/19/-5\n Ve: 7.2 L/min\n PaO2 / FiO2: 397\n Physical Examination\n GEN: Intubated & sedated, not responding\n CV: irreg/irreg with intermittent gr 2 early peaking SEM over LSB, does\n not radiate\n RESP: BS over RLL base, moving air over LLL, bronchial BS, no w/r\n Abd: soft, NT/ND/NABS\n Extr: 2+ pitting edema bilaterally, warm\n Labs / Radiology\n CT Chest/abd/pelvis:\n IMPRESSION:\n 1. No evidence of loculated pleural effusion or empyema, though evalua\n tion is\n limited without intravenous contrast.\n 2. New opacification at the right lung base, and posterior segment of\n the\n right upper lobe, concerning for pneumonia, possibly related to aspirat\n ion.\n 3. Unchanged appearance of nonspecific focally distended loops of smal\n l\n bowel. No specific evidence of bowel obstruction.\n 4. Unchanged appearance of numerous calcified lesions throughout the\n peritoneum and abdomen, limited evaluation without intravenous contrast\n , but\n suspicious for metastatic foci.\n 5. Unchanged appearance of predominantly cystic left adnexal mass.\n 56 K/uL\n 8.1 g/dL\n 106 mg/dL\n 2.8 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 107 mEq/L\n 137 mEq/L\n 25.1 %\n 12.7 K/uL\n [image002.jpg]\n 05:30 AM\n 12:52 PM\n 02:33 PM\n 03:20 PM\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n WBC\n 28.6\n 12.8\n 10.6\n 12.7\n Hct\n 32.9\n 27.7\n 26.2\n 25.1\n Plt\n 114\n 76\n 66\n 56\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n TCO2\n 22\n 19\n 21\n 19\n 21\n 20\n Glucose\n 88\n 133\n 104\n 106\n Other labs: PT / PTT / INR:14.8/42.3/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:4.7 mg/dL\n ABG from 6am: pH 7.35/35/119 Peripheral Smear pending today.\n Urine Cx + pseudomonas pan sensitive\n Blood Cx NGTD\n C. Diff negative\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n SHOCK, CARDIOGENIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ATRIAL FIBRILLATION (AFIB)\n AORTIC STENOSIS\n URINARY TRACT INFECTION (UTI)\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition: NPO, on D5 1/2NS for 1L o/n\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin sc TID\n Stress ulcer: Famotidine\n VAP: chlorhexidine mouthwash\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317895,
"text": "Chief Complaint: urosepsis, respiratory failure, delerium\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yo F with severe AS, h/o renal cell and ovarian ca, admitted with\n urosepsis\n 24 Hour Events:\n Episode of Afib with RVR with hypotension, responsive to IVF bolus with\n reversion to NSR, worsening delirium and agitation\n Intubated for worsening acidosis, confusion\n Bolused IVF and pressors weaned off\n - Redose vanco according to levels\n - Consult ID re: antibiotic coverage/double coverage of pseudomonas\n Recheck abg for Ph/CO2 and lactate\n History obtained from Medical records, house staff\n Patient unable to provide history: intubated\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 03:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:30 PM\n Midazolam (Versed) - 05:20 PM\n Fentanyl - 08:22 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: intubated\n Flowsheet Data as of 09:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.6\nC (96.1\n HR: 80 (71 - 151) bpm\n BP: 101/36(57) {70/33(47) - 145/61(95)} mmHg\n RR: 16 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 264 (10 - 266)mmHg\n SvO2: 79%\n Total In:\n 4,373 mL\n 904 mL\n PO:\n TF:\n IVF:\n 3,573 mL\n 904 mL\n Blood products:\n Total out:\n 105 mL\n 133 mL\n Urine:\n 105 mL\n 133 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 771 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 29 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/35/119/19/-5\n Ve: 7.2 L/min\n PaO2 / FiO2: 397\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, No(t) Cyanosis, No(t) Clubbing,\n dependent edema\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,\n Sedated, Tone: Normal\n Labs / Radiology\n 8.1 g/dL\n 56 K/uL\n 106 mg/dL\n 2.8 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 107 mEq/L\n 137 mEq/L\n 25.1 %\n 12.7 K/uL\n [image002.jpg]\n 05:30 AM\n 12:52 PM\n 02:33 PM\n 03:20 PM\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n WBC\n 28.6\n 12.8\n 10.6\n 12.7\n Hct\n 32.9\n 27.7\n 26.2\n 25.1\n Plt\n 114\n 76\n 66\n 56\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n TCO2\n 22\n 19\n 21\n 19\n 21\n 20\n Glucose\n 88\n 133\n 104\n 106\n Other labs: PT / PTT / INR:14.8/42.3/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:4.7 mg/dL\n Imaging: no evidence of loculated effusion or empyema, calcified\n lesions\n no fluid collection, stranding at L hip\n chest xray pending\n Microbiology: urine cx + psuedomonas, pan sensitive\n blood no growth to date c dff neg\n new cx's (blood and urine pending)\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)- psuedomonal urospesis also\n likely with asp pna--improving --off pressors with additional fluid\n resuscitation, wbc trending down\n L hip pain remains problem though no obvious fluid collection on\n imaging, pain with touch, motion on exam--? septic brusitis, ortho\n following and await additonal recs\n continue zosynm f/u cx's\n SHOCK, CARDIOGENIC--cardiogenic in setting of afib with RVR and\n hypotension, now rate controlled\n BP improved, sdtable and off of pressors, cvp difficult to follow given\n severe AS, lactates normalized\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n renal follwoing, atn from sepsis hypotension, cr seems to have peaked,\n phos binder started, all meds renally dosed\n thrombocytopenia--on review of records baseline thromnbocytopenia in\n 50-70 range, with intial elevation here likely from hemoconcentration,\n dic labs negative and HUS/TTP unlikely, check smear, component of\n hemoconcetration likely though HIT possibiloty but given that plt is\n now at baseline--follow for further reduction from baseline, continue\n heparin products for now given low suspicion for HIT\n ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, limited\n given her severe af, respnsive to IVFs but would avoid calcium channel\n blockers, given new drop in hct and plts\n Leukocytosis--improving toward normal, check dc diff, continue vacno\n X 24 more hrs given catheter, clinically improving and highest\n suspicion is of urosepsis, though with line in plae would check\n ultrasound of porta cath and await new cx gram stain and result to show\n no GPs\n AORTIC STENOSIS--severem, preload depedent,\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan senstivie--continue\n zosyn\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed for sedartion\n L hip pain--follow up ortho, pain control with fentanyl\n EKG - At 10:18 AM\n BLOOD CULTURED - At 12:40 PM\n BLOOD CULTURED - At 12:50 PM\n EKG - At 02:10 PM\n INVASIVE VENTILATION - START 03:00 PM\n URINE CULTURE - At 03:39 PM\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): GU likely source, but\n continued elevated WBC and pressor requirement despite broad spectrum\n abx suggest either inadequate coverage of Pseudomonas, or other source\n such as infected hip, c. diff, line infection (portacath), acalculous\n cholecystitis, etc. though she has a benign abd exam and negative\n cultures from her indwelling line.\n - Send repeat cultures\n - Check LFTs\n - CT chest (eval for loculated effusions/empyema as possible source,\n though low suspicion, may have seeded) and CT hip\n\n SHOCK, SEPTIC/CARDIOGENIC: Continues pressor needs, with slow\n escalation. SVO2 is adequate. AS complicates management and assessment\n of volume/cvp\n - Continue fluid boluses and vasopressor with goal to taper off as BP\n allows, carefully monitor oxygen/resp status\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): essentially\n anuric--Likely ATN, though creatinine also increasing slowly.\n - Continue fluid boluses to keep preload elevated, monitor lytes\n - Consult renal\nno acute HD needs\n ATRIAL FIBRILLATION (AFIB): Well rate controlled at present\n AORTIC STENOSIS: Continue boluses.\n URINARY TRACT INFECTION (UTI): Pseudomonas, awaiting sensitivities.\n Renal U/S without perinephric abscess or Hydro\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Showing signs of delirium on\n dilaudid, but she has multiple allergies.\n - Will continue dilaudid at low dose.\n - Add lidocaine patch, standing tylenol\n * DELERIUM: Related to age, ICU, meds.\n - Will begin haldol at low dose\n - Attempt to orient, minimize psychotropic meds.\n ICU Care\n Nutrition:\n Comments: begin TF's via OG tube\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments: upate family\n Code status: DNR (do not resuscitate)\n Disposition :\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317901,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:18 AM- A.fib with no acute ST-T wave changes\n INVASIVE VENTILATION - START 03:00 PM\n URINE & BLOOD CULTUREs - At 03:39 PM\n - Intubated for worsening acidosis, MS changes. ID consulted\n - Afib with RVR & hypotension, resolved with fluid boluses, loaded\n digoxin\n - Urine Cx pan sensitive pseudomonas\n - oliguric renal failure, Renal consulted\n - CT- no e/o fluid collections, ortho consulted for L hip pain\n Pt Intubated, grimacing to pain, will respond to some commands\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 03:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:30 PM\n Midazolam (Versed) - 05:20 PM\n Fentanyl - 08:22 PM\n Other medications: per OMR\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.7\nC (96.2\n HR: 73 (71 - 151) bpm\n BP: 103/36(58) {70/33(47) - 145/61(95)} mmHg\n RR: 9 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 264 (10 - 266)mmHg\n SvO2: 79%\n Total In:\n 4,373 mL\n 745 mL\n PO:\n TF:\n IVF:\n 3,573 mL\n 745 mL\n Blood products:\n Total out:\n 105 mL\n 83 mL\n Urine:\n 105 mL\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 662 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/35/119/19/-5\n Ve: 7.2 L/min\n PaO2 / FiO2: 397\n Physical Examination\n GEN: Intubated & sedated, not responding\n CV: irreg/irreg with intermittent gr 2 early peaking SEM over LSB, does\n not radiate\n RESP: BS over RLL base, moving air over LLL, bronchial BS, no w/r\n Abd: soft, NT/ND/NABS\n Extr: 2+ pitting edema bilaterally, warm\n Labs / Radiology\n CT Chest/abd/pelvis:\n IMPRESSION:\n 1. No evidence of loculated pleural effusion or empyema, though evalua\n tion is\n limited without intravenous contrast.\n 2. New opacification at the right lung base, and posterior segment of\n the\n right upper lobe, concerning for pneumonia, possibly related to aspirat\n ion.\n 3. Unchanged appearance of nonspecific focally distended loops of smal\n l\n bowel. No specific evidence of bowel obstruction.\n 4. Unchanged appearance of numerous calcified lesions throughout the\n peritoneum and abdomen, limited evaluation without intravenous contrast\n , but\n suspicious for metastatic foci.\n 5. Unchanged appearance of predominantly cystic left adnexal mass.\n 56 K/uL\n 8.1 g/dL\n 106 mg/dL\n 2.8 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 107 mEq/L\n 137 mEq/L\n 25.1 %\n 12.7 K/uL\n [image002.jpg]\n 05:30 AM\n 12:52 PM\n 02:33 PM\n 03:20 PM\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n WBC\n 28.6\n 12.8\n 10.6\n 12.7\n Hct\n 32.9\n 27.7\n 26.2\n 25.1\n Plt\n 114\n 76\n 66\n 56\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n TCO2\n 22\n 19\n 21\n 19\n 21\n 20\n Glucose\n 88\n 133\n 104\n 106\n Other labs: PT / PTT / INR:14.8/42.3/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:4.7 mg/dL\n ABG from 6am: pH 7.35/35/119 Peripheral Smear pending today.\n Urine Cx + pseudomonas pan sensitive\n Blood Cx NGTD\n C. Diff negative\n Assessment and Plan : 86 y/o F with PMHx of severe AS & CHF with EF\n 45%, renal cell & ovarian Ca p/w Left hip pain, adm for presumed\n urosepsis on pressors. Intubated on for worsening acidosis,\n oliguric renal failure, hemodynamic instability to Afib with RVR\n and MS changes.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Source of infection presumed\n to be urosepsis with positive UA growing out pan sensitive\n Pseudomonas. Pt was covered with Vanc/Zosyn for 48hr but clinically\n deteriorated yesterday possibly due to incomplete volume resuscitation.\n Pt was intubated and weaned for pressors, WBC ct now trending down and\n acidosis resolving on vent. ID consult, continue ruling out\n other sources of infection. Will check C. diff X 3 given new diarrhea.\n - continue Vanc/Zosyn for coverage of pseudomonas in urine\n - ortho consult for L hip pain and concern for seeding of\n hardware. F/u recs\n - will d/w rads regarding CT chest/abd/pelvis\n - L upper chest wall u/s to rule out abscess near portocath\n - continue to f/u blood & urine cultures\n - bolus prn to maintain Maps>65\n SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed\n Afib with RVR and became hypotensive on . Pressure responded to IVF\n & pressors. Pt was then Intubated and pressors weaned. Pt still in/out\n of Afib but HR has been much better controlled on digoxin.\n - check am digoxin level on \n - avoid CCB/BBs\n - no plan for systemic anticoagulation currently given the plt\n count, will re-consider in am if plts stable\n - fluid bolus prn to maintain maps>60\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely ATN but urine sediment showed sheets of WBCs.\n Creatinine appears to have plateaued and pt having some UOP overnight.\n Renal recs, there is no acute indication for dialysis. Uremia\n likely contributing to acidosis, currently compensated with vent\n support\n - avoid continuous IVF given poor UOP\n - f/u urine sediment, renally dose meds, check C3/4 & urine eos per\n Renal\n - continue phoslo TID & check lytes \n AORTIC STENOSIS: AS with valve area of 0.7cm, very preload\n dependant. Gentle bolus IVF prn to maintain MAP>60\n - continue digoxin, monitor daily CXR & resp status to avoid massive\n volume overload.\n URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Vanc/Zosyn for coverage\n LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation, will discuss final CT read with rads\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition: NPO, on D5 1/2NS for 1L o/n\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin sc TID\n Stress ulcer: Famotidine\n VAP: chlorhexidine mouthwash\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317902,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:18 AM- A.fib with no acute ST-T wave changes\n INVASIVE VENTILATION - START 03:00 PM\n URINE & BLOOD CULTUREs - At 03:39 PM\n - Intubated for worsening acidosis, MS changes. ID consulted\n - Afib with RVR & hypotension, resolved with fluid boluses, loaded\n digoxin\n - Urine Cx pan sensitive pseudomonas\n - oliguric renal failure, Renal consulted\n - CT- no e/o fluid collections, ortho consulted for L hip pain\n Pt Intubated, grimacing to pain, will respond to some commands\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 03:00 PM\n Piperacillin/Tazobactam (Zosyn) - 05:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 12:30 PM\n Midazolam (Versed) - 05:20 PM\n Fentanyl - 08:22 PM\n Other medications: per OMR\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.7\nC (96.2\n HR: 73 (71 - 151) bpm\n BP: 103/36(58) {70/33(47) - 145/61(95)} mmHg\n RR: 9 (0 - 27) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 264 (10 - 266)mmHg\n SvO2: 79%\n Total In:\n 4,373 mL\n 745 mL\n PO:\n TF:\n IVF:\n 3,573 mL\n 745 mL\n Blood products:\n Total out:\n 105 mL\n 83 mL\n Urine:\n 105 mL\n 83 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,268 mL\n 662 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.35/35/119/19/-5\n Ve: 7.2 L/min\n PaO2 / FiO2: 397\n Physical Examination\n GEN: Intubated & sedated, not responding\n CV: irreg/irreg with intermittent gr 2 early peaking SEM over LSB, does\n not radiate\n RESP: BS over RLL base, moving air over LLL, bronchial BS, no w/r\n Abd: soft, NT/ND/NABS\n Extr: 2+ pitting edema bilaterally, warm\n Labs / Radiology\n CT Chest/abd/pelvis:\n IMPRESSION:\n 1. No evidence of loculated pleural effusion or empyema, though evalua\n tion is\n limited without intravenous contrast.\n 2. New opacification at the right lung base, and posterior segment of\n the\n right upper lobe, concerning for pneumonia, possibly related to aspirat\n ion.\n 3. Unchanged appearance of nonspecific focally distended loops of smal\n l\n bowel. No specific evidence of bowel obstruction.\n 4. Unchanged appearance of numerous calcified lesions throughout the\n peritoneum and abdomen, limited evaluation without intravenous contrast\n , but\n suspicious for metastatic foci.\n 5. Unchanged appearance of predominantly cystic left adnexal mass.\n 56 K/uL\n 8.1 g/dL\n 106 mg/dL\n 2.8 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 60 mg/dL\n 107 mEq/L\n 137 mEq/L\n 25.1 %\n 12.7 K/uL\n [image002.jpg]\n 05:30 AM\n 12:52 PM\n 02:33 PM\n 03:20 PM\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n WBC\n 28.6\n 12.8\n 10.6\n 12.7\n Hct\n 32.9\n 27.7\n 26.2\n 25.1\n Plt\n 114\n 76\n 66\n 56\n Cr\n 2.9\n 2.8\n 2.8\n 2.8\n TCO2\n 22\n 19\n 21\n 19\n 21\n 20\n Glucose\n 88\n 133\n 104\n 106\n Other labs: PT / PTT / INR:14.8/42.3/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:7.5\n mg/dL, Mg++:1.7 mg/dL, PO4:4.7 mg/dL\n ABG from 6am: pH 7.35/35/119 Peripheral Smear pending today.\n Urine Cx + pseudomonas pan sensitive\n Blood Cx NGTD\n C. Diff negative\n Assessment and Plan : 86 y/o F with PMHx of severe AS & CHF with EF\n 45%, renal cell & ovarian Ca p/w Left hip pain, adm for presumed\n urosepsis on pressors. Intubated on for worsening acidosis,\n oliguric renal failure, hemodynamic instability to Afib with RVR\n and MS changes.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Source of infection presumed\n to be urosepsis with positive UA growing out pan sensitive\n Pseudomonas. Pt was covered with Vanc/Zosyn for 48hr but clinically\n deteriorated yesterday possibly due to incomplete volume resuscitation.\n Pt was intubated and weaned for pressors, WBC ct now trending down and\n acidosis resolving on vent. ID consult, continue ruling out\n other sources of infection. Will check C. diff X 3 given new diarrhea.\n - continue Vanc/Zosyn for coverage of pseudomonas in urine\n - ortho consult for L hip pain and concern for seeding of\n hardware. F/u recs\n - will d/w rads regarding CT chest/abd/pelvis\n - L upper chest wall u/s to rule out abscess near portocath\n - continue to f/u blood & urine cultures\n - bolus prn to maintain Maps>65\n SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed\n Afib with RVR and became hypotensive on . Pressure responded to IVF\n & pressors. Pt was then Intubated and pressors weaned. Pt still in/out\n of Afib but HR has been much better controlled on digoxin.\n - check am digoxin level on \n - avoid CCB/BBs\n - no plan for systemic anticoagulation currently given the plt\n count, will re-consider in am if plts stable\n - fluid bolus prn to maintain maps>60\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely ATN but urine sediment showed sheets of WBCs.\n Creatinine appears to have plateaued and pt having some UOP overnight.\n Renal recs, there is no acute indication for dialysis. Uremia\n likely contributing to acidosis, currently compensated with vent\n support\n - avoid continuous IVF given poor UOP\n - f/u urine sediment, renally dose meds, check C3/4 & urine eos per\n Renal\n - continue phoslo TID & check lytes \n AORTIC STENOSIS: AS with valve area of 0.7cm, very preload\n dependant. Gentle bolus IVF prn to maintain MAP>60\n - continue digoxin, monitor daily CXR & resp status to avoid massive\n volume overload.\n URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Vanc/Zosyn for coverage\n LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation, will discuss final CT read with rads\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition: NPO, on D5 1/2NS for 1L o/n\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin sc TID\n Stress ulcer: Famotidine\n VAP: chlorhexidine mouthwash\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n ------ Protected Section ------\n Thrombocytopenia: Plts have trended down with IVF, pt baseline in\n 50-70s and currently back to baseline. No e/o coagulopathy, hemolysis\n labs normal, very unlikely that this is TTP/HUS but will review\n peripheral smear today\n - recheck CBC today, if plt ct continues to trend down, will stop all\n heparin products and consider HITs work up.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:01 ------\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318065,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated 2 days ago for worsening acidosis and airway protection. O2\n sats 98-100% and ABG\ns wnl on AC 500X14X30%X5. Suctioned for scant amts\n clear secretions.\n Action:\n Placed on PSV/Cpap 8/5 this am\n Response:\n RR 15-19, ABG\ns 7.34/44/116/-\n Plan:\n Continue to wean vent, diurese with lasix/metazalone for fluid overload\n prn, extubate in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Acute on chronic renal failure due to ATN. Baseline creatinine 1.6-1.8,\n now is running 2.8-2.9\n Action:\n All meds renally dosed. Renal consulted for possible HD.\n Response:\n UO slowly improving 5-140cc/hr clear yellow urine with sediment. Fluid\n balance remains 2L positive.\n Plan:\n Monitor urine output, no plan for HD per renal. give lasix with\n metazalone for diuresis.\n Shock, cardiogenic\n Assessment:\n ABP 107-130/35-49; HR 67-80, NSR with occasional to frequent PAC\ns and\n PVC\n Action:\n No fluid boluses required for hypotension today. Digoxin ordered .125\n qod for rate control.\n Response:\n Plan:\n Monitor hemodynamic status, IVF boluses for hypotension.\n Urinary tract infection (UTI)\n Assessment:\n Afebrile.\n Action:\n Zosyn q 8hrs IV.\n Response:\n UTI clearing\n Plan:\n Continue antibiotic. Follow up cultures.`\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o L hip pain PTA and grimaces when turned..\n Action:\n Sedated on fent 25mcg/midaz 1mg. Lidocaine patch on, no sedation\n boluses required.\n Response:\n Resting with eyes closed. Responds by opening eyes and some grimacing\n when turned side to side.\n Plan:\n Bone scan scheduled for tomorrow to r/o bone metastsis. Continue\n sedation and lido patch.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318067,
"text": "Chief Complaint: urosepsis and hip pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yo F with severe AS, h/o renal cell and ovarian ca in ICU with\n urosepsis c/b Afib/RVR, hypotension, ARF and delirium, intubated for\n worsening acidosis and airway protection--improving\n 24 Hour Events:\n ULTRASOUND - At 11:30 AM of porta cath\n SPUTUM CULTURE - At 05:37 AM\n STOOL CULTURE - At 05:37 AM\n now with 2 colonies GNR in urine\nllikely 2 species pseudomonas\n bolused with LR for MAP decreased to 50's with good response,\n slightly alkalotic ph on ACV\nset RR decreased\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:39 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.7\nC (96.3\n HR: 71 (65 - 80) bpm\n BP: 112/41(65) {92/34(54) - 130/49(78)} mmHg\n RR: 17 (9 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 6 (5 - 232)mmHg\n Total In:\n 2,864 mL\n 430 mL\n PO:\n TF:\n 193 mL\n IVF:\n 2,724 mL\n 87 mL\n Blood products:\n Total out:\n 309 mL\n 60 mL\n Urine:\n 309 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,555 mL\n 370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 271 (271 - 271) mL\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.34/44/116/19/-2\n Ve: 6.1 L/min\n PaO2 / FiO2: 387\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n upper BS, Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Normal\n Labs / Radiology\n 8.6 g/dL\n 56 K/uL\n 99 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 62 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.7 %\n 10.9 K/uL\n [image002.jpg]\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n 04:00 PM\n 06:59 PM\n 05:17 AM\n 05:39 AM\n 10:07 AM\n WBC\n 10.6\n 12.7\n 10.9\n Hct\n 26.2\n 25.1\n 26.7\n Plt\n 66\n 56\n 56\n Cr\n 2.8\n 2.8\n 2.9\n 2.9\n TCO2\n 19\n 21\n 20\n 21\n 20\n 25\n Glucose\n 104\n 106\n 120\n 99\n Other labs: PT / PTT / INR:13.4/35.9/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.0\n mg/dL, Mg++:2.1 mg/dL, PO4:3.9 mg/dL\n Imaging: cxr: ET high (decrease by 2 cm)\n R basilar opacity (some chronic changes from pleurodesis), effusion\n b/l layering R > L, R IJ line in good position, OGT ok\n Microbiology: blood and sputum ngtd, rinu with pan \n pseudomonas--second species pending\n C diff pending ( 2 X neg)\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca in ICU with\n urosepsis c/b Afib/RVR, hypotension, ARF and delirium, intubated for\n worsening acidosis and airway protection--improving\n Respiratory failure\ndoing well on vent with improved acidosis\n but is total body volume up and will need to diurese prior to\n extubation, given some improved urine output today will likely begin\n auto-diuresis phase of ATN, will follow u/o and consider gentle\n diuresis later today with goal even to negative 500 today prior to\n extubation\n continue PS and lighten sedation with SBT in am\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-most likely source is\n pseudomonal urosepsis now improving\n WBC trending down, hemodynamically stable, porta cath without\n fluid by u/s and low suspicion of seeding given GNRs rather than GPCs\n L hip pain remains problem for possible met/lytic lesion or\n fx, no evidence of fluid for tap to suggest septic bursitis/source for\n infection\n Continue zosyn X 14 day course and f/u cx results\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension, now rate controlled and stable hemodynamically off of\n pressors\n preload dependent with severe AS\n cvp difficult to follow given severe AS\n lactates normalized\n follow MAPs and u/o\n ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, responsive\n to IVFs but would avoid calcium channel blockers in setting of RVR\n given severe AS,\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in chronic a- fib,\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n atn from sepsis and hypotension\n cr appears to have peaked and now with increasing u/o--will likely\n start to auto-diurese\n continue phos binder\n all meds renally dosed\n urine eos neg, complement pending and renal service recs\n appreciated\n > Leukocytosis\nnormalizing\n check C diff cx\n d/c vanco as no GPs from cx data and given clinical\n improvement\n continue zosyn for pseudomonas\n clinically improving and highest suspicion remains of\n urosepsis\n > thrombocytopenia--on review of records, baseline thrombocytopenia in\n 50-70 range, with initial elevation here likely from hemoconcentration\n and now likely at baseline, dic labs negative and HUS/TTP unlikely,\n check smear\n follow for further reduction from baseline, continue heparin products\n for now given low suspicion for HIT\n > anemia- h/h now stable, likely component of hemodilution,\n transfuse for < 21 or active bleed or if hypotension\n AORTIC STENOSIS--severe, preload dependent as above\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan sensitive--continue\n zosyn as above X 14 day course\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed while on\n vent\n > Hip pain--dose not seem source of infection but given her significant\n pain concern for some lytic lesion/fx or micro fx or bony mets-- bone\n scan to assess\n > Diarrhea--wbc trending down, c diff neg X 2 with third pending\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 AM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: sq heparin\n Stress ulcer: TFs\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318419,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - EXTUBATED 03:43 PM\n - plts trending down 47>43\n - scheduled metolazone and lasix qam\n Pt sleeping comfortably & sating well on 2L NC\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 66 (66 - 83) bpm\n BP: 116/35(62) {100/32(54) - 152/51(83)} mmHg\n RR: 39 (17 - 42) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 513 mL\n 50 mL\n PO:\n TF:\n 345 mL\n IVF:\n 138 mL\n 50 mL\n Blood products:\n Total out:\n 2,720 mL\n 840 mL\n Urine:\n 2,720 mL\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,207 mL\n -790 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 333 (325 - 333) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 99%\n ABG: 7.38/45/99./23/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 333\n Physical Examination\n GEN: NAD, sleeping comfortably, anasarca\n CV: RRR no m/r/g\n RESP: crackles bilaterally at bases, moving air well, no e/o resp\n ditress\n ABD: edematous, NTTP/NABS, soft\n EXTR: +2 pitting edema bilaterally\n Labs / Radiology\n CXR \n A single portable image of the chest was obtained and compared to\n prior examinations dated and . Allowing for slight\n differences in technique, there is no significant interval change. Mul\n tiple\n wires project over the left hemithorax. The endotracheal and nasogastr\n ic\n tubes and central venous catheter and Port-A-Cath are grossly unchanged\n and in\n satisfactory positions. The cardiomediastinal silhouette is grossly\n unchanged. A large right pleural effusion is seen. The left costophre\n nic\n angle is not included on the image, but there is a hazy opacity at the\n left\n base suggesting underlying effusion.\n IMPRESSION: Stable examination as above\n 40 K/uL\n 8.3 g/dL\n 91 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 109 mEq/L\n 142 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n WBC\n 7.4\n 6.1\n Hct\n 26.6\n 25.4\n Plt\n 47\n 42\n 40\n Cr\n 3.1\n 2.9\n TCO2\n 22\n 25\n 27\n 25\n 24\n 26\n 28\n Glucose\n 144\n 91\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis and\n MS changes.\n #SEPSIS: etiology presumed urosepsis with positive UA growing out pan\n sensitive Pseudomonas, now day 7 of Zosyn. Pt is s/p Intubation on\n for worsening acidosis/MS changes. Pt had transient hypotensive\n episode with worsening acidosis on -intermittently requiring\n pressors. WBC now trending down, afebrile, no recurrence of\n hypotension. Further infectious work up neg to date, L chest U/S neg\n for abscess,Bone scan negative\n - apprec ID consult, continue Zosyn day \n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n - gentle bolus of 250 LR prn to maintain Maps>65\n #SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib\n with RVR and became hypotensive on . Pressure responded to IVF &\n pressors. Pt was intubated and pressors weaned. Pt has been in/out of\n Afib but HR better controlled on digoxin. Transiently hypotensive on\n , required pressors approx 5hrs, likely due to severe AS and\n preload dependence. Pt with extravasc volume overload and complicated\n fluid balance\n - continue Digoxin 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - schedule metolazone and lasix daily, repeat in pm if volume up\n - EKG shows sinus with RBBB, frequent PACs. Will repeat this am for ?\n st depressions\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation.\n WBC ct down, it is unlikely that this due to a new PNA, but will\n reculture and broaden Abx if pt clinically deteriorates. Pulm edema\n and extravascular volume overload may be a barrier to extubation.\n - tolerated well. ABGs show normal acid base status, oxygenating &\n ventilating well.\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Creatinine improved & having increased UOP. Acidosis improved on vent\n with AC, unclear etiology of metabolic acidosis leading to intubation.\n Apprec renal recs, will admin Lasix & Metolazone this am to attempt\n diuresis. Improved urine output but Cr still well above baseline.\n - monitor i/os, goal net negative\n - renally dose all meds\n - continue phoslo TID\n # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant\n & delicate fluid balance. Gentle bolus with 250cc LR prn to maintain\n MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation.\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n - repeat UA\n test of cure\n # LEFT HIP PAIN: Etiology unclear but not an infectious source. Not a\n septic joint on admission, but clearly painful on manipulation now. CT\n neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n - continue Fentanyl for pain control\n -Tylenol and dilaudid for pain prn\n #Thrombocytopenia\n baseline 50-70s, 47 this am\n - re-check pm plts\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 318421,
"text": "Subjective\n Patient extubated \n Objective\n Pertinent medications: lasix, calcium acetate\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 03:34 AM\n Glucose Finger Stick\n 125\n 11:00 PM\n BUN\n 69 mg/dL\n 03:34 AM\n Creatinine\n 2.9 mg/dL\n 03:34 AM\n Sodium\n 142 mEq/L\n 03:34 AM\n Potassium\n 3.9 mEq/L\n 03:34 AM\n Chloride\n 109 mEq/L\n 03:34 AM\n Albumin\n 2.1 g/dL\n 04:56 AM\n Calcium non-ionized\n 9.0 mg/dL\n 03:34 AM\n Phosphorus\n 4.6 mg/dL\n 03:34 AM\n Ionized Calcium\n 1.11 mmol/L\n 10:15 PM\n Magnesium\n 2.1 mg/dL\n 03:34 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Specifics:\n 86 year old female with history of ovarian cancer, CRI and CHF. Patient\n was intubated d/t worsening acidosis and MS changes. Patient now\n extubated, tolerating well. Tube feedings were stopped in anticipation\n of extubation. Currently unable to take PO intake due to mental status.\n Recommend restarting tube feedings if patient continues to be unable to\n take PO intake safely.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If patient continues to be unable to take PO intake, recommend\n restarting tube feeding of Nutren Pulmonary at 35ml/hr, monitor\n tolerance, hold if residuals >150ml\n 2. If mental status improves, recommend swallow evaluation\n 11:31\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318113,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical/renal CA, who presented on w/\n L hip pain x 3 days in the setting of leukocytosis and acute renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation for\n hypotensive episode at ED, SBP 70\n fluid resuscitated and precept\n catheter placed. Etiology of L hip pain still unkown T of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown. Has been\n tolerating weaning from ventilator with plan of extubating this am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on PS 5/5, lung sounds clear, dim at bases. Suctioned\n small amount of yellow-tan colored secretions. ABG at 10pm shows more\n acidosis with pH of 7.28 though patient has good volume.\n Action:\n Switched to AC 450x16 same FiO2 of 30% peep of 5\n Response:\n pH improved 7.35, this am\ns ABG 7.35/36/150\n Plan:\n Keep patient on AC, unable to do RSBI, patient seems very sedated.\n Sedation off at 0500 patient not opening eyes but grimaces to pain. (\n patient did open eyes wide at 0300 during bathing) Continue assess\n mental status, switch to PS once patient start to wake-up.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Oliguric, UO 0-20cc/hr BUN creatinine rising, approx 6L positive for\n LOS ( patient had no urine output in setting of hypotension SBP 79-82\n with MAP 49-51\n Action:\n Received 500cc of fluid bolus to support BP, renal is following\n patient, no need for dialysis this time. Suggested for lasix but\n patient\ns BP is not great 90-110\n Response:\n Remains oliguric, BUN creatinine 65/31 this am, consistently rising\n Plan:\n Continue to monitor UO, follow BUN crea for need of dialysis if\n hemodynamically stable\n Shock, cardiogenic\n Assessment:\n Hypotensive high70\ns-low 80\ns with MAP 49-51, remains SR with\n occasional PVC\n Action:\n Fluid bolus 500cc given but not responsive, started on levophed now @\n 0.065mcg.kg/ min\n Response:\n Able to wean down on pressors SBP > 90 with MAP > 60, patient is\n putting more urine now that BP is high\n Plan:\n Wean down on levophed as tolerated\n Urinary tract infection (UTI)\n Assessment:\n WBC 14.7, afebrile\n Action:\n Zosyn q8hrs given dose\n Response:\n Urine clear, remains afebrile\n Plan:\n Continue antibiotic treatment, follow-up cultures\n Pain control (acute pain, chronic pain)\n Assessment:\n Grimaces during repositioning\n Action:\n Continues on versed and fentanyl for comfort. Sedation off at 0500\n since patient remained apneic during RSBI test. Not opening eyes, but\n grimace during repositioning.\n Response:\n Comfortable even without sedation\n Plan:\n Bone scan this 11 am to r/o bone metastasis, continue off sedations as\n tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318120,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hypotensive to 70s, not resposive to 500cc bolus, re-started levophed\n with good response\n - ABGs progressively more acidemic, switched back to AC following\n midnight ABG with good response\n - d/c'd vanc\n Pt intubated/sedated, not responding to commands. Still on Levophed\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.7\nC (98\n HR: 66 (66 - 99) bpm\n BP: 133/43(73) {82/34(50) - 133/49(78)} mmHg\n RR: 14 (9 - 24) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 7 (-1 - 10)mmHg\n Total In:\n 1,656 mL\n 434 mL\n PO:\n TF:\n 653 mL\n 259 mL\n IVF:\n 734 mL\n 115 mL\n Blood products:\n Total out:\n 620 mL\n 152 mL\n Urine:\n 570 mL\n 152 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,036 mL\n 282 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 351 (271 - 387) mL\n PS : 0 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 20 cmH2O\n SpO2: 98%\n ABG: 7.35/36/150/19/-4\n Ve: 7 L/min\n PaO2 / FiO2: 500\n Physical Examination\n GEN: NAD, intubated, comfortable on vent\n CV: RRR gr 3 SEM over LSB, does not radiate\n RESP: CTAB, BS over bases\n ABD: ND, mildly tense, no grimacing to palp,NABS\n EXTR: 2+pitting edema bilaterally\n Labs / Radiology\n 72 K/uL\n 9.3 g/dL\n 161 mg/dL\n 3.1 mg/dL\n 19 mEq/L\n 4.0 mEq/L\n 65 mg/dL\n 106 mEq/L\n 135 mEq/L\n 28.9 %\n 14.7 K/uL\n [image002.jpg]\n 06:59 PM\n 05:17 AM\n 05:39 AM\n 10:07 AM\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n WBC\n 10.9\n 14.7\n Hct\n 26.7\n 28.9\n Plt\n 56\n 72\n Cr\n 2.9\n 3.0\n 3.1\n TCO2\n 21\n 20\n 25\n 21\n 22\n 21\n 21\n Glucose\n 99\n 127\n 161\n Other labs: PT / PTT / INR:12.9/33.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Assessment and Plan: 86 y/o F with PMHx of severe AS & CHF with EF 45%,\n renal cell & ovarian Ca p/w Left hip pain, adm for presumed urosepsis\n on pressors. Intubated on for worsening acidosis, oliguric renal\n failure, hemodynamic instability to Afib with RVR and MS changes.\n ► SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Source of infection\n presumed to be urosepsis with positive UA growing out pan sensitive\n Pseudomonas. Pt clinically deteriorated on with worsening\n acidosis/MS changes and was intubated. Pressors were weaned\n immediately and pt has been maintaining MAPs with occais 500cc\n boluses. WBC ct trended down and acidosis resolved on minimal vent\n settings. L chest U/S was neg for abscess, CT was unrevealing for addl\n infectious sources.\n - ID consult, 2nd GNR in Ucx likely pseudomonas\n - continue Zosyn for coverage of pseudomonas, d/c Vancomycin today as\n there is no e/o line infection.\n - ortho consult for L hip pain, unconcerned for L hip as source of\n infection\n - continue to f/u blood & urine cultures\n - bolus prn to maintain Maps>65\n ► SHOCK, CARDIOGENIC: resolved, pt with severe AS & CHF with EF\n 45% developed Afib with RVR and became hypotensive on . Pressure\n responded to IVF & pressors. Pt was then Intubated and pressors\n weaned. Pt still in/out of Afib but HR has been much better controlled\n on digoxin.\n - dig level 1.4 this am, will continue Digoxing 0.125mg every other day\n - avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n low, will reconsider in am\n - fluid bolus prn to maintain maps>60\n ►RESP FAILURE: Pt was intubated on due to worsening acidosis\n & MS changes. CXR shows bilateral effusions & pulm edema. CT showed\n possible airspace disease in , have been aspiration\n peri-intubation. Afebrile, WBC ct trending down, this is unlikely a\n new PNA\n - wean vent settings to today, repeat ABG in pm\n - f/u RSBI in am, possible extubation in 24-48hrs\n ► RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with\n oliguric renal failure likely hypoperfusion vs ATN in setting of\n shock. Urine sediment filled with WBCs, no e/o casts. Creatinine\n appears to have plateaued and pt having increased UOP overnight.\n Renal recs, there is no acute indication for dialysis. Acidosis\n resolved on vent, unclear if metabolic acidosis leading to intubation\n was all uremia. renal recs- C3 low, C4 normal, urine eos\n negative.\n - avoid continuous IVF given poor UOP\n - renally dose all meds\n - continue phoslo TID & check lytes \n ► AORTIC STENOSIS: AS with valve area of 0.7cm, very preload\n dependant. Gentle bolus IVF prn to maintain MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n ► URINARY TRACT INFECTION (UTI): presumed source of infection\n with UA + pseudomonas, pan sensitive\n - continue Vanc/Zosyn for coverage\n ► LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did\n not suggest a septic joint on admission, clearly very painful on\n manipulation. CT neg for joint effusion. Consider f/u MRI.\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 07:33 PM 35 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318491,
"text": "This is an 86 yr old woman who presented to the EW w/L hip pain 0n\n . Tmax 100.1. Urine Cx positive for pseudomonas. Patient became\n hypotensive, requiring 5L IVF & levophed to suppoert her BP. Code\n sepsis started. Patient was intubated & transferred to MICU. She was\n extubated . Patient is stable off pressors.\n Atrial fibrillation (Afib)\n Assessment:\n Patient converted to A-fib w/RVR @ rate up to 150 @ 2100.\n Action:\n Given 500cc NS\n Response:\n Converted back to ST/SR w/ frequent APC\ns & occasional PVC\ns. Converted\n back to AF, w/rate up to 150 @ 2315, BP 120\ns/systolic. Given 5mg IV\n lopressor to convert back to SR.\n Plan:\n Consider dosing again w/5mg IV lopressor for A-fib w/RVR if BP\n tolerates.\n Altered mental status:\n Patient was A&OX1 (oriented to self). C/o hunger & thirst. She was\n able to be fed soft solids (jello & custard) & drink water through a\n straw this evening. Sat up @ 90 degrees. No choking. Took her pills\n crushed in apple sauce. As night progressed & patient became more\n tired, her mental status waned. She called out to people not present.\n She talked to herself constantly all night. Patient checked frequently.\n Bed alarm on. Bed low & locked. 3 side rails up. Curtains pulled back\n for increased visibility. Call light w/in easy reach.\n Expect call out today or tomorrow. Needs PT consult.\n Changed coccyx drsg @ 0530. Wound unchanged. Washed w/NS, telfa & ABD\n applied. Antifungal barrier cream applied to reddened skin @ perirectal\n area.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318492,
"text": "Chief Complaint:\n 24 Hour Events:\n PRESEP CATHETER - STOP 12:06 PM\n ARTERIAL LINE - STOP 12:06 PM\n - all heparin products d/c'd for plts 40, HIT Ab sent\n - diuresing & developped A.Fib with RVR, BP stable, responded to IV\n bolus but required Metoprolol 5mg IV x 1 for rate control\n - MS , S/S recommended NPO till further evaluation\n Pt still confused this am, was awake most of the night.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00\n Metoprolol - 11:25 PM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.9\nC (96.6\n HR: 89 (66 - 120) bpm\n BP: 111/36(56) {100/29(47) - 138/61(71)} mmHg\n RR: 24 (17 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,050 mL\n 463 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,750 mL\n 463 mL\n Blood products:\n Total out:\n 3,275 mL\n 710 mL\n Urine:\n 3,275 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GEN: NAD, confused, talking\n HEENT: anasarca, diffuse edema\n CV: RRR gr 3 SEM over LSB, does not radiate\n RESP: crackles bilaterally at bases, otherwise clear\n Abd: BS, NTTP, ND, edematous\n Extr: +2 pitting edema bilaterally\n Sacrum: skin tears, ecchymosis and diffuse intertriguin. rash\n Labs / Radiology\n 40 K/uL\n 8.3 g/dL\n 109 mg/dL\n 2.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 70 mg/dL\n 110 mEq/L\n 146 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n WBC\n 6.1\n Hct\n 25.4\n Plt\n 42\n 40\n Cr\n 2.9\n 2.9\n TCO2\n 27\n 25\n 24\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Blood Cx NGTD \n Urine Cx NGTD \n C. Diff neg x 5\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n SHOCK, CARDIOGENIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ATRIAL FIBRILLATION (AFIB)\n AORTIC STENOSIS\n URINARY TRACT INFECTION (UTI)\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition: NPO for now, pending s/s eval\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: H2 blocker\n Code status: DNR (do not resuscitate)\n Disposition: possible out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318493,
"text": "Chief Complaint:\n 24 Hour Events:\n PRESEP CATHETER - STOP 12:06 PM\n ARTERIAL LINE - STOP 12:06 PM\n - all heparin products d/c'd for plts 40, HIT Ab sent\n - diuresing & developped A.Fib with RVR, BP stable, responded to IV\n bolus but required Metoprolol 5mg IV x 1 for rate control\n - MS , S/S recommended NPO till further evaluation\n Pt still confused this am, was awake most of the night.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00\n Metoprolol - 11:25 PM\n Other medications:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.9\nC (96.6\n HR: 89 (66 - 120) bpm\n BP: 111/36(56) {100/29(47) - 138/61(71)} mmHg\n RR: 24 (17 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,050 mL\n 463 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,750 mL\n 463 mL\n Blood products:\n Total out:\n 3,275 mL\n 710 mL\n Urine:\n 3,275 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GEN: NAD, confused, talking\n HEENT: anasarca, diffuse edema\n CV: RRR gr 3 SEM over LSB, does not radiate\n RESP: crackles bilaterally at bases, otherwise clear\n Abd: BS, NTTP, ND, edematous\n Extr: +2 pitting edema bilaterally\n Sacrum: skin tears, ecchymosis and diffuse intertriguin. rash\n Labs / Radiology\n 40 K/uL\n 8.3 g/dL\n 109 mg/dL\n 2.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 70 mg/dL\n 110 mEq/L\n 146 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n WBC\n 6.1\n Hct\n 25.4\n Plt\n 42\n 40\n Cr\n 2.9\n 2.9\n TCO2\n 27\n 25\n 24\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Blood Cx NGTD \n Urine Cx NGTD \n C. Diff neg x 5\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis &\n extubated successfully on .\n #SEPSIS: resolved, presumed urosepsis with positive UA growing out pan\n Pseudomonas, now day Zosyn. Pt was intubation on for\n worsening acidosis/MS changes, successfully extubated. BP has been\n stable >72 hrs, WBC trending down, afebrile, no recurrence of\n hypotension. Other infectious w/u neg to date, L chest U/S neg for\n abscess,Bone scan neg\n - Zosyn day today\n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n #CV: Pt with severe AS & CHF with EF 45%. Pt was aggressively diuresed\n and developped Afib with RVR again overnight, responded to IV bolus &\n BB. Pt with massive extravasc volume overload, will need to be slowly\n diuresed as pt is very preload dependant & tends to develop A.Fib with\n RVR when preload drops.\n - continue Digoxin 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - Lasix 120mg IV daily, avoid metolazone, goal i/os of neg 1L.\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation,\n more likely chronic changes to pleurodeisis. Pt extubated\n successfully on and currently sating well on 2L NC.\n - continue with supplemental O2 & diuresis\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock. UOP\n currently improving. Apprec renal recs, will admin Lasix 120mg IV to\n continue diuresis, avoid aggressive volume loss, appears to precipitate\n A. Fib with RVR. Monitor creatinine with diuresis\n - monitor i/os, goal net negative 1000cc/day\n - renally dose all meds\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n - d/c foley as soon as possible\n # MS changes: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay.\n - d/c lines & d/c restraints\n - start Olanzapine \n - speech & swallow eval prior to adv diet\n # LEFT HIP PAIN: Etiology unclear but not an infectious source. Not a\n septic joint on admission, but clearly painful on manipulation now. CT\n neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n -Tylenol and dilaudid for pain prn\n - PT consulted\n #Thrombocytopenia\n baseline 50-70s, trended down over last 2 days but\n stable overnight at 40 since stopping at Heparin products. Concern for\n HITs but suspician low.\n -continue holding heparin products and f/u HIT Ab\n ICU Care\n Nutrition: NPO for now, pending s/s eval\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: H2 blocker\n Code status: DNR (do not resuscitate)\n Disposition: possible out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318494,
"text": "Impaired Skin Integrity\n Assessment:\n Skin over both buttocks is reddened w/open area. Reddened perianal\n skin.\n Action:\n Wash buttocks w/NS, apply telfa & ABD. Apply antifungal to reddened\n perianal skin.\n Response:\n Plan:\n Wound care consult.\n Atrial fibrillation (Afib)\n Assessment:\n Converted X2 evening to AF\n Action:\n Replaced fluid X1 when overdiuresed. Given 5mg IV lopressor X1\n Response:\n Converted back to SR/ST w/ APC\ns & PVC\ns w/ 500cc NS w/ 1^st episode &\n 5mg IV lopressor w/2^nd episode.\n Plan:\n Continue to monitor.\n Delirium / confusion\n Assessment:\n Patient sundowned, speaking to people that were not there, reaching for\n things that were not present.\n Action:\n Given zyprexa .\n Response:\n Cleared as day progressed.\n Plan:\n Bed alarm. Keep bed low & locked. Orient patient prn.\n Urinary tract infection (UTI)\n Assessment:\n Afebrile. Urine clear. WBC:\n Action:\n Pseudomonas UTI treated w/zosyn IV.\n Response:\n Pseudomonas sensitive to zosyn\n Plan:\n Continue to give zosyn IV. Continue to check temperature.\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318064,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Mode changed to PSV from A/C\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317711,
"text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 07:04 PM\n PRESEP CATHETER - START 07:05 PM\n Pt presented to ED c/o Left hip pain, found to have UTI & hypotension,\n fluid resussitated, admitted on levophed. WBC rising on Zosyn. Pt\n still c/o Left pain, some relief with Dilaudid. Otherwise, no\n SOB/CB/Abd pain\n On team rounds, pt c/o nauseated & having some emesis, complaining of\n diffuse/achey pains, but mentating well and denying any SOB.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:23 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin, Insulin, Famotidine\n Other medications:\n Tamoxifen\n Dilaudid\n Heparin\n Bisacodyl\n Allopurinol\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.5\nC (95.9\n HR: 84 (69 - 88) bpm\n BP: 127/41(59) {80/34(46) - 127/57(70)} mmHg\n RR: 14 (9 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 21 (0 - 21)mmHg\n SvO2: 76%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 1,883 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 1,883 mL\n Blood products:\n Total out:\n 383 mL\n 105 mL\n Urine:\n 83 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 1,778 mL\n Respiratory support: 2L NC\n SpO2: 99%\n ABG: 7.24/55/139/26/-4\n Physical Examination\n General Appearance: NAD, comfortable\n Cardiovascular: (S1: Normal), (S2: Normal) quiet heart sounds, gr2-3\n early peaking ejection murmur, prominent S2\n Resp: CTAB\n Abd: soft, NT/ND, NABS\n Extr: trace to +1 pitting edema\n Skin: warm, pink\n Neuro: appropriate\n Labs / Radiology\n Renal U/S:\n IMPRESSION: Limited portable ultrasound performed. No hydronephrosis\n or\n stones in the left kidney. The right kidney which is small could not b\n e\n visualized given overlying bowel gas. A CT abdomen and pelvis may be o\n btained\n if warranted for further evaluation.\n Bilateral Hip films\n Preliminary Report\n No cortical irregularity or disruption of trabecular lines detected to\n suggest\n acute fracture in the left hip. Right hip replacement and pelvis simil\n ar in\n appearence to previous. No hip dislocation. Given osteopenia, dedicate\n d left\n hip views vs CT/MRI may be considered if indicated to evaluate subtle\n fractures.\n CXR:\n IMPRESSION:\n 1. Low-lying new central venous catheter, which should be partially\n withdrawn; no definite pneumothorax.\n 2. CHF with bilateral pleural effusions.\n 121 K/uL\n 10.1 g/dL\n 89 mg/dL\n 2.4 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 58 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.9 %\n 24.5 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n WBC\n 20.6\n 24.5\n Hct\n 30\n 31.6\n 32.9\n Plt\n 83\n 121\n Cr\n 2.3\n 2.4\n TropT\n 0.11\n 0.12\n TCO2\n 25\n Glucose\n 147\n 89\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:45/9/0.12, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:2.0 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n 86 y/o F with PMHx of Renal Cell Carcinoma, Ovarian Ca, recurrent UTIs\n on chronic prophylaxis of Keflex p/w Left hip pain & found to be\n hypotensive in ED with UTI, adm to with urosepsis on levophed\n with rising WBC ct.\n #Urosepsis: Pt with h/o recurrent UTIs on prophylactic Keflex, recent\n urine Cx positive for pan-sensitive Psuedomonas, now uroseptic and\n urine cx pending. Pt having poor UOP despite volume resuscitation,\n still on Levophed and unable to wean o/n.\n - continue Zosyn for now, d/w ID- would avoid gentamicin due to renal\n toxicity and no FQ due to allergy\n - adding Vancomycin for indwelling portocath\n - concern for indwelling hip hardware & portocath giving likely\n bacteremia\n - will gently fluid bolus today, monitor for UOP response\n - A line placement today, attempt to wean pressors\n - Zofran TID prn nausea\n # Left Hip pain: etiology unclear and plain films negative for fracture\n - MRI pending, pt currently to unstable for transfer\n - repeat exam, attempt ROM after dilaudid to r/o septic joint\n #Acute on Chronic Renal Failure: likely due to UTI/sepsis & moderate AS\n still having poor UOP and requiring pressors, will attempt gentle fluid\n boluses today\n - monitor UOP with boluses\n # CHF/Severe AS: Moderate to Severe AS with valve area of 0.7cm &\n recent LVEF of 45% on lasix & nitrates as outpt\n - likely very preload dependant, attempting fluid boluses. CXR reveals\n CHF with bilateral effusions, but pt denying SOB, sating well on 2L\n NC. Unable to wean from pressors o/n, continue Levophed\n - intermittent A-Fib noted on telemetry, monitor for now, no need for\n anticoagulation in first 24-48hrs.\n # GOUT- continue allopurinol renally dosed\n # h/o Ovarian Cancer, RCC: RCC treated with Gammaknife. H/o treatment\n for ovarian not documented in , continue Tamoxifen and d/w\n patient/family to clarify history\n Nutrition: NPO for now on IVF\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT: Heparin sc TID\n Stress ulcer: PPI\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317781,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:30 AM- Afib, RBBB, no acute ST-T waves changes\n ARTERIAL LINE - START 04:15 PM\n - CE negative\n - vanc added\n - urine grew out pseudomonas, did not double cover per ID\n - MRI hip ordered, not performed\n - uable to wean pressors overnight\n Pt doing okay this am, still some L hip pain, but otherwise, breathing\n comfortably, no CP/SOB/Abd pain.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 09:45 AM\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Infusions:\n Norepinephrine - 0.13 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Famotidine (Pepcid) - 11:00 PM\n Hydromorphone (Dilaudid) - 01:00 AM\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 90 (84 - 101) bpm\n BP: 94/40(60) {90/37(-17) - 109/44(66)} mmHg\n RR: 16 (9 - 23) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 13 (13 - 27)mmHg\n SvO2: 75%\n Total In:\n 6,279 mL\n 214 mL\n PO:\n 1,020 mL\n TF:\n IVF:\n 5,259 mL\n 214 mL\n Blood products:\n Total out:\n 159 mL\n 20 mL\n Urine:\n 159 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,120 mL\n 194 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n GEN: NAD, comfortable, HOH\n HEENT: RIJ in place, NCAT, unable to visualize JVP\n CV: irreg/irreg, gr early peaking SEM over LSB, prominent S2\n Resp: CTAB ant lung fields, BS over LLL, no w/r\n ABD: soft/NT/ND/NABS\n EXTR: 2+ pitting edema bilaterally\n Neuro: AXO, HOH\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 88 mg/dL\n 2.9 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 60 mg/dL\n 101 mEq/L\n 133 mEq/L\n 32.9 %\n 28.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n 02:04 PM\n 05:30 AM\n WBC\n 20.6\n 24.5\n 33.3\n 28.6\n Hct\n 30\n 31.6\n 32.9\n 31.6\n 32.9\n Plt\n 83\n 121\n 114\n 114\n Cr\n 2.3\n 2.4\n 2.4\n 2.9\n TropT\n 0.11\n 0.12\n 0.11\n TCO2\n 25\n Glucose\n 147\n 89\n 74\n 88\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:6.0 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n SHOCK, CARDIOGENIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ATRIAL FIBRILLATION (AFIB)\n AORTIC STENOSIS\n URINARY TRACT INFECTION (UTI)\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition: NPO with ice chips\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin 5000 TID\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317785,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 11:30 AM- Afib, RBBB, no acute ST-T waves changes\n ARTERIAL LINE - START 04:15 PM\n - CE negative\n - vanc added\n - urine grew out pseudomonas, did not double cover per ID\n - MRI hip ordered, not performed\n - uable to wean pressors overnight\n Pt doing okay this am, still some L hip pain, but otherwise, breathing\n comfortably, no CP/SOB/Abd pain.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 09:45 AM\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Infusions:\n Norepinephrine - 0.13 mcg/Kg/min\n Other ICU medications:\n Heparin TID, Allopurinol,\n Famotidine, Tamoxifen,\n Dilaudid, Zofran, Insulin,\n Bisacodyl, Colace\n Other medications:\n Flowsheet Data as of 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.1\nC (97\n HR: 90 (84 - 101) bpm\n BP: 94/40(60) {90/37(-17) - 109/44(66)} mmHg\n RR: 16 (9 - 23) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n CVP: 13 (13 - 27)mmHg\n SvO2: 75%\n Total In:\n 6,279 mL\n 214 mL\n PO:\n 1,020 mL\n TF:\n IVF:\n 5,259 mL\n 214 mL\n Blood products:\n Total out:\n 159 mL\n 20 mL\n Urine:\n 159 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,120 mL\n 194 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n GEN: NAD, comfortable, HOH\n HEENT: RIJ in place, NCAT, unable to visualize JVP\n CV: irreg/irreg, gr early peaking SEM over LSB, prominent S2\n Resp: CTAB ant lung fields, BS over LLL, no w/r\n ABD: soft/NT/ND/NABS\n EXTR: 2+ pitting edema bilaterally\n Neuro: AXO, HOH\n Labs / Radiology\n 114 K/uL\n 9.9 g/dL\n 88 mg/dL\n 2.9 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 60 mg/dL\n 101 mEq/L\n 133 mEq/L\n 32.9 %\n 28.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n 02:04 PM\n 05:30 AM\n WBC\n 20.6\n 24.5\n 33.3\n 28.6\n Hct\n 30\n 31.6\n 32.9\n 31.6\n 32.9\n Plt\n 83\n 121\n 114\n 114\n Cr\n 2.3\n 2.4\n 2.4\n 2.9\n TropT\n 0.11\n 0.12\n 0.11\n TCO2\n 25\n Glucose\n 147\n 89\n 74\n 88\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:1.9 mg/dL, PO4:6.0 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n SHOCK, CARDIOGENIC\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ATRIAL FIBRILLATION (AFIB)\n AORTIC STENOSIS\n URINARY TRACT INFECTION (UTI)\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition: NPO with ice chips\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin 5000 TID\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317798,
"text": "Chief Complaint: Urosepsis\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 11:30 AM: afib, no ischemic change\n ARTERIAL LINE - START 04:15 PM\n * U cx with pseudomonas\n * Oliguric\n * Remains on levophed\n * MRI deferred instability\n Subj: Continues to complain of L hip pain\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 09:45 AM\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 PM\n Famotidine (Pepcid) - 11:00 PM\n Hydromorphone (Dilaudid) - 08:00 AM\n Other medications:\n allopurinol, SQ heparin, tamoxifen, ISS\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 89 (84 - 100) bpm\n BP: 109/48(70) {88/37(-17) - 109/48(70)} mmHg\n RR: 9 (9 - 23) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 70 kg (admission): 62 kg\n CVP: 15 (12 - 21)mmHg\n SvO2: 83%\n Total In:\n 6,297 mL\n 447 mL\n PO:\n 1,020 mL\n TF:\n IVF:\n 5,277 mL\n 447 mL\n Blood products:\n Total out:\n 159 mL\n 30 mL\n Urine:\n 159 mL\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,138 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.9 g/dL\n 114 K/uL\n 88 mg/dL\n 2.9 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 60 mg/dL\n 101 mEq/L\n 133 mEq/L\n 32.9 %\n 28.6 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n 02:04 PM\n 05:30 AM\n WBC\n 20.6\n 24.5\n 33.3\n 28.6\n Hct\n 30\n 31.6\n 32.9\n 31.6\n 32.9\n Plt\n 83\n 121\n 114\n 114\n Cr\n 2.3\n 2.4\n 2.4\n 2.9\n TropT\n 0.11\n 0.12\n 0.11\n TCO2\n 25\n Glucose\n 147\n 89\n 74\n 88\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:39/8/0.11, Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2\n %, Mono:4.5 %, Eos:0.1 %, Lactic Acid:1.1 mmol/L, LDH:145 IU/L,\n Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: FENA 1, U NA 30\n Imaging: : R > L pleural effusion slight increase from .\n Possible bibasilar opacities.\n Microbiology: Urine cx - pseudomonas, no sensi\n Blood cx - NGTD\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): GU likely source, but\n continued elevated WBC and pressor requirement despite broad spectrum\n abx suggest either inadequate coverage of Pseudomonas, or other source\n such as infected hip, c. diff, line infection, cholecystitis, etc.\n though she has a benign abd exam and negative cultures from her\n indwelling line.\n - Will get repeat cultures\n - Check LFTs\n - CT chest and CT hip\n - Redose vanco according to levels\n - Consult ID re: antibiotic coverage\n SHOCK, SEPTIC/CARDIOGENIC: Continues to need pressors, with slow\n escalation. SVO2 is adequate. AS complicates management.\n - Continue fluid boluses and vasopressor\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Likely ATN, though\n creatinine also increasing slowly.\n - Continue fluid boluses to keep preload elevated, monitor lytes\n - Consult renal\n ATRIAL FIBRILLATION (AFIB): Well rate controlled\n AORTIC STENOSIS: Continue boluses.\n URINARY TRACT INFECTION (UTI): Pseudomonas, awaiting sensitivities.\n Renal U/S without perinephric abscess or Hydro\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Showing signs of delerium on\n dilaudid, but she has multiple allergies.\n - Will continue dilaudid at low dose.\n - Add lidocaine patch, standing tylenol\n * DELERIUM: Related to age, ICU, meds.\n - Will begin haldol at low dose\n - Attempt to orient, minimize psychotropic meds.\n ICU Care\n Nutrition:\n Comments: Start clear liquids\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318642,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318546,
"text": "86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonas urosepsis\n c/b A fib/RVR, ARF (ATN) and respiratory failure stable since\n extubation\n Atrial fibrillation (Afib)\n Assessment:\n Episodes of afib with RVR up to 144\n Action:\n Received 500cc LR x1, later had second episode of afib RVR received 5mg\n of iv lopressor\n Response:\n Patient went back into SR with occasional pvc and pac\n Plan:\n Lasix and diuril were discontinued, monitor urine output and cardiac\n rhythm\n Delirium / confusion\n Assessment:\n Alert to lethargic oriented to person, daughter but nothing else\n Action:\n Allowed time to rest, oriented frequently, on .olanzapine\n Response:\n Continues to be lethargic and disoriented\n Plan:\n Dilaudid discontinued, use Tylenol 650mg po q 6 round the clock for\n pain, olanzipine, allow rest periods, reorient frequently\n Impaired Skin Integrity\n Assessment:\n Has evidence of deep tissue injury to her sacral/coccyx area the\n entire breaddown measures 8x8.5cm. The area of DTI is deep purple\n along the midline coccyx, gluteal cleft. Measures 4.5x1cm. Moderate amt\n of serosang drainage no odor. Peri-anal area erythematous gluteals,\n posterior thighs, groin and medial thighs are fungal in appearance.\n Action:\n Pt was placed on a kinear bed. Wound RN consulted\n Response:\n .\n Plan:\n Kinear bed, apply thin layer of critic aid antifungal moisture barrier\n cream to affected tissue, reapply only after ery third cleansing,\n wound clean with wound cleaner or NS pat dry, place aquacel dressing\n followed by dry gauze then softsorb change qd, keep skin dry, turn q 2\n hrs and prn\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318553,
"text": "Impaired Skin Integrity\n Assessment:\n Patient\ns drsg injury @ coccyx is D&I.\n Action:\n Turned q 2 hrs. On kinair bed. Change drsg .\n Response:\n Patient has discomfort w/turning. Relieved once turning finished.\n Plan:\n Medicate w/Tylenol for ease w/turning.\n Delirium / confusion\n Assessment:\n Patient was alert in early evening & oriented X1. As she became more\n sleepy, she became more confused. Talked to herself for most of the\n night.\n Action:\n Unable to use bed alarm on kinair bed. Increased visibility by pulling\n curtains back. Bed locked & low. All siderails up as kinair bed is off\n the ground by a good amount even in low position. Checked patient\n frequently. Given zyprexa. Held off on feeding patient while she was\n so confused.\n Response:\n Patient continued to be confused.\n Plan:\n Orient patient . Check w/MD\ns re: plan to feed patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs sound clear @ upper lungs, crackles to diminished @ bases.\n RR20-35 O2 sat 93-99% on 2-3L NP. Desatted to 88% on room air. CXR\n am showed large R pleural effusion & suggestion of substantial pleural\n fluid on L as well.\n Action:\n Given 120mg IV lasix @ 2245.\n Response:\n U/o 300cc in 1 hr\n Plan:\n Continue to monitor for resp distress. Continue to monitor O2 sats.\n Continue to minitor u/o.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318555,
"text": "Impaired Skin Integrity\n Assessment:\n Patient\ns drsg injury @ coccyx is D&I.\n Action:\n Turned q 2 hrs. On kinair bed. Change drsg .\n Response:\n Patient has discomfort w/turning. Relieved once turning finished.\n Plan:\n Medicate w/Tylenol for ease w/turning.\n Delirium / confusion\n Assessment:\n Patient was alert in early evening & oriented X1. As she became more\n sleepy, she became more confused. Talked to herself for most of the\n night.\n Action:\n Unable to use bed alarm on kinair bed. Increased visibility by pulling\n curtains back. Bed locked & low. All siderails up as kinair bed is off\n the ground by a good amount even in low position. Checked patient\n frequently. Given zyprexa. Held off on feeding patient while she was\n so confused.\n Response:\n Patient continued to be confused.\n Plan:\n Orient patient . Check w/MD\ns re: plan to feed patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs sound clear @ upper lungs, crackles to diminished @ bases.\n RR20-35 O2 sat 93-99% on 2-3L NP. Desatted to 88% on room air. CXR\n am showed large R pleural effusion & suggestion of substantial pleural\n fluid on L as well.\n Action:\n Given 120mg IV lasix @ 2245.\n Response:\n U/o 300cc in 1 hr\n Plan:\n Continue to monitor for resp distress. Continue to monitor O2 sats.\n Continue to minitor u/o.\n This is an 86 yr old woman admitted w/L hip pain & found to have\n urosepsis. Now treated w/zosyn. Originally on levophed, stable off\n pressors for days. Extubated .\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317871,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical CA, who presented on w/ L hip\n pain x 3 days in the setting of leukocytosis and acute anuric renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation however\n since that time levophed/neo have been d/c and acid base balance has\n largely normalized.\n Overnight pt attempted to pull @ lines/tubes managing to pull out OGT,\n sedation changed from bolus to gtt, OGT reinserted and the pt rested\n comfortably for the remainder of the shift. Stool sent as pt has a hx\n of Cdiff and has been having liquid brown stools. CT of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely poor\n Action:\n Renal consult\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Afib w/ transient sinus beats\n Action:\n Digoxin loading completed overnight, Team ordered a x 1 PO dose of\n digoxin for the morning of no standing dose orders @ this time\n Response:\n HR/BP remained wnl in the absence of all vasoactive meds\n Plan:\n Follow up with maintenance dig.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317872,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical CA, who presented on w/ L hip\n pain x 3 days in the setting of leukocytosis and acute anuric renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation however\n since that time levophed/neo have been d/c and acid base balance has\n largely normalized.\n Overnight pt attempted to pull @ lines/tubes managing to pull out OGT,\n sedation changed from bolus to gtt, OGT reinserted and the pt rested\n comfortably for the remainder of the shift. Stool sent as pt has a hx\n of Cdiff and has been having liquid brown stools. CT of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely poor\n Action:\n Renal consult\n Response:\n Consult recommendation in chart no HD @ this time may require HD should\n renal function fail to improve\n Plan:\n Cont to monitor urine output, repeat U/A tomorrow .Renal to follow\n closely.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Afib w/ transient sinus beats\n Action:\n Digoxin loading completed overnight, Team ordered a x 1 PO dose of\n digoxin for the morning of no standing dose orders @ this time\n Response:\n HR/BP remained wnl in the absence of all vasoactive meds\n Plan:\n Follow up with maintenance dig.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remained off pressors throughout shift, however urine output remains\n very poor\n Action:\n D5\n NS maintenance gtt @ 100cc/hr initiated, cont abx tx.\n Response:\n No change in U/O, remained afebrile, leukocytosis appears to have\n resolved\n Plan:\n Cont abx tx, renal dose all meds, wean vent as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317873,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical/renal CA, who presented on w/\n L hip pain x 3 days in the setting of leukocytosis and acute renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation however\n since that time levophed/neo have been d/c and acid base balance has\n largely normalized.\n Overnight pt attempted to pull @ lines/tubes managing to pull out OGT,\n sedation changed from bolus to gtt, OGT reinserted and the pt rested\n comfortably for the remainder of the shift. Stool sent as pt has a hx\n of Cdiff and has been having liquid brown stools. CT of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely poor\n Action:\n Renal consult\n Response:\n Consult recommendation in chart no HD @ this time may require HD should\n renal function fail to improve\n Plan:\n Cont to monitor urine output, repeat U/A tomorrow .Renal to follow\n closely.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Afib w/ transient sinus beats\n Action:\n Digoxin loading completed overnight, Team ordered a x 1 PO dose of\n digoxin for the morning of no standing dose orders @ this time\n Response:\n HR/BP remained wnl in the absence of all vasoactive meds\n Plan:\n Follow up with maintenance dig.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remained off pressors throughout shift, however urine output remains\n very poor\n Action:\n D5\n NS maintenance gtt @ 100cc/hr initiated, cont abx tx.\n Response:\n No change in U/O, remained afebrile, leukocytosis appears to have\n resolved\n Plan:\n Cont abx tx, renal dose all meds, wean vent as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317874,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical/renal CA, who presented on w/\n L hip pain x 3 days in the setting of leukocytosis and acute renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation however\n since that time levophed/neo have been d/c and acid base balance has\n largely normalized.\n Overnight pt attempted to pull @ lines/tubes managing to pull out OGT,\n sedation changed from bolus to gtt, OGT reinserted and the pt rested\n comfortably for the remainder of the shift. Stool sent as pt has a hx\n of Cdiff and has been having liquid brown stools. CT of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely poor\n Action:\n Renal consult\n Response:\n Consult recommendations are in the chart, no HD @ this time however\n may require HD should renal function fail to improve\n Plan:\n Cont to monitor urine output, repeat U/A tomorrow .Renal to follow\n closely.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Afib w/ transient sinus beats\n Action:\n Digoxin loading completed overnight, Team ordered a x 1 PO dose of\n digoxin for the morning of no standing dose orders @ this time\n Response:\n HR/BP remained wnl in the absence of all vasoactive meds\n Plan:\n Follow up with maintenance dig.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remained off pressors throughout shift, however urine output remains\n very poor\n Action:\n D5\n NS maintenance gtt @ 100cc/hr initiated, cont abx tx.\n Response:\n No change in U/O, remained afebrile, leukocytosis appears to have\n resolved\n Plan:\n Cont abx tx, renal dose all meds, wean vent as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317875,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical/renal CA, who presented on w/\n L hip pain x 3 days in the setting of leukocytosis and acute renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation however\n since that time levophed/neo have been d/c and acid base balance has\n largely normalized.\n Overnight pt attempted to pull @ lines/tubes managing to pull out OGT,\n sedation changed from bolus to gtt, OGT reinserted and the pt rested\n comfortably for the remainder of the shift. Stool sent as pt has a hx\n of Cdiff and has been having liquid brown stools. CT of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/O remains extremely poor\n Action:\n Renal consult\n Response:\n Consult recommendations are in the chart, no HD @ this time however\n may require HD should renal function fail to improve\n Plan:\n Cont to monitor urine output, repeat U/A tomorrow .Renal to follow\n closely.\n Atrial fibrillation (Afib)\n Assessment:\n Remains in Afib w/ transient sinus beats\n Action:\n Digoxin loading completed overnight, Team ordered a x 1 PO dose of\n digoxin for the morning of no standing dose orders @ this time\n Response:\n HR/BP remained wnl in the absence of all vasoactive meds\n Plan:\n Follow up with maintenance dig.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Remained off pressors throughout shift, however urine output remains\n very poor\n Action:\n D5\n NS maintenance gtt @ 100cc/hr initiated, cont abx tx.\n Response:\n No change in U/O, remained afebrile, leukocytosis appears to have\n resolved\n Plan:\n Cont abx tx, renal dose all meds, wean vent as tolerated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318105,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Tubular\n LUL Lung Sounds: Tubular\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt placed on A/C overnight for worsening ABG\nS.Rested on A/C. Unable to\n do RSBI this AM due to no spont resp. Will cont to monitor resp status.\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318255,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n Lung Sounds: Diminished\n RUL Lung Sounds: Tubular\n LUL Lung Sounds: Tubular\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: rsbi DONE ON 0 PEEP/ 5IPS 21.\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318207,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg\ns improved on a/c. minimal amt of secretions.\n Action:\n Placed on ps of \n Response:\n Abg\ns sent at 18:30pm\n Plan:\n Would rest overnight on a\n/c and return to ps in am\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Renal failure slowly improving.\n Action:\n No further fluid boluses. Off levophed.\n Response:\n u/o\ns 30-50cc/hr. urine clear.\n Plan:\n Cont to monitor u/o\n Urinary tract infection (UTI)\n Assessment:\n resolving\n Action:\n On zosyn\n Response:\n Wbc\ns slightly elevated today.\n Plan:\n Continue antibiotics.\n .H/O sepsis without organ dysfunction\n Assessment:\n Off sedation/ bp improved to 140\ns. / pt. slightly responsive this am.\n Presently not responsive to family. , but responds to stimuli such as\n suctioning. And oral care. Nodded appropriately this am. Cvp 2-8. ho\n aware.\n Action:\n Levophed off since the am.\n Response:\n Bp within normal limits.\n Plan:\n fluid boluses for hypotension.\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt. grimaces with turning. Ortho into see pt.. he felt pain could have\n been d/t sepsis.\n Action:\n Fentynl restarted at 25mcqs this am and lido patch applied. Bone scan\n done today.\n Response:\n Pt. nodded that she didn\nt have pain.\n Plan:\n Awaiting results of scan\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318295,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca who\n presented with L hip pain and hypotension, in ICU with pseudomonal\n urosepsis c/b Afib/RVR, ARF (ATN) and respiratory failure\n 24 Hour Events:\n tolerated PS X 5 hrs and rested on ACV overnight, now on PS 12/5\n lasix 40 IV X 1 given with increased u/o\n bone scan negative for hip lesion\n History obtained from housestaff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Fentanyl - 20 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:30 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 76 (67 - 92) bpm\n BP: 106/35(58) {96/32(53) - 154/58(90)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 10 (2 - 12)mmHg\n Total In:\n 1,068 mL\n 599 mL\n PO:\n TF:\n 470 mL\n 411 mL\n IVF:\n 258 mL\n 78 mL\n Blood products:\n Total out:\n 510 mL\n 452 mL\n Urine:\n 510 mL\n 452 mL\n NG:\n Stool:\n Drains:\n Balance:\n 558 mL\n 147 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (363 - 410) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 21\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.37/37/136/22/-3\n Ve: 6.4 L/min\n PaO2 / FiO2: 453\n Physical Examination\n General Appearance: Well nourished, No acute distress, edematous\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender:\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 51 K/uL\n 132 mg/dL\n 2.9 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 65 mg/dL\n 111 mEq/L\n 140 mEq/L\n 27.4 %\n 7.8 K/uL\n [image002.jpg]\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n WBC\n 14.7\n 7.8\n Hct\n 28.9\n 27.4\n Plt\n 72\n 51\n Cr\n 3.0\n 3.1\n 2.9\n TCO2\n 21\n 22\n 21\n 21\n 22\n 24\n 22\n Glucose\n 127\n 161\n 132\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Imaging: R effusion (+ chronic rll changes psot pleurodesis) ET /line\n ok, no change\n bone scan negative for hip lesion\n Microbiology: blood ngtd\n sputum + yeast\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, in ICU with pseudomonal urosepsis c/b\n Afib/RVR, ARF (ATN) and respiratory failure\n Overall improving, volume status and underlying severe AS complicating\n wean\n Active issues remains:\n >Respiratory failure\ndoing well on vent with improved acidosis but is\n total body volume up and will need to diurese prior to extubation\n continue PS wean and follow abg, w/ hope to extubate in next\n 1-2 days after additional diuresis\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine, start thiazide and lasix (goal 500-1 L as BP\n tolerates)\n Continue phos binder and renal dosing of emds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis,\n improving\n Complete zosyn X 14 day course\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n needs to mobilize fluids prior to extubation though recently\n hypotensive as has preload dependence from AS also in setting of\n positive pressure\n Starting to autodiurese and will give lasix and thiazide today\n ATRIAL FIBRILLATION (AFIB)-\n Continue dig\n Daily stoke risk low and would not anticoagulate at this time given\n low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration and now likely at\n baseline, dic labs negative and HUS/TTP unlikely, follow for further\n reduction from baseline, continue heparin products for now given low\n suspicion for HIT\n > anemia- h/h now stable, transfuse for < 21 or active bleed or if\n hypotension\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:51 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318645,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR all noc. HR low 50s-70s, freq pacs, occ pvcs w couplets.\n SBP 90s-100s.\n Action:\n Metoprolol increased to 25mg .\n Response:\n HR dropped to 50s during sleep following Metoprolol.\n Plan:\n Monitor HR, BP, response to metoprolol.\n Delirium / confusion\n Assessment:\n Oriented x2 to person and place, but episodes of confusion. Very\n sleepy most of noc, complains whenever touched or turned to leave her\n alone. Grimaces w any movement but not able to articulate where pain\n is, says\nI have arthritis all over\n Action:\n Held night dose of Olanzapine due to sleepiness. Tylenol q6hrs.\n Response:\n Slept most of noc. Talking when awakened but lethargic.\n Plan:\n Olanzapine dose reduced for day shift, ? if will require it. Monitor\n for pain. Reorient pt when awake.\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 317878,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation YES.\n Procedure location: ICU\n Reason: Bougie used for intubation\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Dysynchrony assessment:\n Comments: Biting ETT at times\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n RSBI deferred due to no spontaneous respirations at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318280,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n tolerated PS X 5 hrs and rested on ACV overnight, now on PS 12/5\n lasix 40 IV X 1 given with increased u/o\n bone scan negative for hip lesion\n History obtained from housestaff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Fentanyl - 20 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 06:30 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 76 (67 - 92) bpm\n BP: 106/35(58) {96/32(53) - 154/58(90)} mmHg\n RR: 19 (8 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 10 (2 - 12)mmHg\n Total In:\n 1,068 mL\n 599 mL\n PO:\n TF:\n 470 mL\n 411 mL\n IVF:\n 258 mL\n 78 mL\n Blood products:\n Total out:\n 510 mL\n 452 mL\n Urine:\n 510 mL\n 452 mL\n NG:\n Stool:\n Drains:\n Balance:\n 558 mL\n 147 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 410 (363 - 410) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 21\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.37/37/136/22/-3\n Ve: 6.4 L/min\n PaO2 / FiO2: 453\n Physical Examination\n General Appearance: Well nourished, No acute distress, edematous\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic, No(t)\n Diastolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender:\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 51 K/uL\n 132 mg/dL\n 2.9 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 65 mg/dL\n 111 mEq/L\n 140 mEq/L\n 27.4 %\n 7.8 K/uL\n [image002.jpg]\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n WBC\n 14.7\n 7.8\n Hct\n 28.9\n 27.4\n Plt\n 72\n 51\n Cr\n 3.0\n 3.1\n 2.9\n TCO2\n 21\n 22\n 21\n 21\n 22\n 24\n 22\n Glucose\n 127\n 161\n 132\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Imaging: R effusion (chronic changes) ET line ok, no change\n bone scan negative\n Microbiology: blood ngtd\n sputum + yeast\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, in ICU with pseudomonal urosepsis c/b\n Afib/RVR, ARF (ATN) and respiratory failure\n Overall improving, volume status and underlying severe AS complicating\n wean\n Active issues remains:\n >Respiratory failure\ndoing well on vent with improved acidosis but is\n total body volume up and will need to diurese prior to extubation\n diurese, continue PS wean and follow abg, w/ hope to extubate in\n next 1-2 days\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis,\n improving, suspect recurrent hypotensive episode overnight may have\n been secondary to volume shifts,\n Continue zosyn X 14 day course\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n needs to mobilize fluids prior to extubation though recently\n hypotensive as has preload dependence from AS also in setting of\n positive pressure\n Starting to autodiurese and will give lasix and thiazide today\n ATRIAL FIBRILLATION (AFIB)-\n Continue dig\n Daily stoke risk low and would not anticoagulate at this time given\n low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n atn from sepsis and hypotension\n cr peaked/palteuad and now with increasing u/o--will likely start\n to auto-diurese and start thiazide and lasix (goal 500-1 L as BP\n tolerates)\n continue phos binder\n all meds renally dosed\n > thrombocytopenia--on review of records, baseline thrombocytopenia in\n 50-70 range, with initial elevation here likely from hemoconcentration\n and now likely at baseline, dic labs negative and HUS/TTP unlikely,\n follow for further reduction from baseline, continue heparin products\n for now given low suspicion for HIT\n > anemia- h/h now stable, likely component of hemodilution,\n transfuse for < 21 or active bleed or if hypotension\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n > Hip pain--dose not seem source of infection but given her significant\n pain concern for some lytic lesion/fx or micro fx or bony mets-- bone\n scan negative\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:51 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318370,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Expectorated / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n PT EXTUBATED THIS EVENING TO 50% COOL AEROSOL TOL WELL WITH SPO2\n 98-99%. GOOD CUFF LEAK ALSO NOTED PRIOR TO EXTUBATION. WILL CONT TO\n MONITOR FOR S/S FATIGUE.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318372,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca who\n presented with L hip pain and hypotension, in ICU with pseudomonal\n urosepsis c/b Afib/RVR, ARF (ATN) and respiratory failure\n 24 Hour Events:\n metolazone and lasix with good response\n abg stable on PS 5 and 5 this am\n RSBI 53\n History obtained from Family / Friend, house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 11:33 AM\n Infusions:\n Fentanyl - 20 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:30 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:36 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 68 (67 - 114) bpm\n BP: 108/32(56) {101/32(56) - 174/62(101)} mmHg\n RR: 19 (8 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 15 (4 - 15)mmHg\n Total In:\n 1,203 mL\n 453 mL\n PO:\n TF:\n 841 mL\n 345 mL\n IVF:\n 252 mL\n 78 mL\n Blood products:\n Total out:\n 1,532 mL\n 1,550 mL\n Urine:\n 1,532 mL\n 1,550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -329 mL\n -1,097 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 428) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 53\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.37/45/129/23/0 on PS()\n Ve: 6.4 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, elderly\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: 2+, Left: 2+, Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, Sedated,\n Tone: Decreased\n Labs / Radiology\n 8.6 g/dL\n 47 K/uL\n 144 mg/dL\n 3.1 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 69 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n WBC\n 14.7\n 7.8\n 7.4\n Hct\n 28.9\n 27.4\n 26.6\n Plt\n 72\n 51\n 47\n Cr\n 3.1\n 2.9\n 3.1\n TCO2\n 21\n 21\n 22\n 24\n 22\n 25\n 27\n Glucose\n 161\n 132\n 144\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr--increased in r hemidiapragm elevation, with known\n chrionic changes from pelurodesis\n Microbiology: no new micro\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, in ICU with pseudomonal urosepsis c/b\n Afib/RVR, ARF (ATN) and respiratory failure\n Overall improving, volume status and underlying severe AS complicating\n wean, though has been diuresing well\n Active issues remains:\n > Respiratory failure\ndoing well w/ minimal vent support, alert and\n following commands, rsbi 50's and diuresing nicely. CXR essentially\n stable with chronic changes at R base (h/o R pleurodesis)\n Check abg on PS 5/5 and if remains stable would extubate.\n Consider trial of NPPV if problems with oxygenation/chf post\n extubation\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine\n Continue thiazide and lasix (goal 500-1 L negative as BP\n tolerates)\n Continue phos binder and renal dosing of meds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis,\n resolved\n Complete zosyn course day \n Repeat ucx for surveillance though clinically improved\n Remains af with normal wbc ct\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP stable\n continue diuresis\n ATRIAL FIBRILLATION (AFIB)-\n appears nsr now with ectopy\n check 12 lead\n Continue dig\n Daily stoke risk low and would not anticoagulate at this time given\n low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration and now appears at\n baseline, dic labs negative and HUS/TTP unlikely, follow for further\n reduction from baseline, continue heparin products for now given low\n suspicion for HIT, recheck plt later today given slight decrease from\n 51-47\n > anemia- h/h now stable, transfuse for < 21 or active bleed or if\n hypotension\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n Hip pain--dose not seem source of infection, given pain have\n further evaluated with bone scan which was negative,\n Continue lido patch, readdress pain level once extubated\ndilaudid or\n tylenol once fent gtt is of\n ICU Care\n Nutrition:\n Comments: NPO pending extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Comments: plan to place peripherals and d/c lines tomorrow\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318637,
"text": "Impaired Skin Integrity\n Assessment:\n Coccyx wound appears to be status quo.\n Action:\n Dressing changed this morning minimal serosang drainage, no odor.\n Turned and positioned q2hour, pt remains on kinair bed to prevent\n further breakdown. Perineum remains excoriated and fungal rash\n persists, cont to cleanse w/foaming soap and w/3^rd cleansing applying\n thin layer of antifungal barrier cream.\n Response:\n No change in skin integrity.\n Plan:\n Cont w/plan of care as outlined by wound care RN\n Atrial fibrillation (Afib)\n Assessment:\n HR 60-80s, appears to be in SR w/occasional APC and VPCs including\n couplets. B/p appears stable\n Action:\n 12.5mg lopressor PO given this morning, no afib noted w/RVR\n Response:\n HR appears undercontrol\n Plan:\n Increased lopressor to 25mg , receive 1^st 25mg this evening,\n cont to monitor response. Continue to crush pills and place in either\n jello or pudding, maintaining aspiration precautions. Pt ate well at\n lunch and dinner when fed, ate at least\n to\n of her meals. Sat\n upright at least 45minutes after eating to prevent aspiration.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317965,
"text": "Shock, cardiogenic\n Assessment:\n ABP 88-116/33-45; CVP 9-13\n Action:\n IVF bolus LR 500cc X2 given for map <60\n Response:\n ABP improved to 100\ns/40\ns with maps >60 but lasted only 4-5hrs then\n required 2^nd bolus.\n Plan:\n Monitor ABP, give IVF boluses slowly due to aortic stenosis for map <60\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Urine output 10-30cc/hr with 24hr fluid balance +2L; creatinine 2.8,\n down from 2.9 yesterday; 1600 labs pending.\n Action:\n IVF boluses, phoslo, meds renally dosed.\n Response:\n Fluid status is 2L positive; hands, arms and legs have + edema;\n Creatinine from 1600 pending.\n Plan:\n Continue to renally dose meds, monitor fluid status and BUN/Cr.\n Urinary tract infection (UTI)\n Assessment:\n +pseudomonas in urine.\n Action:\n Continues on zosyn/vanco IV.\n Response:\n Afebrile, no longer acidotic\n Plan:\n Continue antibiotics as ordered, follow cultures/sensitivities, ID\n recs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Sedated on fent 25mcg/midaz 1mg.\n Action:\n Lidocaine patch in place L hip, boluses of fentanyl given when turned.\n Response:\n Pt resting with eyes closed at rest, grimaces when turned side to side.\n Plan:\n Continue sedation, ortho consult to r/o septic joint\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318036,
"text": "Chief Complaint: respi failure, urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ULTRASOUND - At 11:30 AM of porta cath\n SPUTUM CULTURE - At 05:37 AM\n STOOL CULTURE - At 05:37 AM\n now with 2 colonies GNR in urine--liekly 2 speicies speudomona\n bolusd with LR for MAP in 50's with good response,\n slightly alkalosits so RR on vent decreased\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:39 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.7\nC (96.3\n HR: 71 (65 - 80) bpm\n BP: 112/41(65) {92/34(54) - 130/49(78)} mmHg\n RR: 17 (9 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 6 (5 - 232)mmHg\n Total In:\n 2,864 mL\n 430 mL\n PO:\n TF:\n 193 mL\n IVF:\n 2,724 mL\n 87 mL\n Blood products:\n Total out:\n 309 mL\n 60 mL\n Urine:\n 309 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,555 mL\n 370 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 271 (271 - 271) mL\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 13 cmH2O\n Plateau: 20 cmH2O\n SpO2: 100%\n ABG: 7.34/44/116/19/-2\n Ve: 6.1 L/min\n PaO2 / FiO2: 387\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :\n upper BS, Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Unresponsive, Movement: Not assessed, Sedated,\n Tone: Normal\n Labs / Radiology\n 8.6 g/dL\n 56 K/uL\n 99 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 62 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.7 %\n 10.9 K/uL\n [image002.jpg]\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n 04:00 PM\n 06:59 PM\n 05:17 AM\n 05:39 AM\n 10:07 AM\n WBC\n 10.6\n 12.7\n 10.9\n Hct\n 26.2\n 25.1\n 26.7\n Plt\n 66\n 56\n 56\n Cr\n 2.8\n 2.8\n 2.9\n 2.9\n TCO2\n 19\n 21\n 20\n 21\n 20\n 25\n Glucose\n 104\n 106\n 120\n 99\n Other labs: PT / PTT / INR:13.4/35.9/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.0\n mg/dL, Mg++:2.1 mg/dL, PO4:3.9 mg/dL\n Imaging: cxr high (decrease by 2 cm)\n R basilar opactiry (chronic--from pleuraodesis), efusion b/l, R line in\n place\n Microbiology: blood and sputum ngtd, rinu with pan \n pseudomonas--second species pending\n c diff pending pending ( 2 X neg)\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca in ICU for\n urosepsis with Afib/RVR, hypotension, ARF and delirium, intubated for\n worsening acidosis and airway protection, now improving\n > Respiratory failure--overall volume up and will need to diruese some\n before extubation, may eneter autodiuresis phase of atn soon as now\n making urine--would watch fu/o, try gentel duriesis alter with goal of\n negative prior to extubation, would continue PS and lighten\n sedation/SBT in am\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-most liekly source is\n pseudomonas urosepsis also possible aspiration pna though clinically\n requiring minimal o2 and does have hx/o pelurodesis\n wbc trending down, hemodynamically stable, prota cath without\n fluid by u/s and low suspciaon of seeding given GNR\n L hip pain remains problem though now less liekly\n lower suspicion of septic bursitis, ortho following and\n await additonal recs as fx possibiloity\n Given no gram positives in blood and current clinical\n improvement, lower suspicion of seeded portacath\nwill check u/s for\n fluid collection\n Continue zosyn and f/u cx results\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension, now rate controlled\n BP improved and stable off of pressors, cvp difficult to follow given\n severe AS, lactates normalized\n Treating underlying infection as above\n ontinues on dig--monitor levels given renal failure\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n atn from sepsis and hypotension\n cr appears to have peaked and now making some uringe--wiol liekly\n start to autodiurese, consider diruesis\n renal following, continue phos binder all meds renally dosed\n urine eos neg, complement pending,\n > Leukocytosis\nnormalizing\n check C diff\n d/c vanco\n continue zosyn for pseudomonas\n cliincally improving and highest suspicion remains of\n urosepsis\n > thrombocytopenia--on review of records baseline thrombocytopenia in\n 50-70 range, with initial elevation here likely from hemoconcentration,\n dic labs negative and HUS/TTP unlikely, check smear, component of\n hemodilution likely with aggressive fluids and now at baseline--follow\n for further reduction from baseline, continue heparin products for now\n given low suspicion for HIT\n > anemia- h/h now stable, likely component iof hemodilution,\n transfuse for < 21 or active bleed or if hypotension\n ATRIAL FIBRILLATION (AFIB)--now rate controlled, on dig, responsive\n to IVFs but would avoid calcium channel blockers in setting of RVR\n given severe AS,\n Would not anticoagulate at this time given new drop in hct and\n plts (suspect hemodilution), though would reassess as clinical picutre\n improes as may remain in chromnic fib, daily stoke risk extremely\n low\n AORTIC STENOSIS--severe, preload dependent,\n URINARY TRACT INFECTION (UTI)--pseudomonas, pan sensitive--continue\n zosyn as above X 14 day course\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additonal oncological hx\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) fent and versed for sedation\n on vent\n > Hip pain--dose not seem source of infection but given her significant\n pain concern for some lytic or bone invovlement--consider bone scan\n possible mri\n > Diarrhea--wbc trending down, c diff neg X 2 with third pending\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 AM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318052,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:30 AM\n SPUTUM CULTURE - At 05:37 AM\n STOOL CULTURE - At 05:37 AM\n -- Two colonies of GNR, likely both pseudo per ID, no change in abx\n -- Ordered sputum cx from ET given concerning opacity\n -- pressures low, MAP of 50, gave 500cc LR, and appropriate response\n -- ABG w/ increasing alkalosis, decreased frequency on vent\n Pt comfortable on the vent, no grimacing, not responding to commands\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:39 AM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.5\nC (95.9\n HR: 70 (65 - 87) bpm\n BP: 106/35(58) {92/34(54) - 119/45(69)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 194 (5 - 261)mmHg\n Total In:\n 2,864 mL\n 258 mL\n PO:\n TF:\n 94 mL\n IVF:\n 2,724 mL\n 74 mL\n Blood products:\n Total out:\n 309 mL\n 40 mL\n Urine:\n 309 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,555 mL\n 218 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.41/31/195/19/-3\n Ve: 7.1 L/min\n PaO2 / FiO2: 650\n Physical Examination\n GEN: Intubated, NAD, not responding to commands\n CV: irreg/irreg gr 2-3 SEM over LSB, no radiation\n RESP: CTAB, BS at bases, moving air well\n ABD: BS present, not distended but more tense than baseline, no\n grimacing to palp\n EXTR: 2+ pitting edema bilaterally\n Labs / Radiology\n Left Chest U/S- no evidence of abscess\n Chest Portable :\n FINDINGS: In comparison with the study of , there is little overal\n l\n change. Extensive bilateral pleural effusions persist, much more promi\n nent on\n the right. Various tubes remain in place. Specifically, the endotrach\n eal\n tube is about 4.6 cm above the carina.\n 56 K/uL\n 8.6 g/dL\n 99 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 62 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.7 %\n 10.9 K/uL\n [image002.jpg]\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n 04:00 PM\n 06:59 PM\n 05:17 AM\n 05:39 AM\n WBC\n 12.8\n 10.6\n 12.7\n 10.9\n Hct\n 27.7\n 26.2\n 25.1\n 26.7\n Plt\n 76\n 66\n 56\n 56\n Cr\n 2.8\n 2.8\n 2.8\n 2.9\n 2.9\n TCO2\n 19\n 21\n 20\n 21\n 20\n Glucose\n 133\n 104\n 106\n 120\n 99\n Other labs: PT / PTT / INR:13.4/35.9/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.0\n mg/dL, Mg++:2.1 mg/dL, PO4:3.9 mg/dL\n Sputum pending, C. Diff neg x 2, third C. Diff pending\n Blood Cx NGTD\n Urine Cx 2 diff GNR species\n Urine Cx + pseudomonas pan sensitive\n ABG this am on pH 7.34/44/116\n Assessment and Plan: 86 y/o F with PMHx of severe AS & CHF with EF 45%,\n renal cell & ovarian Ca p/w Left hip pain, adm for presumed urosepsis\n on pressors. Intubated on for worsening acidosis, oliguric renal\n failure, hemodynamic instability to Afib with RVR and MS changes.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Source of infection presumed\n to be urosepsis with positive UA growing out pan sensitive\n Pseudomonas. Pt clinically deteriorated on with worsening\n acidosis/MS changes and was intubated. Pressors were weaned\n immediately and pt has been maintaining MAPs with occais 500cc\n boluses. WBC ct trended down and acidosis resolved on minimal vent\n settings. L chest U/S was neg for abscess, CT was unrevealing for addl\n infectious sources.\n - ID consult, 2^nd GNR in Ucx likely pseudomonas\n - continue Zosyn for coverage of pseudomonas, d/c Vancomycin today as\n there is no e/o line infection.\n - ortho consult for L hip pain, unconcerned for L hip as source of\n infection\n - continue to f/u blood & urine cultures\n - bolus prn to maintain Maps>65\n SHOCK, CARDIOGENIC: resolved, pt with severe AS & CHF with EF 45%\n developed Afib with RVR and became hypotensive on . Pressure\n responded to IVF & pressors. Pt was then Intubated and pressors\n weaned. Pt still in/out of Afib but HR has been much better controlled\n on digoxin.\n - dig level 1.4 this am, will continue Digoxing 0.125mg every other day\n - avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n low, will reconsider in am\n - fluid bolus prn to maintain maps>60\nRESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR shows bilateral effusions & pulm edema. CT showed\n possible airspace disease in , have been aspiration\n peri-intubation. Afebrile, WBC ct trending down, this is unlikely a\n new PNA\n - wean vent settings to today, repeat ABG in pm\n - f/u RSBI in am, possible extubation in 24-48hrs\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Urine sediment filled with WBCs, no e/o casts. Creatinine appears to\n have plateaued and pt having increased UOP overnight. Renal\n recs, there is no acute indication for dialysis. Acidosis resolved on\n vent, unclear if metabolic acidosis leading to intubation was all \n uremia. renal recs- C3 low, C4 normal, urine eos negative.\n - avoid continuous IVF given poor UOP\n - renally dose all meds\n - continue phoslo TID & check lytes \n AORTIC STENOSIS: AS with valve area of 0.7cm, very preload\n dependant. Gentle bolus IVF prn to maintain MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Vanc/Zosyn for coverage\n THROMBOCYTOPENIA: Stable at pts baseline. Monitoring daily.\n LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation. CT neg for joint effusion. Consider f/u MRI.\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin 5000u sc TID\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318254,
"text": "Chief Complaint:\n 24 Hour Events:\n - BP stable off pressors, no bolus requirement\n - UOP adequate, still net positive\n - tolerated for 5 hrs, ABGs improved\n - admin Lasix 40mg IV this am\n Pt intubated, sedated, opening eyes but only intermittently responding\n to commands.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 35.9\nC (96.6\n HR: 74 (67 - 92) bpm\n BP: 132/39(69) {96/32(53) - 154/58(90)} mmHg\n RR: 16 (8 - 21) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 9 (2 - 12)mmHg\n Total In:\n 1,068 mL\n 306 mL\n PO:\n TF:\n 470 mL\n 220 mL\n IVF:\n 258 mL\n 66 mL\n Blood products:\n Total out:\n 510 mL\n 45 mL\n Urine:\n 510 mL\n 45 mL\n NG:\n Stool:\n Drains:\n Balance:\n 558 mL\n 261 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 363 (363 - 405) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n SpO2: 100%\n ABG: 7.37/37/136/22/-3\n Ve: 7.7 L/min\n PaO2 / FiO2: 453\n Physical Examination\n GEN: NAD, intubated, opening eyes to commands\n HEENT: swollen, edematous face\n CV: irreg/irreg gr 3 SEM over LSB\n RESP: crackles bilaterally at bases, no w/r\n ABD: soft,NT/ND/NABS\n Extr: 2+ pitting edema bilaterally\n Labs / Radiology\n BONE\n SCAN: No scintigraphic evidence of hip metastasis or pathologic fractur\n e.\n Portable CXR:\n FINDINGS: In comparison with study of , there is no change in the\n appearance of the endotracheal and nasogastric tubes and central venous\n catheter and Port-A-Cath. No change in the appearance of the\n cardiomediastinal silhouette. Large right and smaller left pleural eff\n usions\n persist. No evidence of acute focal pneumonia.\n IMPRESSION: Little change.\n 51 K/uL\n 8.7 g/dL\n 132 mg/dL\n 2.9 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 65 mg/dL\n 111 mEq/L\n 140 mEq/L\n 27.4 %\n 7.8 K/uL\n [image002.jpg]\n 05:21 PM\n 05:48 PM\n 10:31 PM\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n WBC\n 14.7\n 7.8\n Hct\n 28.9\n 27.4\n Plt\n 72\n 51\n Cr\n 3.0\n 3.1\n 2.9\n TCO2\n 21\n 22\n 21\n 21\n 22\n 24\n 22\n Glucose\n 127\n 161\n 132\n Other labs: PT / PTT / INR:12.9/33.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n C Diff negative x 4, Blood Cx NGTD\n Urine Culture + Pseudomonas pan sensitive\n Sputum Culture + yeast\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis and\n MS changes.\n .\n #SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): etiology presumed urosepsis\n with positive UA growing out pan sensitive Pseudomonas, now day 6 of\n Zosyn. Pt is s/p Intubation on for worsening acidosis/MS\n changes. Pt had transient hypotension with worsening acidosis on ABGs\n intermittently requiring pressors. No recurrence of hypotension\n since. Etiology of acidosis/hypotension unclear, possibly due to\n uremia, NS resussitation and preload dependance. Further infectious\n work up neg to date, L chest U/S neg for abscess, CT unrevealing. Bone\n scan negative.\n - ID consult, continue Zosyn day \n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n - gentle bolus of 250 LR prn to maintain Maps>65\n - will repeat cultures if any recurrence of hypotension\n .\n #SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib\n with RVR and became hypotensive on . Pressure responded to IVF &\n pressors. Pt was intubated and pressors weaned. Pt has been in/out of\n Afib but HR better controlled on digoxin. Transient hypotension on\n , did not respond to bolus, required pressors approx 5hrs. This\n was likely due to severe AS and preload dependance but concern for\n ongoing sepsis. Extravascular volume overload and complicated fluid\n balance, goal of net even to negative i/os.\n - continue Digoxing 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - fluid bolus 250cc LR prn to maintain maps>60\n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR shows bilateral effusions & pulm edema. CT showed\n possible airspace disease in , have been aspiration\n peri-intubation. WBC ct down, it is unlikely that this due to a new\n PNA, but will reculture and broaden Abx if pt clinically deteriorates.\n Pulm edema and extravascular volume overload may be a barrier to\n extubation. Goal to run i/os even to neg.\n - tolerated well for 5hrs o/n. ABGs show normal acid base status,\n oxygenating & ventilating well.\n - f/u RSBI in am, possible extubation over weekend\n .\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Urine sediment filled with WBCs, no e/o casts. Creatinine improved &\n having increased UOP. Acidosis improved on vent with AC, unclear if\n metabolic acidosis leading to intubation was uremia vs NS\n resussitation. renal recs, admin Lasix 40mg IV this am to\n attempt diuresis\n - monitor i/os, goal net negative 500cc\n - renally dose all meds\n - continue phoslo TID\n .\n # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant\n & delicate fluid balance. Gentle bolus with 250cc LR prn to maintain\n MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n .\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n # LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:51 AM 35 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin sc TID\n Stress ulcer: H2 blocker\n VAP: Chlorhexidine\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317683,
"text": "Chief Complaint: Urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86F with hx RCC, presented to ED with hip pain. Found to be in shock,\n with positive UA.\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 07:04 PM\n PRESEP CATHETER - START 07:05 PM\n Started Zosyn\n 6.6L NS\n Levophed, now tapering\n Converted to AF (new)\n Oliguric\n Renal U/S prelim no perinephric abscess/pyelo\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:23 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n Currently complaining of chills, nausea\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Edema, Tachycardia, af\n Gastrointestinal: Nausea, Emesis\n Genitourinary: Foley, oliguria\n Musculoskeletal: Joint pain\n Flowsheet Data as of 09:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.5\nC (95.9\n HR: 89 (69 - 89) bpm\n BP: 120/48(66) {80/34(46) - 127/57(70)} mmHg\n RR: 14 (9 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm), AF (Atrial Fibrillation)\n CVP: 21 (0 - 21)mmHg\n SvO2: 78%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 1,955 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 1,955 mL\n Blood products:\n Total out:\n 383 mL\n 123 mL\n Urine:\n 83 mL\n 123 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 1,832 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.24/55/139/26/-4\n Physical Examination\n General Appearance: Thin, Anxious\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Abdominal: Soft, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.1 g/dL\n 121 K/uL\n 89 mg/dL\n 2.4 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 58 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.9 %\n 24.5 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n WBC\n 20.6\n 24.5\n Hct\n 30\n 31.6\n 32.9\n Plt\n 83\n 121\n Cr\n 2.3\n 2.4\n TropT\n 0.11\n 0.12\n TCO2\n 25\n Glucose\n 147\n 89\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:45/9/0.12, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:2.0 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI)\n - Continue Zosyn, add additional gram negative coverage (will d/w ID)\n - Follow up culture data\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Likely GU source, but\n portacath and hip are also very possible sources. Currently on\n Levophed, clinically requires additional fluid challenge.\n - Broaden GNR coverage (as above), also add Vanco for gram positives.\n - Place A-line for hemodynamic monitoring\n - Will consider further imaging of hip\n - Fluid boluses\n - Consider dobutamine if SVO2 remains low\n * Afib: new, likely related to acute illness, levophed\n - Attempt to wean levophed\n - Hold off on anticoag for now\n - Obtain 12-lead EKG\n - Cycle cardiac enzymes\n * Nausea/vomiting: be related to dilaudid, ruling out cardiac\n etiology\n - Zofran PRN\n - Cycle enzymes\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n CANCER (MALIGNANT NEOPLASM), OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317763,
"text": "Briefly this is an 86 y/o F w/ PMH significant for ovarian CA,CRI\n (baseline CR 1.8) chronic UTI (on keflex @ home), R hip replacement,\n who presented to the ED on complaining of new onset L hip pain x 3\n days. While in the ED became hypotensive to 70s systolic in the\n setting of a positive U/A and elevated WBC code sepsis called, central\n line placed, levophed initiated and was transferred to the M/SICU for\n further management of ? urosepsis.\n Urine output remains extremely low overnight, team is aware, became\n hypotensive to 80 systolic s/p .5mg IVP dilaudid for L hip pain. Unable\n to wean levophed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Cr continues to trend up, urine output extremely low\n Action:\n Foley irrigated easily, no evidence of obstruction found, Renal U/S\n from unremarkable\n Response:\n U/O remains <5cc/hr\n Plan:\n ? ATN from hypotensive episode, cont to monitor, renal consult may be\n beneficial.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317764,
"text": "Briefly this is an 86 y/o F w/ PMH significant for ovarian CA,CRI\n (baseline CR 1.8) chronic UTI (on keflex @ home), R hip replacement,\n who presented to the ED on complaining of new onset L hip pain x 3\n days. While in the ED became hypotensive to 70s systolic in the\n setting of a positive U/A and elevated WBC code sepsis called, central\n line placed, levophed initiated and was transferred to the M/SICU for\n further management of ? urosepsis.\n Urine output remains extremely low overnight, team is aware, became\n hypotensive to 80 systolic s/p .5mg IVP dilaudid for L hip pain. Unable\n to wean levophed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Cr continues to trend up, urine output extremely low\n Action:\n Foley irrigated easily, no evidence of obstruction found, Renal U/S\n from unremarkable\n Response:\n U/O remains <5cc/hr\n Plan:\n ? ATN from hypotensive episode, cont to monitor, renal consult may be\n beneficial.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n On levophed gtt @ .1mcg/kg/min, SVO monitor setup however SQI is 4, WBC\n 33 on AM labs pending @ this time, remains afebrile\n Action:\n Multiple attempts to wean levophed gtt were unsuccessful, Abx per\n orders\n Response:\n Remains on .1mcg/kg/min\n Plan:\n Titrate levophed gtt, trend WBC, broaden Abx coverage as necessary\n Urinary tract infection (UTI)\n Assessment:\n Culture from pos for pseudomonas\n Action:\n Cont on zosyn, vanco not recommended @ this time as pt remains in renal\n failure\n Response:\n Plan:\n Cont to monitor\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Moderate to severe L hip pain, exacerbated by repositioning\n Action:\n .5mg IVP dilaudid q 4hrs\n Response:\n Became hypotensive to 80 systolic immediately after administration,\n however pain relieved for approx 4 hours and was able to rest\n comfortably.\n Plan:\n MRI of L hip planned for this AM however pt remains on levophed so\n imaging remains unlikely, cont to medicate prn.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317765,
"text": "Briefly this is an 86 y/o F w/ PMH significant for ovarian CA,CRI\n (baseline CR 1.8) chronic UTI (on keflex @ home), R hip replacement,\n who presented to the ED on complaining of new onset L hip pain x 3\n days. While in the ED became hypotensive to 70s systolic in the\n setting of a positive U/A and elevated WBC code sepsis called, central\n line placed, levophed initiated and was transferred to the M/SICU for\n further management of ? urosepsis.\n Urine output remains extremely low overnight, team is aware, became\n hypotensive to 80 systolic s/p .5mg IVP dilaudid for L hip pain. Unable\n to wean levophed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Cr continues to trend up, urine output extremely low\n Action:\n Foley irrigated easily, no evidence of obstruction found, Renal U/S\n from unremarkable\n Response:\n U/O remains <5cc/hr\n Plan:\n ? ATN from hypotensive episode, cont to monitor, renal consult may be\n beneficial.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n On levophed gtt @ .1mcg/kg/min, SVO monitor setup however SQI is 4,AM\n labs pending however WBC was 33 on . remains afebrile\n Action:\n Multiple attempts to wean levophed gtt were unsuccessful, Abx per\n orders\n Response:\n Remains on .1mcg/kg/min\n Plan:\n Titrate levophed gtt, trend WBC, broaden Abx coverage as necessary\n Urinary tract infection (UTI)\n Assessment:\n Culture from pos for pseudomonas\n Action:\n Cont on zosyn, vanco not recommended @ this time as pt remains in renal\n failure\n Response:\n Plan:\n Cont to monitor\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Moderate to severe L hip pain, exacerbated by repositioning\n Action:\n .5mg IVP dilaudid q 4hrs\n Response:\n Became hypotensive to 80 systolic immediately after administration,\n however pain relieved for approx 4 hours and was able to rest\n comfortably.\n Plan:\n MRI of L hip planned for this AM however pt remains on levophed so\n imaging remains unlikely, cont to medicate prn.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318248,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n ABGs grad improving. LS diminished, occ crackles. Minimal\n secretions.\n Action:\n On PSV for 5 hrs, from 5-10pm. Placed back on AC to rest o/n. CXR\n done this am.\n Response:\n ABGs at 5am shows sl less acidosis, pH wnl.\n Plan:\n Will place back on PSV for # of hours on day shift.\n .H/O sepsis without organ dysfunction\n Assessment:\n SBP remained high all noc 110-160s, highest during nsg care. Pt on\n Fentanyl 2.5mcg/kg/min. Pt responds to commands inconsistently.\n Nods\n to pain. Pain usu sleeping except when disturbed. Opens\n eyes to voice. Grimacing and thrashing during nsg care and turning.\n Action:\n Extra fent boluses given during bath. Levophed off since yesterday\n am.\n Response:\n BP wnl.\n Plan:\n require more sedation, but plan for PSV this am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal failure improving per Cr, from 3.1 to 2.9 this am. U/o remains\n low 15-25mls/hr, team aware. UTI resolving.\n Action:\n Monitor labs. Zosyn cont for UTI.\n Response:\n Cr down to 2.9. WBC down to 7.8 from 11.7. W/o remains low.\n Plan:\n Given SBP has remained up all noc, team plans to start Lasix this am.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317662,
"text": "86 yo female admitted to ED after 3 days of new onset left hip pain.\n She is s/p right hip replacement. Pt also has chronic UTI\ns and was on\n keflex at home. She presented to ED for evaluation of hip pain and\n work up for possible pathological fracture. Pt was noted to by\n hypotensive to the 70\ns systolic. Her WBC was elevated and her U/A was\n positive. CXR was negative for PNA. Her initial lactate was 2.1. A\n central line was placed and pt started on antibiotics for infection and\n levophed for BP support.\n She was transferred to MICU for further evlauation and treatment of\n urosepsis.\n Upon arrival to MICU\n pt stated she was comfortable and felt much\n better. Pt received 1 mg dilaudid IV in the ED. SVO2 set up and pt\n continued on levophed for BP support.\n .H/O hypotension (not Shock)\n Assessment:\n Pt continues to have low BP not responding to IVF\n Action:\n Continues to require levophed at .1mcg/kg/min\n Response:\n BP stable with systolic 95-110\n Plan:\n Wean levophed as tolerated\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt was very comfortable upon arrival to floor and did well until 3am\n turn. Pt is not able to lie on left side at all\n even for very short\n period of time.\n Action:\n Pt turned from right side to back. Medicated x1 with dilaudid .5 mg\n IV.\n Response:\n Pt states the pain is improved but not gone. She is very helpful with\n turns and what she wants\n Plan:\n Continue to reposition as tolerated and medicate with dilaudid if BP\n can tolerate it and as pt needs it.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt appears to have sepsis from either bladder or hip site. Pt to go to\n MRI for hip today. Presept catheter in and pt tolerating it well.\n Action:\n Pt started on antibiotics and SVO2 being monitored continuously\n Response:\n Pt appears to be responding to treatment.\n Plan:\n Monitor pt closely for any changes in status.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317664,
"text": "86 yo female admitted to ED after 3 days of new onset left hip pain.\n She is s/p right hip replacement. Pt also has chronic UTI\ns and was on\n keflex at home. She presented to ED for evaluation of hip pain and\n work up for possible pathological fracture. Pt was noted to by\n hypotensive to the 70\ns systolic. Her WBC was elevated and her U/A was\n positive. CXR was negative for PNA. Her initial lactate was 2.1. A\n central line was placed and pt started on antibiotics for infection and\n levophed for BP support.\n She was transferred to MICU for further evlauation and treatment of\n urosepsis.\n Upon arrival to MICU\n pt stated she was comfortable and felt much\n better. Pt received 1 mg dilaudid IV in the ED. SVO2 set up and pt\n continued on levophed for BP support.\n .H/O hypotension (not Shock)\n Assessment:\n Pt continues to have low BP not responding to IVF\n Action:\n Continues to require levophed at .1mcg/kg/min\n Response:\n BP stable with systolic 95-110\n Plan:\n Wean levophed as tolerated\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Pt was very comfortable upon arrival to floor and did well until 3am\n turn. Pt is not able to lie on left side at all\n even for very short\n period of time.\n Action:\n Pt turned from right side to back. Medicated x1 with dilaudid .5 mg\n IV.\n Response:\n Pt states the pain is improved but not gone. She is very helpful with\n turns and what she wants\n Plan:\n Continue to reposition as tolerated and medicate with dilaudid if BP\n can tolerate it and as pt needs it.\n .H/O sepsis without organ dysfunction\n Assessment:\n Pt appears to have sepsis from either bladder or hip site. Pt to go to\n MRI for hip today. Presept catheter in and pt tolerating it well.\n Action:\n Pt started on antibiotics and SVO2 being monitored continuously\n Response:\n Pt appears to be responding to treatment.\n Plan:\n Monitor pt closely for any changes in status.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 317678,
"text": "Chief Complaint:\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 07:04 PM\n PRESEP CATHETER - START 07:05 PM\n Pt presented to ED c/o Left hip pain, found to have UTI & hypotension,\n fluid resussitated, admitted on levophed. WBC rising on Zosyn. Pt\n still c/o Left pain, relief with Dilaudid. Otherwise, no SOB/CB/Abd\n pain\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:23 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin, Insulin, Famotidine\n Other medications:\n Tamoxifen\n Dilaudid\n Heparin\n Bisacodyl\n Allopurinol\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation, regular BM o/n\n Musculoskeletal: pain in Left Hip\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.5\nC (95.9\n HR: 84 (69 - 88) bpm\n BP: 127/41(59) {80/34(46) - 127/57(70)} mmHg\n RR: 14 (9 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 21 (0 - 21)mmHg\n SvO2: 76%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 1,883 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 1,883 mL\n Blood products:\n Total out:\n 383 mL\n 105 mL\n Urine:\n 83 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 1,778 mL\n Respiratory support\n SpO2: 99%\n ABG: 7.24/55/139/26/-4\n Physical Examination\n General Appearance: NAD, comfortable\n Cardiovascular: (S1: Normal), (S2: Normal) quiet heart sounds, gr2-3\n early peaking ejection murmur, prominent S2\n Resp: CTAB\n Abd: soft, NT/ND, NABS\n Extr: trace to +1 pitting edema\n Skin: warm, pink\n Neuro: appropriate\n Labs / Radiology\n Renal U/S:\n IMPRESSION: Limited portable ultrasound performed. No hydronephrosis\n or\n stones in the left kidney. The right kidney which is small could not b\n e\n visualized given overlying bowel gas. A CT abdomen and pelvis may be o\n btained\n if warranted for further evaluation.\n Bilateral Hip films\n Preliminary Report\n No cortical irregularity or disruption of trabecular lines detected to\n suggest\n acute fracture in the left hip. Right hip replacement and pelvis simil\n ar in\n appearence to previous. No hip dislocation. Given osteopenia, dedicate\n d left\n hip views vs CT/MRI may be considered if indicated to evaluate subtle\n fractures.\n CXR:\n IMPRESSION:\n 1. Low-lying new central venous catheter, which should be partially\n withdrawn; no definite pneumothorax.\n 2. CHF with bilateral pleural effusions.\n 121 K/uL\n 10.1 g/dL\n 89 mg/dL\n 2.4 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 58 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.9 %\n 24.5 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n WBC\n 20.6\n 24.5\n Hct\n 30\n 31.6\n 32.9\n Plt\n 83\n 121\n Cr\n 2.3\n 2.4\n TropT\n 0.11\n 0.12\n TCO2\n 25\n Glucose\n 147\n 89\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:45/9/0.12, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:2.0 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n ICU Care\n 86 y/o F with PMHx of Renal Cell Carcinoma, Ovarian Ca, recurrent UTIs\n on chronic prophylaxis of Keflex p/w Left hip pain & found to be\n hypotensive in ED, with UTI. Pt adm to with urosepsis, still on\n levophed with rising WBC ct.\n 1. Urosepsis\n 2. Hip Pain\n 3. Acute on Chronic Renal Failure: still with poor UOP\n 4. CHF/Severe AS: LVEF of 45% on lasix\n 5. HTN\n 6. GOUT\n 7. h/o Ovarian Cancer, RCC: RCC treated with , unclear\n h/o treatment for ovarian, continue Tamoxifen\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317761,
"text": "Briefly this is an 86 y/o F w/ PMH significant for ovarian CA,CRI\n (baseline CR 1.8) chronic UTI (on keflex @ home), R hip replacement,\n who presented to the ED on sunday complaining of new onset L hip\n pain x 3 days exacerbated by ambulation. While in the ED became\n hypotensive to 70s systolic in the setting of a positive U/A and\n elevated WBC code sepsis called, central line placed, levophed\n initiated and was transferred to the M/SICU for further management of ?\n urosepsis.\n Urine output remains extremely low overnight, team is aware, became\n hypotensive to 80 systolic s/p .5mg IVP dilaudid for L hip pain. Unable\n to wean levophed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318189,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type: Standard\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Nuclear medicine twice\n 30\n none\n Traveled without incident\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318190,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type: Standard\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Nuclear medicine twice\n 30\n none\n Traveled without incident\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318365,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n metolazone and lasix with good response, repeated at 4 am\n abg stable on PS 5 and 5\n RSBI 53\n History obtained from Family / Friend, house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 11:33 AM\n Infusions:\n Fentanyl - 20 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 04:30 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:36 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 68 (67 - 114) bpm\n BP: 108/32(56) {101/32(56) - 174/62(101)} mmHg\n RR: 19 (8 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 15 (4 - 15)mmHg\n Total In:\n 1,203 mL\n 453 mL\n PO:\n TF:\n 841 mL\n 345 mL\n IVF:\n 252 mL\n 78 mL\n Blood products:\n Total out:\n 1,532 mL\n 1,550 mL\n Urine:\n 1,532 mL\n 1,550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -329 mL\n -1,097 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 325 (325 - 428) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 53\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.37/45/129/23/0 on PS()\n Ve: 6.4 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: 2+, Left: 2+, Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, Sedated,\n Tone: Decreased\n Labs / Radiology\n 8.6 g/dL\n 47 K/uL\n 144 mg/dL\n 3.1 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 69 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n WBC\n 14.7\n 7.8\n 7.4\n Hct\n 28.9\n 27.4\n 26.6\n Plt\n 72\n 51\n 47\n Cr\n 3.1\n 2.9\n 3.1\n TCO2\n 21\n 21\n 22\n 24\n 22\n 25\n 27\n Glucose\n 161\n 132\n 144\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: cxr--increased in r hemidiapragm elevation, with known\n chrionic changes from pelurodesis\n Microbiology: no new micro\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, in ICU with pseudomonal urosepsis c/b\n Afib/RVR, ARF (ATN) and respiratory failure\n Overall improving, volume status and underlying severe AS complicating\n wean\n Active issues remains:\n > Respiratory failure\ndoing well minimal vent support, alert and\n following commands, rsbi 50's and had been diuresing nicely. CXR\n essentially stable ith chronic changes from h/o R pleurodesis\n check abg on then plan to extubate. could trial NPPV if\n problems with .\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine, start thiazide and lasix (goal 500-1 L as BP\n tolerates)\n Continue phos binder and renal dosing of meds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis,\n resolved\n Complete zosyn day day course,\n Repeat ucx for surveillance though clinically improved\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP stable\n continue diuresis\n Starting to autodiurese and will give lasix and thiazide today\n woth goal for 500-1 Lneg\n ATRIAL FIBRILLATION (AFIB)-\n appears nsr w=now with ectopy will check 12 lead\n Continue dig\n Daily stoke risk low and would not anticoagulate at this time given\n low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration and now likely at\n baseline, dic labs negative and HUS/TTP unlikely, follow for further\n reduction from baseline, continue heparin products for now given low\n suspicion for HIT, rechek today given slight decrease from 51-47...\n > anemia- h/h now stable, transfuse for < 21 or active bleed or if\n hypotension\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative, lido patch, readdress\n once extubated--dilaudid tylenol once fent gtt is oof\n ICU Care\n Nutrition:\n Comments: NPO pending extubation\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Comments: plan to place peripherals and d/c lines tomorrow\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317762,
"text": "Briefly this is an 86 y/o F w/ PMH significant for ovarian CA,CRI\n (baseline CR 1.8) chronic UTI (on keflex @ home), R hip replacement,\n who presented to the ED on complaining of new onset L hip pain x 3\n days. While in the ED became hypotensive to 70s systolic in the\n setting of a positive U/A and elevated WBC code sepsis called, central\n line placed, levophed initiated and was transferred to the M/SICU for\n further management of ? urosepsis.\n Urine output remains extremely low overnight, team is aware, became\n hypotensive to 80 systolic s/p .5mg IVP dilaudid for L hip pain. Unable\n to wean levophed\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318347,
"text": "Chief Complaint: Urosepsis\n 24 Hour Events:\n -- given diuril + lasix w/ good response, repeated at 4am\n -- ABG unchanged\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:02 PM\n Infusions:\n Fentanyl - 20 mcg/hour\n Other ICU medications:\n Heparin Sodium - 12:13 PM\n Furosemide (Lasix) - 04:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36\nC (96.8\n HR: 74 (68 - 114) bpm\n BP: 147/41(72) {96/32(53) - 174/62(101)} mmHg\n RR: 18 (8 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 15 (4 - 15)mmHg\n Total In:\n 1,203 mL\n 308 mL\n PO:\n TF:\n 841 mL\n 293 mL\n IVF:\n 252 mL\n 14 mL\n Blood products:\n Total out:\n 1,532 mL\n 900 mL\n Urine:\n 1,532 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -329 mL\n -592 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 369 (363 - 428) mL\n PS : 10 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI: 53\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: 7.37/45/129/23/0\n Ve: 7.1 L/min\n PaO2 / FiO2: 430\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, No(t) Bowel sounds present\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 47 K/uL\n 8.6 g/dL\n 144 mg/dL\n 3.1 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 69 mg/dL\n 110 mEq/L\n 138 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 12:18 AM\n 04:56 AM\n 05:04 AM\n 03:43 PM\n 06:34 PM\n 05:00 AM\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n WBC\n 14.7\n 7.8\n 7.4\n Hct\n 28.9\n 27.4\n 26.6\n Plt\n 72\n 51\n 47\n Cr\n 3.1\n 2.9\n 3.1\n TCO2\n 21\n 21\n 22\n 24\n 22\n 25\n 27\n Glucose\n 161\n 132\n 144\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis and\n MS changes.\n .\n #SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): etiology presumed urosepsis\n with positive UA growing out pan sensitive Pseudomonas, now day 7 of\n Zosyn. Pt is s/p Intubation on for worsening acidosis/MS\n changes. Pt had transient hypotensive episode with worsening acidosis\n on -intermittently requiring pressors. WBC now trending down,\n afebrile, no recurrence of hypotension. Further infectious work up neg\n to date, L chest U/S neg for abscess,Bone scan negative.\n - apprec ID consult, continue Zosyn day \n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n - gentle bolus of 250 LR prn to maintain Maps>65\n - will repeat cultures if any recurrence of hypotension\n .\n #SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed Afib\n with RVR and became hypotensive on . Pressure responded to IVF &\n pressors. Pt was intubated and pressors weaned. Pt has been in/out of\n Afib but HR better controlled on digoxin. Transiently hypotensive on\n , required pressors approx 5hrs, likely due to severe AS and\n preload dependence. Pt with extravasc volume overload and complicated\n fluid balance.\n - continue Digoxing 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - attempt aggressive diuresis today, goal -500cc\n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation.\n WBC ct down, it is unlikely that this due to a new PNA, but will\n reculture and broaden Abx if pt clinically deteriorates. Pulm edema\n and extravascular volume overload may be a barrier to extubation. Goal\n to run i/os negative 500cc today\n - tolerated well for 5hrs o/n. ABGs show normal acid base status,\n oxygenating & ventilating well.\n - f/u RSBI in am, possible extubation over weekend\n .\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Creatinine improved & having increased UOP. Acidosis improved on vent\n with AC, unclear etiology of metabolic acidosis leading to intubation.\n Apprec renal recs, will admin Lasix & Metolazone this am to attempt\n diuresis\n - monitor i/os, goal net negative 500cc\n - renally dose all meds\n - continue phoslo TID\n .\n # AORTIC STENOSIS: AS with valve area of 0.7cm, very preload dependant\n & delicate fluid balance. Gentle bolus with 250cc LR prn to maintain\n MAP>60\n - continue digoxin, monitor daily CXR & resp status, avoid volume\n overload preventing successful extubation\n .\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n # LEFT HIP PAIN: Etiology unclear but not an infectious source. Not a\n septic joint on admission, but clearly painful on manipulation now. CT\n neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n - continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 04:00 AM 35 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, RSBI\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 317853,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location: ICU\n Reason: Bougie used for intubation\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Bronchial\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Bronchial\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: Biting ETT at times\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 318008,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Known difficult intubation: Yes,Bougie used by anesthesia.\n Procedure location: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 22 cm at teeth. Rotated and re-taped.\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment: Pt remains sedated on full vent\n support.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n RSBI attempted but pt had no spontaneous respirations at this time.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318022,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:30 AM\n SPUTUM CULTURE - At 05:37 AM\n STOOL CULTURE - At 05:37 AM\n -- Two colonies of GNR, likely both pseudo per ID, no change in abx\n -- Ordered sputum cx from ET given concerning RLL opacity\n -- pressures low, MAP of 50, gave 500cc LR, and appropriate response\n -- ABG w/ increasing alkalosis, decreased frequency on vent\n Pt comfortable on the vent, no grimacing, not responding to commands\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:39 AM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.5\nC (95.9\n HR: 70 (65 - 87) bpm\n BP: 106/35(58) {92/34(54) - 119/45(69)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 194 (5 - 261)mmHg\n Total In:\n 2,864 mL\n 258 mL\n PO:\n TF:\n 94 mL\n IVF:\n 2,724 mL\n 74 mL\n Blood products:\n Total out:\n 309 mL\n 40 mL\n Urine:\n 309 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,555 mL\n 218 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.41/31/195/19/-3\n Ve: 7.1 L/min\n PaO2 / FiO2: 650\n Physical Examination\n GEN: Intubated, NAD, not responding to commands\n CV: irreg/irreg gr 2-3 SEM over LSB, no radiation\n RESP: CTAB, BS at bases, moving air well\n ABD: BS present, not distended but more tense than baseline, no\n grimacing to palp\n EXTR: 2+ pitting edema bilaterally\n Labs / Radiology\n Left Chest U/S- no evidence of abscess\n Chest Portable :\n FINDINGS: In comparison with the study of , there is little overal\n l\n change. Extensive bilateral pleural effusions persist, much more promi\n nent on\n the right. Various tubes remain in place. Specifically, the endotrach\n eal\n tube is about 4.6 cm above the carina.\n 56 K/uL\n 8.6 g/dL\n 99 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 62 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.7 %\n 10.9 K/uL\n [image002.jpg]\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n 04:00 PM\n 06:59 PM\n 05:17 AM\n 05:39 AM\n WBC\n 12.8\n 10.6\n 12.7\n 10.9\n Hct\n 27.7\n 26.2\n 25.1\n 26.7\n Plt\n 76\n 66\n 56\n 56\n Cr\n 2.8\n 2.8\n 2.8\n 2.9\n 2.9\n TCO2\n 19\n 21\n 20\n 21\n 20\n Glucose\n 133\n 104\n 106\n 120\n 99\n Other labs: PT / PTT / INR:13.4/35.9/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.0\n mg/dL, Mg++:2.1 mg/dL, PO4:3.9 mg/dL\n Sputum pending, C. Diff neg x 2, third C. Diff pending\n Blood Cx NGTD\n Urine Cx 2 diff GNR species\n Urine Cx + pseudomonas pan sensitive\n Assessment and Plan: 86 y/o F with PMHx of severe AS & CHF with EF 45%,\n renal cell & ovarian Ca p/w Left hip pain, adm for presumed urosepsis\n on pressors. Intubated on for worsening acidosis, oliguric renal\n failure, hemodynamic instability to Afib with RVR and MS changes.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Source of infection presumed\n to be urosepsis with positive UA growing out pan sensitive\n Pseudomonas. Pt was covered with Vanc/Zosyn for 48hr but clinically\n deteriorated yesterday possibly due to incomplete volume resuscitation.\n Pt was intubated and weaned for pressors, WBC ct now trending down and\n acidosis resolving on vent. ID consult, continue ruling out\n other sources of infection. L chest U/S neg for abscess\n - continue Vanc/Zosyn for coverage of pseudomonas in urine\n - ortho consult for L hip pain and concern for seeding of\n hardware. F/u recs\n - will d/w rads regarding CT chest/abd/pelvis\n - ORTHO? Not concerned\n - continue to f/u blood & urine cultures\n - bolus prn to maintain Maps>65\n SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed\n Afib with RVR and became hypotensive on . Pressure responded to IVF\n & pressors. Pt was then Intubated and pressors weaned. Pt still in/out\n of Afib but HR has been much better controlled on digoxin.\n - check am digoxin level on \n - avoid CCB/BBs\n - no plan for systemic anticoagulation currently given the plt\n count, will re-consider in am if plts stable\n - fluid bolus prn to maintain maps>60\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely ATN but urine sediment showed sheets of WBCs.\n Creatinine appears to have plateaued and pt having some UOP overnight.\n Renal recs, there is no acute indication for dialysis. Uremia\n likely contributing to acidosis, currently compensated with vent\n support\n - avoid continuous IVF given poor UOP\n - f/u urine sediment, renally dose meds, check C3/4 & urine eos per\n Renal\n - continue phoslo TID & check lytes \n AORTIC STENOSIS: AS with valve area of 0.7cm, very preload\n dependant. Gentle bolus IVF prn to maintain MAP>60\n - continue digoxin, monitor daily CXR & resp status to avoid massive\n volume overload.\n URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Vanc/Zosyn for coverage\n LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation, will discuss final CT read with rads\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin 5000u sc TID\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-17 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 317731,
"text": "Chief Complaint: Urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86F with hx RCC, presented to ED with hip pain. Found to be in shock,\n with positive UA.\n 24 Hour Events:\n INDWELLING PORT (PORTACATH) - START 07:04 PM\n PRESEP CATHETER - START 07:05 PM\n Started Zosyn\n 6.6L NS\n Levophed, now tapering\n Converted to AF (new)\n Oliguric\n Renal U/S prelim no perinephric abscess/pyelo\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:23 AM\n Infusions:\n Norepinephrine - 0.1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n Currently complaining of chills, nausea\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Edema, Tachycardia, af\n Gastrointestinal: Nausea, Emesis\n Genitourinary: Foley, oliguria\n Musculoskeletal: Joint pain\n Flowsheet Data as of 09:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.5\nC (95.9\n HR: 89 (69 - 89) bpm\n BP: 120/48(66) {80/34(46) - 127/57(70)} mmHg\n RR: 14 (9 - 19) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm), AF (Atrial Fibrillation)\n CVP: 21 (0 - 21)mmHg\n SvO2: 78%\n Mixed Venous O2% Sat: 73 - 73\n Total In:\n 6,663 mL\n 1,955 mL\n PO:\n TF:\n IVF:\n 1,663 mL\n 1,955 mL\n Blood products:\n Total out:\n 383 mL\n 123 mL\n Urine:\n 83 mL\n 123 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,280 mL\n 1,832 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.24/55/139/26/-4\n Physical Examination\n General Appearance: Thin, Anxious\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Abdominal: Soft, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.1 g/dL\n 121 K/uL\n 89 mg/dL\n 2.4 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 58 mg/dL\n 106 mEq/L\n 140 mEq/L\n 32.9 %\n 24.5 K/uL\n [image002.jpg]\n 05:23 PM\n 08:30 PM\n 10:15 PM\n 04:30 AM\n WBC\n 20.6\n 24.5\n Hct\n 30\n 31.6\n 32.9\n Plt\n 83\n 121\n Cr\n 2.3\n 2.4\n TropT\n 0.11\n 0.12\n TCO2\n 25\n Glucose\n 147\n 89\n Other labs: PT / PTT / INR:15.0/32.1/1.3, CK / CKMB /\n Troponin-T:45/9/0.12, Lactic Acid:1.1 mmol/L, LDH:145 IU/L, Ca++:8.1\n mg/dL, Mg++:2.0 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n URINARY TRACT INFECTION (UTI)\n - Continue Zosyn, add additional gram negative coverage (will d/w ID)\n - Follow up culture data\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Likely GU source, but\n portacath and hip are also very possible sources.\n If worsening, increased pressor needs consider porta cath removal\n Currently on Levophed, clinically requires additional fluid challenge.\n - Broaden GNR coverage (as above), also add Vanco for gram positives.\n - Place A-line for hemodynamic monitoring\n - Will consider further imaging of hip when stable for MRI or CT,\n concern for infection or pathologic fx given pain\n - Consider dobutamine if SVO2 remains low\nrecheck after additional IVF\n boluses\n * Afib: new, likely related to acute illness, levophed\n - Attempt to wean levophed\n - Hold off on anticoag for now\n - Obtain 12-lead EKG\n - Cycle cardiac enzymes\n * Nausea/vomiting: be related to dilaudid, ruling out cardiac\n etiology\n - Zofran PRN\n - Cycle enzymes\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)\n CANCER (MALIGNANT NEOPLASM), OTHER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 45\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318011,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:30 AM\n SPUTUM CULTURE - At 05:37 AM\n STOOL CULTURE - At 05:37 AM\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.5\nC (95.9\n HR: 70 (65 - 87) bpm\n BP: 106/35(58) {92/34(54) - 119/45(69)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 194 (5 - 261)mmHg\n Total In:\n 2,864 mL\n 258 mL\n PO:\n TF:\n 94 mL\n IVF:\n 2,724 mL\n 74 mL\n Blood products:\n Total out:\n 309 mL\n 40 mL\n Urine:\n 309 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,555 mL\n 218 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.41/31/195/19/-3\n Ve: 7.1 L/min\n PaO2 / FiO2: 650\n Physical Examination\n GEN: Intubated, NAD\n CV:\n RESP:\n ABD:\n EXTR:\n Labs / Radiology\n 56 K/uL\n 8.6 g/dL\n 99 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 62 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.7 %\n 10.9 K/uL\n [image002.jpg]\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n 04:00 PM\n 06:59 PM\n 05:17 AM\n 05:39 AM\n WBC\n 12.8\n 10.6\n 12.7\n 10.9\n Hct\n 27.7\n 26.2\n 25.1\n 26.7\n Plt\n 76\n 66\n 56\n 56\n Cr\n 2.8\n 2.8\n 2.8\n 2.9\n 2.9\n TCO2\n 19\n 21\n 20\n 21\n 20\n Glucose\n 133\n 104\n 106\n 120\n 99\n Other labs: PT / PTT / INR:13.4/35.9/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.0\n mg/dL, Mg++:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318012,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:30 AM\n SPUTUM CULTURE - At 05:37 AM\n STOOL CULTURE - At 05:37 AM\n -- Two colonies of GNR, likely both pseudo per ID, no change in abx\n -- Ordered sputum cx from ET given concerning RLL opacity\n -- pressures low, MAP of 50, gave 500cc LR, and appropriate response\n -- ABG w/ increasing alkalosis, decreased frequency on vent\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:39 AM\n Other medications:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.5\nC (95.9\n HR: 70 (65 - 87) bpm\n BP: 106/35(58) {92/34(54) - 119/45(69)} mmHg\n RR: 14 (11 - 18) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 70 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 194 (5 - 261)mmHg\n Total In:\n 2,864 mL\n 258 mL\n PO:\n TF:\n 94 mL\n IVF:\n 2,724 mL\n 74 mL\n Blood products:\n Total out:\n 309 mL\n 40 mL\n Urine:\n 309 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,555 mL\n 218 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 30%\n RSBI Deferred: No Spon Resp\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n SpO2: 99%\n ABG: 7.41/31/195/19/-3\n Ve: 7.1 L/min\n PaO2 / FiO2: 650\n Physical Examination\n GEN: Intubated, NAD\n CV:\n RESP:\n ABD:\n EXTR:\n Labs / Radiology\n 56 K/uL\n 8.6 g/dL\n 99 mg/dL\n 2.9 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 62 mg/dL\n 109 mEq/L\n 138 mEq/L\n 26.7 %\n 10.9 K/uL\n [image002.jpg]\n 04:30 PM\n 04:41 PM\n 09:15 PM\n 09:33 PM\n 05:07 AM\n 05:21 AM\n 04:00 PM\n 06:59 PM\n 05:17 AM\n 05:39 AM\n WBC\n 12.8\n 10.6\n 12.7\n 10.9\n Hct\n 27.7\n 26.2\n 25.1\n 26.7\n Plt\n 76\n 66\n 56\n 56\n Cr\n 2.8\n 2.8\n 2.8\n 2.9\n 2.9\n TCO2\n 19\n 21\n 20\n 21\n 20\n Glucose\n 133\n 104\n 106\n 120\n 99\n Other labs: PT / PTT / INR:13.4/35.9/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, LDH:124 IU/L, Ca++:8.0\n mg/dL, Mg++:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan: 86 y/o F with PMHx of severe AS & CHF with EF 45%,\n renal cell & ovarian Ca p/w Left hip pain, adm for presumed urosepsis\n on pressors. Intubated on for worsening acidosis, oliguric renal\n failure, hemodynamic instability to Afib with RVR and MS changes.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION): Source of infection presumed\n to be urosepsis with positive UA growing out pan sensitive\n Pseudomonas. Pt was covered with Vanc/Zosyn for 48hr but clinically\n deteriorated yesterday possibly due to incomplete volume resuscitation.\n Pt was intubated and weaned for pressors, WBC ct now trending down and\n acidosis resolving on vent. ID consult, continue ruling out\n other sources of infection. Will check C. diff X 3 given new diarrhea.\n - continue Vanc/Zosyn for coverage of pseudomonas in urine\n - ortho consult for L hip pain and concern for seeding of\n hardware. F/u recs\n - will d/w rads regarding CT chest/abd/pelvis\n - L upper chest wall u/s to rule out abscess near portocath\n - continue to f/u blood & urine cultures\n - bolus prn to maintain Maps>65\n SHOCK, CARDIOGENIC: Pt with severe AS & CHF with EF 45% developed\n Afib with RVR and became hypotensive on . Pressure responded to IVF\n & pressors. Pt was then Intubated and pressors weaned. Pt still in/out\n of Afib but HR has been much better controlled on digoxin.\n - check am digoxin level on \n - avoid CCB/BBs\n - no plan for systemic anticoagulation currently given the plt\n count, will re-consider in am if plts stable\n - fluid bolus prn to maintain maps>60\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely ATN but urine sediment showed sheets of WBCs.\n Creatinine appears to have plateaued and pt having some UOP overnight.\n Renal recs, there is no acute indication for dialysis. Uremia\n likely contributing to acidosis, currently compensated with vent\n support\n - avoid continuous IVF given poor UOP\n - f/u urine sediment, renally dose meds, check C3/4 & urine eos per\n Renal\n - continue phoslo TID & check lytes \n AORTIC STENOSIS: AS with valve area of 0.7cm, very preload\n dependant. Gentle bolus IVF prn to maintain MAP>60\n - continue digoxin, monitor daily CXR & resp status to avoid massive\n volume overload.\n URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Vanc/Zosyn for coverage\n LEFT HIP PAIN: Etiology unclear, ortho recs. Exam did not\n suggest a septic joint on admission, clearly very painful on\n manipulation, will discuss final CT read with rads\n - f/u ortho recs, continue Fentanyl for pain control\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 12:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Prophylaxis:\n DVT: Heparin 5000u sc TID\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 317831,
"text": "86 yo F with severe AS admitted with urosepsis and L hip pain, with\n persistent vasopressor requirements, leukocytosis, and anuric ARF. Pt\n intub for worsening ms . Pt lethargic, hallucinating ,\n stated saw faces floating in room. C/CO severe left hip pain,\n100/10\n med with dilaudid 0.5mg iv, then 0.125mg iv. Also received haldol 0.5mg\n po and Tylenol 1000mg po. Pt with worsening lethargy, and , and\n was intub. Presently receiving prn fent/versed with good effect.\n Vasopressin gtt added, and both levophed and vasopressin weaned to off\n by end of shift. Pt received ns total 2500cc in bolus. Pt with\n episodes of RAF with Hr up to 160\ns, team aware and dig load started.\n Plan for CT scan of chest/abd/pelvis at 1800.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib, occas having sinus beats. 12 lead x2 done this\n shift. Pt with episode of raf with hr up to 160. Hr broke on own after\n ivf bolus, hr presenly well controlled. Digoxin load started, pt\n received .25mg iv dose, and will need repeat dose at 2100.\n Action:\n Digoxin load\n Response:\n Hr improved after ivf and dig load\n Plan:\n Dog load, next dose at 2100\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n U/o remains poor, 1300cc this shift, team aware. Urine cx sent.\n Action:\n Renal consult\n Response:\n Awaiting recs\n Plan:\n Follow u/o, and cx data\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt conts with worsening hypotension in setting of new , pH\n 7.16. Pt received 1 dose 50meq nahco3. After total 2500cc in ns bolus,\n was able to wean off vasopressin and levophed gtts. Pt inutb at ~1500\n for decreasing MS, and worsening aciodsis, vent setting ac 16 peep 5\n 450 50%. Pt occas breathing over set rate. Pt remains afebrile,\n bld cx x2 sent, urine cx sent. Pt needs spec for c-diff. One time dose\n of vanco 1gm iv given.\n Action:\n Inutb and ivf bolus, weaning pressors\n Response:\n Pt presently resting comfortably on vent\n Plan:\n Wean from vent as tol, follow cx data, iv abx as odered, ABG.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318090,
"text": "Briefly this is an 86 y/o F with a PMH significant for severe aortic\n stenosis, chronic UTI, CRI, cervical/renal CA, who presented on w/\n L hip pain x 3 days in the setting of leukocytosis and acute renal\n failure. Intubated on for resp acidosis w/ associated mental\n status changes pt had required pressors prior to intubation for\n hypotensive episode at ED, SBP 70\n fluid resuscitated and precept\n catheter placed. Etiology of L hip pain still unkown T of\n chest/abd/pelvis performed @ 1800 on was unchanged from recent\n prior CT\ns, etiology of severe L hip pain remains unknown. Has been\n tolerating weaning from ventilator with plan of extubating this am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Urinary tract infection (UTI)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318666,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, HR low 50s-70s, freq diff to see P waves on monitor, but\n present on a strip. Freq pacs at times, pvcs w couplets. SBP 90s-100s.\n Action:\n Metoprolol increased to 25mg .\n Response:\n HR dropped to 50s during sleep following Metoprolol.\n Plan:\n Monitor HR, BP, response to metoprolol.\n Delirium / confusion\n Assessment:\n Oriented x2 to person and place, but freq confusion. Very sleepy most\n of noc, complains whenever touched or turned to leave her alone.\n Grimaces w any movement but not able to articulate where pain is, says\nI have arthritis all over\n. Moaned when head was moved.\n Action:\n Held night dose of Olanzapine due to sleepiness. Tylenol q6hrs.\n Response:\n Slept most of noc. Talking when awakened but lethargic.\n Plan:\n Olanzapine dose reduced for day shift, ? if will require it. Monitor\n for pain. Reorient pt when awake.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Stable CRI per labs, cr 2.8. U/o cont low ~ 20mls/hr.\n Action:\n Receiving 75mls/hr D5W to be finished ~ 5am.\n Response:\n U/o cont low. Pt taking po flds fairly well.\n Plan:\n Will D/c D5W when liter finishes. If u/o falls below 20mls/hr, notify\n team and may give fld bolus.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318800,
"text": "Chief Complaint: urosepsis, afib with rvr, delirium\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n a rib with rvr and hyptension eysterday\n emporic antibx and pan cxs sent\n family mtg with goals of care--> change in code status to dnr/dni, no\n lines poressors\n recurrent transient hypotension overnight responded to IVF blous\n remains agitated delirius\n BLOOD CULTURED - At 12:15 PM\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:10 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 113 (40 - 113) bpm\n BP: 115/42(66) {71/16(39) - 123/86(91)} mmHg\n RR: 24 (16 - 45) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 2,855 mL\n 995 mL\n PO:\n 480 mL\n 20 mL\n TF:\n IVF:\n 2,000 mL\n 915 mL\n Blood products:\n 375 mL\n Total out:\n 336 mL\n 130 mL\n Urine:\n 336 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.34/53/86/28/0\n Physical Examination\n General Appearance: No acute distress, agitated, confused, elderly\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases, No(t) Wheezes : , Diminished: bases), poor coop with exam\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender: ,\n Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing,\n decreased edema\n Skin: Warm\n Neurologic: Responds to: somnolent, Movement: Not assessed, Tone: Not\n assessed\n Labs / Radiology\n 9.6 g/dL\n 68 K/uL\n 68 mg/dL\n 3.2 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 74 mg/dL\n 109 mEq/L\n 146 mEq/L\n 29.4 %\n 10.0 K/uL\n [image002.jpg]\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n 10:45 AM\n 12:07 PM\n 05:01 AM\n WBC\n 5.7\n 7.0\n 8.5\n 10.0\n Hct\n 25.8\n 25.9\n 22.5\n 29.4\n Plt\n 58\n 60\n 61\n 68\n Cr\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n 3.2\n TropT\n 0.20\n TCO2\n 30\n Glucose\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n 68\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/3/0.20, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n Fluid analysis / Other labs: vanco level 18\n dig level pending\n nr rpr\n Imaging: echo--mod sym lvh, ef 50%, mild 1+ ar, mod-sev as, mod 2+ mr\n sm peric eff without tamponande physiology\n no cxr today\n Microbiology: urine blood ngtd\n c diff pending\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, now with\n recurrant afib, hypotension\n family mtg yesterday with readdressing of goals of\n care--rtransitoning otward hsopice with dnr dni status and no pressors\n lines,\n Active issues remains:\n # hypotension--\n - Recurrent afib with ongoing difficulty optiming vsaolume\n statius in setting of mod-to severe as\n - Hypotension likely is cardiogenic, possible ischemia in\n setting of severe AS and reduced co, though infection possibility given\n compeltion of antibx\n - Gentle ivf boluses, monitoring resp status\n - Autodiureses and sensitive to volume shifts, preload\n dependant though appears volume up with elevated JVD and anasarca\n - Continue dig, hold bb\n - Empiric antibx vanco/zosyn with cx's--on stnading\n tylenol for pain so may not mount temp, now with mild increase in wbc,\n continue antibx X 48 hrs pednign cx data\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension now with recurrent hypotension and worsening u/o and cr\n supportive care, monitor cr with gentle hydration for BP support,\n hold on diureses\n renal dosing of meds pending further improvement\n # Delirium\nmultiple reasons, component of sundowning at night and\n altered sleep schedule icu, now with recurrent hypotension\n Continue low dose zyprexa, haldol prn, re-orient, optimize sleep\n cycle at night with light and dark cues\n h2 b d/c and changed to PPI\n limit narcotics\n anticipate extremely slow recovery\n > hypoxemia--stable on minimal NC O2, nebs prn\n > Hypernatremia\nimproving with free water\n > Sacral abrasions--wound care following\n > Nutrition--aspiration risk, nector thick diet with supervision\n > Thrombocytopenia--\n baseline and stable, though low suspicion of hit, heparin products\n stopped resend hit , Now improved and at prior baseline.\n # pseudomonal urosepsis, now resolved\n Completed zosyn course X 10 days\n Remains af with normal wbc ct follow up new cx data\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, tylenol\n ICU Care\n Nutrition:\n Comments: purre diet with supervision\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI, no lines pressors\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318715,
"text": "Impaired Skin Integrity\n Assessment:\n Perineal rash status quo, continues to appear inflammed and rash\n persists. Stage 2 coccyx decub status quo, dressing changed again today\n after being soiled w/stool. Aqacel dressing w/small to moderate\n serosang drainage, wound does not appear to be getting contaminated\n w/stool.\n Action:\n Area cleansed after each stool and continues w/antifungal barrier\n cream.\n Response:\n No change in skin integrity from 3/5/8 to today\n Plan:\n Cont w/skin care plan per skin care RN, kinair bed to prevent further\n deterioration, nutrition and cont w/ turning q2hour.\n Atrial fibrillation (Afib)\n Assessment:\n Afib w/RVR, hypotensive, rx w/fluid and metoprolol\n Action:\n PO dose lopressor held as sbp 92, noted afib w/RVR to 140s and dropping\n b/p, initially rx w/IVF 250cc NS boli x 4 and once SBP >100 pt able to\n take 25mg lopressor PO. Pt then hypotensive and HR as low as 40s\n junctional rhythm. Continued w/afib, occasional RVR 140s and then\n bradycardic to 40.\n Response:\n HR irregular, tachy/brady. Hypotensive and bradycardic in response to\n 25mg PO lopressor.\n Plan:\n Continue to monitor, pt now dnr/dni, no pressors.\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318772,
"text": "Chief Complaint:\n 24 Hour Events:\n - developped Afib with RVR & hypotension on , responded to repeat IV\n boluses\n - blood cultures sent, start on empiric Vanc/Zosyn\n - family meeting to address goals- now DNR/DNI, no lines, no pressors\n - received 1upRBCs & has been having minimal UOP\n - recurrent hypotension overnight, given total 750cc of boluses & BP\n stable\n - pt pulling out IVs & portacath\n Pt still confused, pulling out IVs. Denies any SOB/CP & wants to eat.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Day 2 Vancomycin\n Day 2 Piperacillin/Tazobactam (Zosyn)\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:10 PM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 83 (40 - 109) bpm\n BP: 94/34(50) {71/16(39) - 123/86(91)} mmHg\n RR: 17 (16 - 45) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 2,855 mL\n 908 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,000 mL\n 908 mL\n Blood products:\n 375 mL\n Total out:\n 336 mL\n 75 mL\n Urine:\n 336 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 833 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.34/53/86//0\n Physical Examination\n Gen: NAD, mildly agitated, confused\n HEENT: dry mucous membranes, JVP elev\n CV: RRR harsh gr 2-3 SEM over LSB\n RESP: BS at bases, expiratory wheezes noted throughout\n ABD: soft, NT/ND/NABS\n EXTR: +1 pitting edema bilaterally (upper &lower) facial\n Labs / Radiology\n 61 K/uL\n 7.3 g/dL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg] ALL LABS FROM \n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n 10:45 AM\n 12:07 PM\n WBC\n 5.7\n 7.0\n 8.5\n Hct\n 25.8\n 25.9\n 22.5\n Plt\n 58\n 60\n 61\n Cr\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TropT\n 0.20\n TCO2\n 28\n 30\n Glucose\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/3/0.20, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n RPR Negative\n Urine & Blood Cx are NGTD\n C. Diff pending\n ECHO : The left atrium is mildly dilated. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity\n size is normal. Overall left ventricular systolic function is low\n normal (LVEF 50%). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The ascending\n aorta is moderately dilated. The aortic valve leaflets are severely\n thickened/deformed. There is moderate to severe aortic valve stenosis.\n Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Moderate (2+)\n mitral regurgitation is seen. [Due to acoustic shadowing, the severity\n of mitral regurgitation may be significantly UNDERestimated.] The left\n ventricular inflow pattern suggests impaired relaxation. The tricuspid\n valve leaflets are mildly thickened. The supporting structures of the\n tricuspid valve are thickened/fibrotic. There is a small pericardial\n effusion. The effusion appears circumferential. There are no\n echocardiographic signs of tamponade.\n Compared with the findings of the prior report (images unavailable for\n review) of , the findings are similar.\n Assessment and Plan\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR/DNI, no lines, no pressors\n Disposition: possibly called out to floor/home with hospice\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318775,
"text": "Chief Complaint:\n 24 Hour Events:\n - developped Afib with RVR & hypotension on , responded to repeat IV\n boluses\n - blood cultures sent, start on empiric Vanc/Zosyn\n - family meeting to address goals- now DNR/DNI, no lines, no pressors\n - received 1upRBCs & has been having minimal UOP\n - recurrent hypotension overnight, given total 750cc of boluses & BP\n stable\n - pt pulling out IVs & portacath\n Pt still confused, pulling out IVs. Denies any SOB/CP & wants to eat.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Day 2 Vancomycin\n Day 2 Piperacillin/Tazobactam (Zosyn)\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:10 PM\n Other medications:\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 83 (40 - 109) bpm\n BP: 94/34(50) {71/16(39) - 123/86(91)} mmHg\n RR: 17 (16 - 45) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 2,855 mL\n 908 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,000 mL\n 908 mL\n Blood products:\n 375 mL\n Total out:\n 336 mL\n 75 mL\n Urine:\n 336 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 833 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.34/53/86//0\n Physical Examination\n Gen: NAD, mildly agitated, confused\n HEENT: dry mucous membranes, JVP elev\n CV: RRR harsh gr 2-3 SEM over LSB\n RESP: BS at bases, expiratory wheezes noted throughout\n ABD: soft, NT/ND/NABS\n EXTR: +1 pitting edema bilaterally (upper &lower) facial\n Labs / Radiology\n 61 K/uL\n 7.3 g/dL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg] ALL LABS FROM \n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n 10:45 AM\n 12:07 PM\n WBC\n 5.7\n 7.0\n 8.5\n Hct\n 25.8\n 25.9\n 22.5\n Plt\n 58\n 60\n 61\n Cr\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TropT\n 0.20\n TCO2\n 28\n 30\n Glucose\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/3/0.20, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n RPR Negative\n Urine & Blood Cx are NGTD\n C. Diff pending\n ECHO : The left atrium is mildly dilated. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity\n size is normal. Overall left ventricular systolic function is low\n normal (LVEF 50%). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The ascending\n aorta is moderately dilated. The aortic valve leaflets are severely\n thickened/deformed. There is moderate to severe aortic valve stenosis.\n Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Moderate (2+)\n mitral regurgitation is seen. [Due to acoustic shadowing, the severity\n of mitral regurgitation may be significantly UNDERestimated.] The left\n ventricular inflow pattern suggests impaired relaxation. The tricuspid\n valve leaflets are mildly thickened. The supporting structures of the\n tricuspid valve are thickened/fibrotic. There is a small pericardial\n effusion. The effusion appears circumferential. There are no\n echocardiographic signs of tamponade.\n Compared with the findings of the prior report (images unavailable for\n review) of , the findings are similar.\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF admitted with urosepsis, s/p\n extubation on , had recurrent A.fib with RVR & hypotension that\n responded to repeat IV fluid boluses, made DNR/DNI on with\n continued delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 45%. Pt naturally diuresed\n >1.5L overnight and developped Afib with RVR c/b hypotension that\n responded to repeated IVF boluses. Concern for aggressive fluid\n resuscitation sending pt into pulm edema, likely to compromise resp\n status. Per family meeting, pt was made DNR/DNI. Pt developped\n recurrent hypotension overnight required 750cc bolus, BP stable this\n am.\n - continue Digoxin 0.125mg every other day, holding Metoprolol for\n hypotension\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #Hypotension: Pt recently completed a 10 day course of Zosyn for\n pseudomonas urosepsis, successfully extubated on . WBC had trended\n down, afebrile. However, pt developed recurrent hypotension likely\n cardiogenic but will continue to cover with empiric ABx until all Cx\n data negative at 48hrs\n - blood & urine Cx pending\n - continue Vanc/Zosyn renally dosed (follow up am Vanc level) Day 2\n - avoid bolusing IVF if possible\n .\n # RENAL FAILURE, ACUTE: Pt developed oliguric renal failure likely \n hypoperfusion vs ATN in setting of shock. UOP has dropped in setting of\n hypotension, avoiding volume overload/pulm edema, labs pending this am\n - monitor creatinine\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed ?airspace\n disease in RLL likely chronic changes to h/o right sided\n pleurodeisis. Pt extubated successfully on and still maintaining\n sats on 3-4LNC, thought increased resp rate noted this am. Expiratory\n wheeze noted on exam today\n - f/u am CXR\n - continue with supplemental O2\n - albuterol nebs prn\n .\n # MS CHANGES: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed. All restraints have been removed, pt has been pulling out\n lines overnight\n - apprec Geripsych recs, continue Olanzapine 2.5mg qam & 5mg qhs\n - consider sitter\n - NPO for now, per s/s recs, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing to avoid MS \n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts slightly increased\n today at 60. Suspician of HITS very low & f/u HIT ab\n -continue holding heparin products for now\n .\n # Wound: sacral skin breakdown & intertriguinous rash.\n - kinair mattress with reg position changes\n - flexiseal prn loose stools\n - NS cleanser & apply criticaid with aquacel dressing\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR/DNI, no lines, no pressors\n Disposition: possibly called out to floor/home with hospice\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318767,
"text": "This is an 86 yo female pt with severe Aortic Stenosis, h/o renal cell\n and ovarian ca who presented with L hip pain and hypotension, with\n resolved pseudomonal urosepsis c/b a-fib/RVR, ARF (ATN), delirium and\n respiratory failure, now with recurrant afib, and hypotension.\n H/O hypotension (not Shock)\n Assessment:\n BP as low as 74/55, A-Fib, afebrile, oliguric, LS crackles.\n Action:\n Lopressor D/Ced, NS boluses given twice (500cc, then 250 cc), continued\n on antibiotics\n Response:\n BP improved after boluses to as high as 109/78, U/O is still low, HO\n informed, still in A-Fib, tolerating thick PO liquids with meds.\n Plan:\n Monitor BP closely, administer fluid boluses as needed, but be cautious\n because pt has pleural effusion and pulmonary edema, yesterday with\n agreement of family pt was made DNI/DNR, no pressors, no invasive\n lines.\n Delirium / confusion\n Assessment:\n Pt is alert, oriented to name and place (), dioriented to\n date/time, confused most of the times, pulled her IV out, pulled her O2\n NC frequently, tried to pull the Foley catheter out many times, HO\n informed, yet didn\nt agree on restraining pt until pt finally pulled\n her portocath line. Pt was able to communicate with her daughter who\n from to visit her this shift, though she was still\n confused most of the time, kept on asking to remove the flexiseal,\n which was D/Ced and asked to apply 2 diapers on her, which were changed\n frequently due to moderate brownish loose stool.\n Action:\n Given Zyprexa as ordered, Mental status assessed frequently,\n re-oriented every time mental status is assessed, restrained as\n ordered, IV nurses called in to re-access the portocath line.\n Response:\n Continued to be oriented x2, until at 0545 when she became only\n oriented to her name; she continued to be confused all through.\n Plan:\n Continue monitoring mental status and re-orienting pt frequently,\n administer anxio;ytic meds as ordered and as BP tolerates.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318692,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n , consult appreciated\n harsh murmur\n this am--recurrent afib with rvr, bp's 90's lopressor held, fluid bolus\n and BB then hypotensive to 70's\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 78 (57 - 83) bpm\n BP: 98/33(47) {55/22(40) - 135/75(78)} mmHg\n RR: 36 (22 - 43) insp/min\n SpO2: 91%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 907 mL\n 1,447 mL\n PO:\n 160 mL\n 480 mL\n TF:\n IVF:\n 747 mL\n 967 mL\n Blood products:\n Total out:\n 2,490 mL\n 155 mL\n Urine:\n 2,490 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,583 mL\n 1,292 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, No(t) Overweight / Obese, Thin,\n Anxious, confused, somnolent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), do not\n appreciate diastoloc murmur or rub,irreg\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : , Rhonchorous: diffuse), poor air mvoement\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): confused, Movement: Non -purposeful,\n No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 7.3 g/dL\n 61 K/uL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg]\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n WBC\n 6.1\n 5.7\n 7.0\n 8.5\n Hct\n 25.4\n 25.8\n 25.9\n 22.5\n Plt\n 40\n 58\n 60\n 61\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n Fluid analysis / Other labs: folate nl, vit b12 high, tsh pending\n Imaging: cxr--no chnage, small volumes, chronic r changes, b/l effusion\n tracking up, congestion small volumes\n Microbiology: no new micro\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, now with\n recurrant afib, hypotension\n Active issues remains:\n # hypotension--\n # Recurrent afib this am, appears cardiogenic, likely\n ischemic in setting of severe AS, though infection possibility given\n off antibx\n Continues to be senstivie to volume shifts, preload\n dependant but appears clinically asnd by imaging to be\n Vol up\n Continue dig, hold bb, ecg, cardiac enzymes, echo to reasess\n as, wedge, blood transfuse though may require pressors, a-line\n Family discussions regarding goals of care\n Empiric antibx vanco/zosyn with cx's\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension now with recurrent hypotension\n Auto-diureses phase of atn with good u/o, creatinine stable\n blood and hemodynamic management as above\n Renal dosing of meds pending further improvement\n > Delirium\ncontinues to be main issue, large component of sundowning\n at night and altered sleep schedule icu, now with recurrent\n hyppotension\n continue low dose zyprexa, haldol prn, re-orient, optimize sleep\n cycle at night\n h2 b d/c and changed to PPI\n limit narcotics\n anticipate extremely slow recovery\n # anemia--transfuse colloid--prbc's given slow drop\n > hypoxemia--stable on minimal NC o2 though with very tenuous\n respiratory status in setting of hypotension and severe AS, would prob\n not tol central line/lying flat without intubation, continue family\n discussion\n > Hypernatremia\nimproving with free water, remains NPO and diuresis,\n > Sacral abrasions--wound care following, mattress\n > Nutrition--aspiration risk and agitated so will hold on placing NGT\n NPO given tenuous status\n > Thrombocytopenia--\n Low ate baseline, though low suspicion of hit, heparin products\n stopped resend hit , Now improved and at prior baseline.\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n Completed zosyn course X 10 days\n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BB\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, tylenol\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318701,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, now with\n recurrant afib, hypotension\n 24 Hour Events:\n consult for delirium appreciated\n this am--recurrent afib with rvr, bp's 90's lopressor held, fluid bolus\n and BB then hypotensive to 70's\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 78 (57 - 83) bpm\n BP: 98/33(47) {55/22(40) - 135/75(78)} mmHg\n RR: 36 (22 - 43) insp/min\n SpO2: 91%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 907 mL\n 1,447 mL\n PO:\n 160 mL\n 480 mL\n TF:\n IVF:\n 747 mL\n 967 mL\n Blood products:\n Total out:\n 2,490 mL\n 155 mL\n Urine:\n 2,490 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,583 mL\n 1,292 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///30/\n Physical Examination\n General Appearance: somnolent, No(t) Overweight / Obese, Thin, Anxious,\n confused, somnolent\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WN, + JVD\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), do not\n appreciate diastolic murmur or rub,irreg\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t)\n Clear : , Crackles : , Rhonchorous: diffuse), poor air movement\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, Clubbing\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): confused, Movement: Non -purposeful,\n No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 7.3 g/dL\n 61 K/uL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg]\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n WBC\n 6.1\n 5.7\n 7.0\n 8.5\n Hct\n 25.4\n 25.8\n 25.9\n 22.5\n Plt\n 40\n 58\n 60\n 61\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n Fluid analysis / Other labs: folate nl, vit b12 high, tsh pending\n Imaging: cxr--no chnage, small volumes, chronic r changes, b/l effusion\n tracking up, congestion small volumes\n Microbiology: no new micro\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, now with\n recurrant afib, hypotension\n Active issues remains:\n # hypotension--\n - Recurrent afib this am\n - Hypotension likely is cardiogenic, possible ischemia in\n setting of severe AS and reduced co, though infection possibility given\n compeltion of antibx\n - Autodiureses and sensitive to volume shifts, preload\n dependant though appears volume up with elevated JVD and anasarca\n - Continue dig, hold bb, check stat ecg, cardiac enzymes,\n echo to reasess, blood transfuse though may require pressors if remains\n hypotensive, place a-line\n - Family discussions regarding goals of care\n - Empiric antibx vanco/zosyn with cx's\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension now with recurrent hypotension\n Auto-diureses phase of atn with good u/o, creatinine has been\n stable\n Blood transfuse and hemodynamic management as above\n Renal dosing of meds pending further improvement\n # Delirium\ncomponent of sundowning at night and altered sleep schedule\n icu, now with recurrent hyppotension\n continue low dose zyprexa, haldol prn, re-orient, optimize sleep\n cycle at night\n h2 b d/c and changed to PPI\n limit narcotics\n anticipate extremely slow recovery\n # anemia--transfuse colloid--prbc's\n > hypoxemia--stable on minimal NC o2 though with very tenuous\n respiratory status in setting of hypotension and severe AS, would not\n tol central line/lying flat without intubation, continue family\n discussion reagrding goals of care\n > Hypernatremia\nimproving with free water, remains NPO\n > Sacral abrasions--wound care following\n > Nutrition--aspiration risk and agitated so will hold on placing NGT,\n NPO given tenuous status\n > Thrombocytopenia--\n Low ate baseline, though low suspicion of hit, heparin products\n stopped resend hit , Now improved and at prior baseline.\n # pseudomonal urosepsis, now resolved\n Completed zosyn course X 10 days\n Remains af with normal wbc ct\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, tylenol\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate). Family mtg reagrding current\n condition and readdressing goals of care\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318738,
"text": "Impaired Skin Integrity\n Assessment:\n Perineal rash status quo, continues to appear inflammed and rash\n persists. Stage 2 coccyx decub status quo, dressing changed again today\n after being soiled w/stool. Aquacel dressing w/small to moderate\n serosang drainage, wound does not appear to be getting contaminated\n w/stool yet. Flexiseal rectal tube placed after 4^th incontinence of\n loose OB- stool.\n Action:\n Area cleansed after each stool and continues w/antifungal barrier\n cream.\n Response:\n No change in skin integrity from 3/5/8 to today\n Plan:\n Cont w/skin care plan per skin care RN, kinair bed to prevent further\n deterioration, nutrition and cont w/ turning q2hour.\n Atrial fibrillation (Afib)\n Assessment:\n Afib w/RVR, hypotensive, rx w/fluid and metoprolol\n Action:\n PO dose lopressor held as sbp 92, noted afib w/RVR to 140s and dropping\n b/p, initially rx w/IVF 250cc NS boli x 4 and once SBP >100 pt able to\n take 25mg lopressor PO. Pt then hypotensive and HR as low as 40s\n junctional rhythm. Continued w/afib, occasional RVR 140s and then\n bradycardic to 40.\n Response:\n HR irregular, tachy/brady. Hypotensive and bradycardic in response to\n 25mg PO lopressor.\n Plan:\n Continue to monitor, pt now dnr/dni, no pressors.\n Delirium / confusion\n Assessment:\n Mental status clearer today, no need for antipsychotic medication\n Action:\n Zyprexa held since 0800 dose\n Response:\n Minimal confusion, oriented to self and place, appears appropriate in\n conversing w/dtr and associating family members correctly.\n :\n Cont to hold zyprexa as allowed, reorient PRN and encourage normal\n sleep/wake cycle.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318802,
"text": "Chief Complaint:\n 24 Hour Events:\n - developped Afib with RVR & hypotension on , responded to repeat IV\n boluses\n - blood cultures sent, start on empiric Vanc/Zosyn\n - family meeting to address goals- now DNR/DNI, no lines, no pressors\n - received 1upRBCs & has been having minimal UOP\n - recurrent hypotension overnight, given total 750cc of boluses & BP\n stable\n - pt pulling out IVs & portacath\n Pt still confused, pulling out IVs. Denies any SOB/CP & wants to eat.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Day 2 Vancomycin\n Day 2 Piperacillin/Tazobactam (Zosyn)\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:10 PM\n Other medications:\n Allopurinol, Digoxin, Tylenol, Zyprexa, PPI\n Flowsheet Data as of 05:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36\nC (96.8\n HR: 83 (40 - 109) bpm\n BP: 94/34(50) {71/16(39) - 123/86(91)} mmHg\n RR: 17 (16 - 45) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 2,855 mL\n 908 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,000 mL\n 908 mL\n Blood products:\n 375 mL\n Total out:\n 336 mL\n 75 mL\n Urine:\n 336 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 833 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.34/53/86//0\n Physical Examination\n Gen: NAD, mildly agitated, confused\n HEENT: dry mucous membranes, JVP elev\n CV: RRR harsh gr 2-3 SEM over LSB\n RESP: BS at bases, expiratory wheezes noted throughout\n ABD: soft, NT/ND/NABS\n EXTR: +1 pitting edema bilaterally (upper &lower) facial\n Labs / Radiology\n 68\n 68\n 3.2\n 28\n 3.9\n 74\n 109\n 146\n 29.4\n 10\n [image002.jpg]\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n 10:45 AM\n 12:07 PM\n WBC\n 5.7\n 7.0\n 8.5\n Hct\n 25.8\n 25.9\n 22.5\n Plt\n 58\n 60\n 61\n Cr\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TropT\n 0.20\n TCO2\n 28\n 30\n Glucose\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/3/0.20, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n RPR Negative\n Urine & Blood Cx are NGTD\n C. Diff pending\n ECHO : The left atrium is mildly dilated. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity\n size is normal. Overall left ventricular systolic function is low\n normal (LVEF 50%). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The ascending\n aorta is moderately dilated. The aortic valve leaflets are severely\n thickened/deformed. There is moderate to severe aortic valve stenosis.\n Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Moderate (2+)\n mitral regurgitation is seen. [Due to acoustic shadowing, the severity\n of mitral regurgitation may be significantly UNDERestimated.] The left\n ventricular inflow pattern suggests impaired relaxation. The tricuspid\n valve leaflets are mildly thickened. The supporting structures of the\n tricuspid valve are thickened/fibrotic. There is a small pericardial\n effusion. The effusion appears circumferential. There are no\n echocardiographic signs of tamponade.\n Compared with the findings of the prior report (images unavailable for\n review) of , the findings are similar.\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF admitted with urosepsis, s/p\n extubation on , had recurrent A.fib with RVR & hypotension that\n responded to repeat IV fluid boluses, made DNR/DNI on with\n continued delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 50%. Pt developped Afib\n with RVR c/b hypotension that responded to repeated IVF boluses.\n Concern for aggressive fluid resuscitation sending pt into pulm edema,\n likely to compromise resp status. Per family meeting, pt was made\n DNR/DNI, no lines, no pressors. Pt have some recurrent hypotension\n overnight requiring 750cc bolus, BP stable this am. Avoiding\n aggressive volume boluses due to tenous volume status\n - continue Digoxin 0.125mg every other day, f/u am dig level, holding\n Metoprolol due to hypotension\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #Hypotension: Pt recently completed a 10 day course of Zosyn for\n pseudomonas urosepsis, successfully extubated on . WBC had trended\n down, afebrile. However, pt developed recurrent hypotension likely\n cardiogenic etiology but will continue to cover with empiric ABx until\n all Cx data negative at 48hrs. WBC ct mildly elevated this am, will\n continue to monitor.\n - f/u blood & urine Cx\n - continue Vanc/Zosyn renally dosed Day 2 (Vanc level 18, will admin 1\n gram today & f/u am level)\n - avoid large volume bolusing if possible\n .\n # RENAL FAILURE, ACUTE: Pt initially with oliguric renal failure likely\n hypoperfusion vs ATN in setting of shock. Pt began to naturally\n diurese, then UOP dropped in setting of hypotension am. Currently,\n avoiding volume overload with gentle IVF boluses. Creatinine mildly\n increased at 3.2 today and minimal UOP overnight.\n - monitor creatinine daily, supportive care\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with bilateral pleural effusions R>L & pulm edema. CT on\n showed possible airspace disease in RLL vs chronic changes to\n right sided pleurodeisis. Pt extubated successfully on and has been\n maintaining sats on 2-3LNC. Expiratory wheeze noted on exam today\n - continue with supplemental O2\n - albuterol nebs prn\n .\n # MS CHANGES: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed. Pt has been pulling out lines overnight, had to place\n restraints temporary.\n - d/c restraints as soon as possible\n - apprec Geripsych recs, continue Olanzapine 2.5mg qam & 5mg qhs\n - pleasure feeds with pureed nectar thickened feeds with aspiration\n precautions & monitoring\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing (avoid MS )\n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down to 40 &\n heparin products held . Plts have been stable in 60s. Suspician\n of HITS very low and HIT Ab never sent from lab.\n -continue holding heparin products for now due to thrombocytopenia\n .\n # Wound: sacral skin breakdown & intertriguinous rash. Apprec Wound\n care rec\n - kinair mattress with reg position changes\n - NS cleanser & apply criticaid with aquacel dressing\n ICU Care\n Nutrition: pleasure feeds with pureed nectar thickened feeds (maintain\n strict aspiration precautions)\n Glycemic Control: ISS\n Lines: Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR/DNI, no lines, no pressors\n Disposition: called out to medicine\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318425,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n extubated yesterday\n diruesing\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 71 (66 - 83) bpm\n BP: 139/44(76) {100/32(54) - 152/52(85)} mmHg\n RR: 28 (17 - 42) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 513 mL\n 50 mL\n PO:\n TF:\n 345 mL\n IVF:\n 138 mL\n 50 mL\n Blood products:\n Total out:\n 2,720 mL\n 1,495 mL\n Urine:\n 2,720 mL\n 1,495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,207 mL\n -1,445 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 333 (333 - 333) mL\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100% (2L)\n ABG: 7.38/45/99./23/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 333\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, anasarca\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), nsr\n with ectopy\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: 2+, Left: 2+, RUE with increased edema\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 40 K/uL\n 91 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 109 mEq/L\n 142 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n WBC\n 7.4\n 6.1\n Hct\n 26.6\n 25.4\n Plt\n 47\n 42\n 40\n Cr\n 3.1\n 2.9\n TCO2\n 22\n 25\n 27\n 25\n 24\n 26\n 28\n Glucose\n 144\n 91\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Imaging: no new imaging\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b Afib/RVR, ARF (ATN) and respiratory failure stable since\n extubation\n Active issues remains:\n > Respiratory failure\nstable since extibation with excellent\n ventilation and oxygetation still with significant vol o/l with\n ciontnued good response to diuresis, stable cxr appearanced (h/o r\n pleurodesis)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine\n Continue thiazide and lasix (goal 500-1 L negative as BP\n tolerates) as she is somewhat preload dep with sig AS\n Continue phos binder and renal dosing of meds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n complete zosyn course day \n Repeat ucx for surveillance is pending though clinically improved\n Remains af with normal wbc ct\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP stable\n continue diuresis\n ATRIAL FIBRILLATION (AFIB)- now in sinus rythm w/ ectopy\n check 12\n lead\n Continue dig for now though this could be d/c'd if she\n rtemains stable in NSR\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration and now appears at\n baseline, dic labs negative and HUS/TTP unlikely, follow for further\n reduction from baseline, although low suspicion for hit--will d/c hepo\n products and send hit panel, start pneumoboots\n > anemia- h/h now stable, transfuse for < 21 or active bleed or if\n hypotension\n CANCER (MALIGNANT NEOPLASM), GYNECOLOGICAL (OVARIAN, UTERINE,\n CERVICAL, ENDOMETRIAL)--f/u on additional oncological hx\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n Continue lido patch, readdress pain level once extubated dilaudid\n > delirium--sundowning, would start zyprexa, d/c foley as ms \nICU Care\n Nutrition:\n Comments: crushed pills, speech and swallow and advance with\n supervision pending assessment\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Comments: d/c central line and a-line, using porta cath and try for\n peripherals\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318434,
"text": "Chief Complaint: urosepsis, a fib\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b Afib/RVR, ARF (ATN) and respiratory failure stable since\n extubation\n 24 Hour Events:\n extubated yesterday\n diuresing\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 71 (66 - 83) bpm\n BP: 139/44(76) {100/32(54) - 152/52(85)} mmHg\n RR: 28 (17 - 42) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 513 mL\n 50 mL\n PO:\n TF:\n 345 mL\n IVF:\n 138 mL\n 50 mL\n Blood products:\n Total out:\n 2,720 mL\n 1,495 mL\n Urine:\n 2,720 mL\n 1,495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,207 mL\n -1,445 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 333 (333 - 333) mL\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100% (2L)\n ABG: 7.38/45/99./23/0\n Ve: 5.8 L/min\n PaO2 / FiO2: 333\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, anasarca\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), nsr\n with ectopy\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n Obese\n Extremities: Right: 2+, Left: 2+, RUE with increased edema\n Musculoskeletal: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 40 K/uL\n 91 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 109 mEq/L\n 142 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n WBC\n 7.4\n 6.1\n Hct\n 26.6\n 25.4\n Plt\n 47\n 42\n 40\n Cr\n 3.1\n 2.9\n TCO2\n 22\n 25\n 27\n 25\n 24\n 26\n 28\n Glucose\n 144\n 91\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Imaging: no new imaging\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure stable since\n extubation\n Active issues remains:\n respiratory failure\nstable since extubation with excellent\n ventilation and oxygenation\n stable cxr appearanc (h/o r pleurodesis)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine\n Continue thiazide and lasix (goal 500-1 L negative as BP\n tolerates) as she is preload dependent with sig AS\n Continue phos binder and renal dosing of meds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n complete zosyn course day \n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP stable\n continue diuresis\n ATRIAL FIBRILLATION (AFIB)- now in sinus w/\n ectopy\n check 12 lead\n Continue dig for now though this can be d/c'd if she remains\n stable in NSR\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration then at abseline,\n dic labs negative and HUS/TTP unlikely,\n Have dropped now below prior baseline--although low suspicion for\n hit--will d/c heparin products and send hit panel, start pneumoboots\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n Continue lido patch, readdress pain level once extubated dilaudid\n > delirium-- start zyprexa\n ICU Care\n Nutrition:\n Comments: crushed pills, speech and swallow and advance with\n supervision pending assessment\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM\n Arterial Line - 04:15 PM\n Comments: d/c central line and a-line, using porta cath and try for\n peripherals\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318517,
"text": "86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonas urosepsis\n c/b A fib/RVR, ARF (ATN) and respiratory failure stable since\n extubation\n Atrial fibrillation (Afib)\n Assessment:\n Episode of afib with RVR up to 144\n Action:\n Received 500cc LR x1\n Response:\n Patient went back into SR with occasional pvc and pac\n Plan:\n Lasix and diuril were discontinued, monitor urine output and cardiac\n rhythm\n Delirium / confusion\n Assessment:\n Alert to lethargic oriented to person, daughter but nothing else\n Action:\n Allowed time to rest, oriented frequently, on .olanzapine\n Response:\n Continues to be lethargic and disoriented\n Plan:\n Dilaudid discontinued, use Tylenol 650mg po q 6 round the clock for\n pain, olanzipine, allow rest periods, reorient frequently\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318533,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca who\n presented with L hip pain and hypotension, with resolved pseudomonal\n urosepsis c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure\n stable since extubation\n 24 Hour Events:\n PRESEP CATHETER - STOP 12:06 PM\n ARTERIAL LINE - STOP 12:06 PM\n afib with rvr overnight, response to IVF and metoprolol\n failed speech and swallow,\n a line and r ij d/c'd\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 11:25 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.5\nC (95.9\n HR: 143 (69 - 143) bpm\n BP: 106/44(60) {100/29(47) - 138/61(71)} mmHg\n RR: 25 (17 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (11 - 12)mmHg\n Total In:\n 2,050 mL\n 767 mL\n PO:\n 300 mL\n 240 mL\n TF:\n IVF:\n 1,750 mL\n 527 mL\n Blood products:\n Total out:\n 3,275 mL\n 950 mL\n Urine:\n 3,275 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, confused\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), tachy, irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases r> L)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to):\n confused, Movement: Purposeful, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 58 K/uL\n 156 mg/dL\n 3.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 69 mg/dL\n 106 mEq/L\n 143 mEq/L\n 25.8 %\n 5.7 K/uL\n [image002.jpg]\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n WBC\n 6.1\n 5.7\n Hct\n 25.4\n 25.8\n Plt\n 42\n 40\n 58\n Cr\n 2.9\n 2.9\n 3.0\n TCO2\n 25\n 24\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.7 mg/dL\n Imaging: cxr--b/l effusions, small volumes, chronic changes R base\n Microbiology: urine ngtd,\n c diff neg mulitple\n blood ngtd\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, stable\n since extubation\n Active issues remains:\n ATRIAL FIBRILLATION (AFIB)- recurrent afib overnight likely in\n setting of significant diuresis and volume shifts, improving with ivf\n and BB\n Continue dig, BB prn, monitor u/o and lasix prn\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration then at abseline,\n heparin products d/c'd yesterday and hit panel sent given\n slow drop, though low suspicion of hit. Now improved and at prior\n baseline. ,\n > delirium-- icu and impaired sleep wake cycle, narcotics, continue\n zyprexa, reorient, optimize sleep cycle at night\n limit narcotics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine\n Continue phos binder and renal dosing of meds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n completing zosyn course day \n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP stable\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, readdress pain level once extubated dilaudid\n ICU Care\n Nutrition:\n Comments: NPO, repeat speech and swallow\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments: PT consult\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU, possible floor transfer later if heart rate stable,\n given recurrent afib w/rvr\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318535,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca who\n presented with L hip pain and hypotension, with resolved pseudomonal\n urosepsis c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure,\n extubated\n 24 Hour Events:\n PRESEP CATHETER - STOP 12:06 PM\n ARTERIAL LINE - STOP 12:06 PM\n afib with rvr overnight, response to IVF and metoprolol\n failed speech and swallow,\n a line and r ij d/c'd\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 11:25 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.5\nC (95.9\n HR: 143 (69 - 143) bpm\n BP: 106/44(60) {100/29(47) - 138/61(71)} mmHg\n RR: 25 (17 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (11 - 12)mmHg\n Total In:\n 2,050 mL\n 767 mL\n PO:\n 300 mL\n 240 mL\n TF:\n IVF:\n 1,750 mL\n 527 mL\n Blood products:\n Total out:\n 3,275 mL\n 950 mL\n Urine:\n 3,275 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, confused\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), tachy, irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases r> L)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to):\n confused, Movement: Purposeful, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 58 K/uL\n 156 mg/dL\n 3.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 69 mg/dL\n 106 mEq/L\n 143 mEq/L\n 25.8 %\n 5.7 K/uL\n [image002.jpg]\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n WBC\n 6.1\n 5.7\n Hct\n 25.4\n 25.8\n Plt\n 42\n 40\n 58\n Cr\n 2.9\n 2.9\n 3.0\n TCO2\n 25\n 24\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.7 mg/dL\n Imaging: cxr--b/l effusions, small volumes, chronic changes R base\n Microbiology: urine ngtd,\n c diff neg mulitple\n blood ngtd\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, stable\n since extubation\n Active issues remains:\n ATRIAL FIBRILLATION (AFIB)- recurrent afib overnight in setting of\n significant diuresis and volume shifts, improving with ivf and BB\n Continue dig, BB prn\nbut will start standing PO, monitor u/o\n and give lasix prn\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > Thrombocytopenia--\n slow drop, though low suspicion of hit, heparin products stopped\n and Hit panel sent, Now improved and at prior baseline.\n > Delirium\n icu, impaired sleep wake cycle, narcotics, continue\n zyprexa, reorient, optimize sleep cycle at night\n limit narcotics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n A uto-diureses phase of atn and expect to start seeing\n improvement in creatinine\n Continue phos binder and renal dosing of meds pending further\n improvement\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n Completing zosyn course day \n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, readdress pain level once extubated dilaudid\n ICU Care\n Nutrition:\n Comments: NPO, repeat speech and swallow\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments: PT consult\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU, possible floor transfer later if heart rate stable,\n given recurrent afib w/rvr\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318613,
"text": "Chief Complaint:\n 24 Hour Events:\n -- significantly more delerious\n -- 2 episodes of AF w/ RVR requiring iv metoprolol w/ improvement\n -- started on 12.5mg po metoprolol standing\n -- too delerious for swallow study, cont pleasure feeding w/ thickened\n diet, but recommended TF until resolves, patient too delerious to\n approach for NG tube placement\n -- completed zosyn course\n Pt confused, not speaking in sentences or responding appropriately to\n questions\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam last dose \n Infusions:\n Other ICU medications:\n Metoprolol - 03:30 PM\n Furosemide (Lasix) - 10:59 PM\n Other medications:\n Allopurinol, Tamoxifen, Famotidine, Phoslo, Olanzapine, Colace,\n Metoprolol, digoxin\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.7\nC (96.3\n HR: 77 (63 - 143) bpm\n BP: 130/39(62) {101/19(41) - 134/70(78)} mmHg\n RR: 33 (16 - 41) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 1,577 mL\n 75 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,337 mL\n 75 mL\n Blood products:\n Total out:\n 2,240 mL\n 1,400 mL\n Urine:\n 2,240 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -663 mL\n -1,325 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n GEN: NAD, confused, anasarca improved, noncompliant with exam\n CV: RRR harsh gr 3 SEM over LSB\n RESP: pt not compliant with exam, crackles at LLL base, BS over\n RLL base\n ABD: soft, NT, ND, BS:\n EXTR: edema still + pitting bilaterally\n Labs / Radiology\n CXR from pending\n 60 K/uL\n 8.5 g/dL\n 95 mg/dL\n 2.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 67 mg/dL\n 107 mEq/L\n 148 mEq/L\n 25.9 %\n 7.0 K/uL\n [image002.jpg]\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n WBC\n 6.1\n 5.7\n 7.0\n Hct\n 25.4\n 25.8\n 25.9\n Plt\n 42\n 40\n 58\n 60\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n No new culture data\n Free water deficit of approx 2.5L\n ASSESSMENT & PLAN:\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n urosepsis, s/p extubation on , still having intermittent A.fib\n with RVR and delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 45%. Pt has been\n aggressively diuresed and developped Afib with RVR again overnight,\n responded to IV Lopressor. Started on Metoprolol 12.5mg . Pt with\n extravascular volume overload but intravascularly dry. (free water\n deficit of 2.5L, with rising Na) Pt very preload dependant & tends to\n develop A.Fib with RVR when preload drops. Holding diuresis today and\n watching resp status, will get CXR today to better eval lung fields.\n - continue Digoxin 0.125mg every other day, increase Metoprolol to 25mg\n today\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #SEPSIS/UTI: resolved, presumed urosepsis with UCx positive for\n Pseudomonas, completed 10/10 days of Zosyn. Pt was intubated on \n for worsening acidosis/MS changes, successfully extubated on . WBC\n down, afebrile, no recurrence of hypotension. Other infectious w/u\n neg, L chest U/S neg for abscess,Bone scan neg\n - Blood Cx NGTD, Urine culture was + 2 diff pseudomonas, both pan\n sensitive, s/p 10 days of Zosyn\n .\n # RENAL FAILURE, ACUTE: Pt developed oliguric renal failure likely \n hypoperfusion vs ATN in setting of shock. UOP improved & responded well\n to Lasix diuresis. Now with rising Na & free water deficit of approx\n 2.5L likely due to large insensible losses. Hold diurectics today, will\n admin D5W at 75cc/hr for total of 1L.\n - monitor i/os, goal net negative even\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed ?airspace\n disease in RLL likely chronic changes to h/o right sided\n pleurodeisis. Pt extubated successfully on and currently sating\n well on 2L NC. Pt intermittently tachypneic likely agitation, will\n f/u CXR today\n -continue with supplemental O2 & goal even i/os\n .\n # MS changes: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed, will d/c H2 blocker, holding all narcotics. All restraints\n have been removed, line\ns d/c\n - consult Geripsych today\n - continue Olanzapine \n - speech & swallow f/u eval prior to adv diet, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing to avoid MS \n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts slightly increased\n today at 60. Suspician of HITS very low but will f/u HIT Ab currently\n pending\n -continue holding heparin products fow now\n .\n # Wound: sacral skin breakdown & intertriguinous rash.\n - apprec wound care consult, will f/u recs\n - konair mattress with reg position changes\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines: Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: d/c\nd famotidine\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318813,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318816,
"text": "Briefly this is an 86 y/o F w/ a PMH significant for severe aortic\n stenosis, CHF, CRI & A-fib who was admitted with urosepsis, extubated\n on without complication however has had recurrent episodes of A-fib\n w/ RVR and associated hypotension which responds well to repeat IV\n fluid boluses. Pt is DNR/DNI and the family has expressed the desire\n not to pursue aggressive therapy (central lines/pressors etc...) At\n this time the family is considering changing code status to CMO but\n requested more time to discuss with other family members.\n Impaired Skin Integrity\n Assessment:\n Stage II sacrum, stage I coccyx\n Action:\n Wound cleanser, soft sorb applied, currently on a Air mattress\n Response:\n Skin integrity remains impaired\n Plan:\n Continue Q 2 hr turns, wound care, and air mattress to facilitate wound\n healing and prevent further breakdown\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Baseline Cr 1.8 currently 3.2, remains oliguric w/ urine output\n <15cc/hr\n Action:\n Renally dose all meds, small fluid boluses for hypotension\n Response:\n Plan:\n Continue with current management as pt is not a candidate for HD\n Atrial fibrillation (Afib)\n Assessment:\n Severe AS & CHF with an EF of 50% developed RVR overnight, currently\n rate controlled.\n Action:\n 500cc NS bolus x 2 overnight\n Response:\n Rhythm broke and has remained rate controlled\n Plan:\n Fluid boluses for rate control of RVR, cont to hold lopressor due to\n hypotension, cont w/ q OD digoxin follow up with dig level each AM.\n Delirium / confusion\n Assessment:\n Mental status waxes and wanes, delirium likely related to prolonged ICU\n stay/poly pharmacy/ discomfort, pulled out IV and de-accessed port a\n cath overnight\n Action:\n Frequently reoriented, zyprexa 2.5am & 5mg HS, soft wrist restraints\n for the protection of lines/tubes.\n Response:\n Sleep wake cycle remains disturbed sleeping mostly during the day\n Plan:\n Cont to reorient and re assess need for restraints.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318817,
"text": "Briefly this is an 86 y/o F w/ a PMH significant for severe aortic\n stenosis, CHF, CRI & A-fib who was admitted with urosepsis, extubated\n on without complication however has had recurrent episodes of A-fib\n w/ RVR and associated hypotension which responds well to repeat IV\n fluid boluses. Pt is DNR/DNI and the family has expressed the desire\n not to pursue aggressive therapy (central lines/pressors etc...) At\n this time the family is considering changing code status to CMO but\n requested more time to discuss with other family members.\n Impaired Skin Integrity\n Assessment:\n Stage II sacrum, stage I coccyx\n Action:\n Wound cleanser, soft sorb applied, currently on a Air mattress\n Response:\n Skin integrity remains impaired\n Plan:\n Continue Q 2 hr turns, wound care, and air mattress to facilitate wound\n healing and prevent further breakdown\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Baseline Cr 1.8 currently 3.2, remains oliguric w/ urine output\n <15cc/hr\n Action:\n Renally dose all meds, small fluid boluses for hypotension\n Response:\n Plan:\n Continue with current management as pt is not a candidate for HD\n Atrial fibrillation (Afib)\n Assessment:\n Severe AS & CHF with an EF of 50% developed RVR overnight, currently\n rate controlled.\n Action:\n 500cc NS bolus x 2 overnight\n Response:\n Rhythm broke and has remained rate controlled\n Plan:\n Fluid boluses for rate control of RVR, cont to hold lopressor due to\n hypotension, cont w/ q OD digoxin follow up with dig level each AM.\n Delirium / confusion\n Assessment:\n Mental status waxes and wanes, delirium likely related to prolonged ICU\n stay/poly pharmacy/ discomfort, pulled out IV and de-accessed port a\n cath overnight\n Action:\n Frequently reoriented, zyprexa 2.5am & 5mg HS, soft wrist restraints\n for the protection of lines/tubes.\n Response:\n Sleep wake cycle remains disturbed sleeping mostly during the day,\n confusion persists\n Plan:\n Cont to reorient and re assess need for restraints.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318818,
"text": "Chief Complaint: urosepsis, afib with rvr, delirium, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 86 yo F with severe AS, h/o renal cell and ovarian ca w/\n complicated and prolonged ICU course\n resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure, with\n recurrent afib, hypotension\n 24 Hour Events:\n a rib with rvr and hyptension yesterday\n empiric antibx coverage restarted, pan cxs sent\n family mtg with goals of care readdressed --> change in code status to\n dnr/dni,\n no lines pressors\n recurrent transient hypotension overnight responded to IVF bolus\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 12:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:10 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 113 (40 - 113) bpm\n BP: 115/42(66) {71/16(39) - 123/86(91)} mmHg\n RR: 24 (16 - 45) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 2,855 mL\n 995 mL\n PO:\n 480 mL\n 20 mL\n TF:\n IVF:\n 2,000 mL\n 915 mL\n Blood products:\n 375 mL\n Total out:\n 336 mL\n 130 mL\n Urine:\n 336 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,519 mL\n 865 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.34/53/86/28/0\n Physical Examination\n General Appearance: No acute distress, agitated, confused, elderly\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases, No(t) Wheezes : , Diminished: bases), poor coop with exam\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender: ,\n Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing,\n decreased edema\n Skin: Warm\n Neurologic: Responds to: somnolent\n Labs / Radiology\n 9.6 g/dL\n 68 K/uL\n 68 mg/dL\n 3.2 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 74 mg/dL\n 109 mEq/L\n 146 mEq/L\n 29.4 %\n 10.0 K/uL\n [image002.jpg]\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n 10:45 AM\n 12:07 PM\n 05:01 AM\n WBC\n 5.7\n 7.0\n 8.5\n 10.0\n Hct\n 25.8\n 25.9\n 22.5\n 29.4\n Plt\n 58\n 60\n 61\n 68\n Cr\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n 3.2\n TropT\n 0.20\n TCO2\n 30\n Glucose\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n 68\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/3/0.20, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.5 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:7.9 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n Fluid analysis / Other labs: vanco level 18\n dig level pending\n nr rpr\n Imaging: echo--mod sym lvh, ef 50%, mild 1+ ar, mod-sev as, mod 2+ mr\n sm peric eff without tamponande physiology\n no cxr today\n Microbiology: urine blood ngtd\n c diff pending\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca w/ complicated\n and prolonged ICU course\n resolved pseudomonal urosepsis c/b a-fib/RVR,\n ARF (ATN), delirium and respiratory failure, with recurrent a-fib,\n hypotension\n Family mtg yesterday, readdressing of goals of care\ntransitioning\n toward hospice, now dnr/dni status and no pressors or lines,\n Active issues remains:\n # hypotension--\n - Recurrent a-fib with ongoing difficulty optimizing volume\n status in setting of mod-to severe as and arf\n - Hypotension likely cardiogenic, possible ischemia in setting\n of severe AS and reduced co, though infection remains possibility\n - Gentle ivf boluses, monitoring resp status\n - remains very sensitive to volume shifts, preload\n dependant\n - Continue dig, hold bb for now\n - Continue empiric antibx , vanco/zosyn X 48 hrs pending\n cx data\nas on standing tylenol for pain so may not mount temp, now with\n mild luekocytosis\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension now with recurrent hypotension and decreased u/o\n continue supportive care, monitor cr with gentle hydration for BP\n support, hold on diureses\n renal dosing of meds pending further improvement\n # Delirium\nmultiple reasons, component of sun-downing at night and\n altered sleep schedule icu, now with recurrent hypotension\n Continue low dose zyprexa, haldol prn, re-orient, optimize sleep\n cycle at night with light and dark cues\n h2 b d/c\n changed to PPI\n limit narcotics\n anticipate extremely slow recovery\n > hypoxemia--stable on minimal NC O2, nebs prn\n > Hypernatremia\nimproving with free water\n > Sacral abrasions--wound care following\n > Nutrition--aspiration risk, nector thick puree diet with supervision\n > Thrombocytopenia--\n baseline and stable, though low suspicion of hit, holding heparin\n productas and using pneumoboots for prophy\n # pseudomonal urosepsis, now resolved\n Completed zosyn course X 10 days\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, tylenol\n ICU Care\n Nutrition:\n Comments: puree diet with supervision\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI, no lines pressors\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318819,
"text": "Briefly this is an 86 y/o F w/ a PMH significant for severe aortic\n stenosis, CHF, CRI & A-fib who was admitted with urosepsis, extubated\n on without complication however has had recurrent episodes of A-fib\n w/ RVR and associated hypotension which responds well to repeat IV\n fluid boluses. Pt is DNR/DNI and the family has expressed the desire\n not to pursue aggressive therapy (central lines/pressors etc...) they\n are currently considering changing code status to CMO but requested\n more time to discuss with other family members.\n Impaired Skin Integrity\n Assessment:\n Stage II sacrum, stage I coccyx\n Action:\n Wound cleanser, soft sorb applied, currently on a Air mattress\n Response:\n Skin integrity remains impaired\n Plan:\n Continue Q 2 hr turns, wound care, and air mattress to facilitate wound\n healing and prevent further breakdown\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Baseline Cr 1.8 currently 3.2, remains oliguric w/ urine output\n <15cc/hr\n Action:\n Renally dose all meds, small fluid boluses for hypotension\n Response:\n Plan:\n Continue with current management as pt is not a candidate for HD\n Atrial fibrillation (Afib)\n Assessment:\n Severe AS & CHF with an EF of 50% developed RVR overnight, currently\n rate controlled.\n Action:\n 500cc NS bolus x 2 overnight\n Response:\n Rhythm broke and has remained rate controlled\n Plan:\n Fluid boluses for rate control of RVR, cont to hold lopressor due to\n hypotension, cont w/ q OD digoxin follow up with dig level each AM.\n Delirium / confusion\n Assessment:\n Mental status waxes and wanes, delirium likely related to prolonged ICU\n stay/poly pharmacy/ discomfort, pulled out IV and de-accessed port a\n cath overnight\n Action:\n Frequently reoriented, zyprexa 2.5am & 5mg HS, soft wrist restraints\n for the protection of lines/tubes.\n Response:\n Sleep wake cycle remains disturbed sleeping mostly during the day,\n confusion persists\n Plan:\n Cont to reorient and re assess need for restraints.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318821,
"text": "Demographics\n Attending MD:\n ,\n Admit diagnosis:\n UTI/ PYELONEPHRITIS\n Code status:\n DNR (do not resuscitate)\n Height:\n 60 Inch\n Admission weight:\n 62 kg\n Daily weight:\n 74.8 kg\n Allergies/Reactions:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Precautions: Contact\n PMH: Diabetes - Oral , GI Bleed, Renal Failure\n CV-PMH: CHF, Hypertension\n Additional history: 20years hx. of ovarian ca with mets to liver,\n bowel, s/p chemo, XRT, bowel resection in past. recurrent UTIs, DJD of\n knees, gout, Bells palsy,left renal tumor x2 s/p cyberknife\n radioablation in ,CHF - moderate AS and EF 50%,\n HTN, diverticulitis, s/p Left CEA, TAH/BSO 19 years ago, CRI Cr 1.3-1.6\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:102\n D:40\n Temperature:\n 96.2\n Arterial BP:\n S:145\n D:46\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 67 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,295 mL\n 24h total out:\n 150 mL\n Pertinent Lab Results:\n Sodium:\n 146 mEq/L\n 05:01 AM\n Potassium:\n 3.9 mEq/L\n 05:01 AM\n Chloride:\n 109 mEq/L\n 05:01 AM\n CO2:\n 28 mEq/L\n 05:01 AM\n BUN:\n 74 mg/dL\n 05:01 AM\n Creatinine:\n 3.2 mg/dL\n 05:01 AM\n Glucose:\n 68 mg/dL\n 05:01 AM\n Hematocrit:\n 29.4 %\n 05:01 AM\n Finger Stick Glucose:\n 104\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Hearing aids: (Right Ear, Left Ear )\n Other valuables:\n Clothes: Sent home with: daughters\n / :\n No money / \n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: M/\n Transferred to: 11 R\n Date & time of Transfer: 12:00 AM\n Briefly this is an 86 y/o F w/ a PMH significant for severe aortic\n stenosis, CHF, CRI & A-fib who was admitted with urosepsis, extubated\n on without complication however has had recurrent episodes of A-fib\n w/ RVR and associated hypotension which responds well to IV fluid\n boluses. Pt is DNR/DNI and the family has expressed the desire not to\n pursue aggressive therapy (central lines/pressors etc...) they are\n currently considering changing code status to CMO but requested more\n time to discuss with other family members.\n Impaired Skin Integrity\n Assessment:\n Stage II sacrum, stage I coccyx\n Action:\n Wound cleanser, soft sorb applied, currently on a Air mattress\n Response:\n Skin integrity remains impaired\n Plan:\n Continue Q 2 hr turns, wound care, and air mattress to facilitate wound\n healing and prevent further breakdown\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Baseline Cr 1.8 currently 3.2, remains oliguric w/ urine output\n <15cc/hr\n Action:\n Renally dose all meds, small fluid boluses for hypotension\n Response:\n Plan:\n Continue with current management as pt is not a candidate for HD\n Atrial fibrillation (Afib)\n Assessment:\n Severe AS & CHF with an EF of 50% developed RVR overnight, currently\n rate controlled.\n Action:\n 500cc NS bolus x 2 overnight\n Response:\n Rhythm broke and has remained rate controlled\n Plan:\n Fluid boluses for rate control of RVR, cont to hold lopressor due to\n hypotension, cont w/ q OD digoxin follow up with dig level each AM.\n Delirium / confusion\n Assessment:\n Mental status waxes and wanes, delirium likely related to prolonged ICU\n stay/poly pharmacy/ discomfort, pulled out IV and de-accessed port a\n cath overnight\n Action:\n Frequently reoriented, zyprexa 2.5am & 5mg HS, soft wrist restraints\n for the protection of lines/tubes.\n Response:\n Sleep wake cycle remains disturbed sleeping mostly during the day,\n confusion persists\n Plan:\n Cont to reorient and re assess need for restraints.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318500,
"text": "86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b Afib/RVR, ARF (ATN) and respiratory failure stable since\n extubation\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 318505,
"text": "Chief Complaint: urosepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n PRESEP CATHETER - STOP 12:06 PM\n ARTERIAL LINE - STOP 12:06 PM\n afib with rvr, overnight, response to IVF and metoprolol\n failed speech and swallow,\n a line and r ij d/c'd\n History obtained from house staff\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 11:25 PM\n Other medications:\n per (reviewed)\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 35.5\nC (95.9\n HR: 143 (69 - 143) bpm\n BP: 106/44(60) {100/29(47) - 138/61(71)} mmHg\n RR: 25 (17 - 32) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (11 - 12)mmHg\n Total In:\n 2,050 mL\n 767 mL\n PO:\n 300 mL\n 240 mL\n TF:\n IVF:\n 1,750 mL\n 527 mL\n Blood products:\n Total out:\n 3,275 mL\n 950 mL\n Urine:\n 3,275 mL\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, confused\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), tachy, irreg\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases r> L)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, Oriented (to):\n confused, Movement: Purposeful, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.3 g/dL\n 58 K/uL\n 156 mg/dL\n 3.0 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 69 mg/dL\n 106 mEq/L\n 143 mEq/L\n 25.8 %\n 5.7 K/uL\n [image002.jpg]\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n WBC\n 6.1\n 5.7\n Hct\n 25.4\n 25.8\n Plt\n 42\n 40\n 58\n Cr\n 2.9\n 2.9\n 3.0\n TCO2\n 25\n 24\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:4.7 mg/dL\n Imaging: cxr--b/l effusions, small volumes, chronic changes R base\n Microbiology: urine ngtd,\n c diff neg mulitple\n blood ngtd\n Assessment and Plan\n 86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonal urosepsis\n c/b a-fib/RVR, ARF (ATN), delirium and respiratory failure stable since\n extubation\n Active issues remains:\n ATRIAL FIBRILLATION (AFIB)- recurrent afib overnight likely in\n setting of significant diuresis and volume shifts, improving with ivf\n and BB\n Continue dig, BB prn, monitor u/o and lasix prn\n Daily stoke risk low and would not anticoagulate at this time\n given low plts at baseline, though would reassess as clinical picture\n improves as may remain in paroxysmal afib\n > thrombocytopenia--baseline thrombocytopenia in 50-70 range, with\n initial elevation here likely from hemoconcentration then at abseline,\n heparin products d/c'd yesterday and hit panel sent given\n slow drop, though low suspicion of hit. Now improved and at prior\n baseline. ,\n > delirium-- icu and impaired sleep wake cycle, narcotics, continue\n zyprexa, reorient, optimize sleep cycle at night\n limit narcotics\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) atn from sepsis and\n hypotension\n Entering auto-diureses phase of atn and expect to start seeing\n improvement in creatinine\n Continue phos binder and renal dosing of meds\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)-pseudomonal urosepsis, now\n resolved\n completing zosyn course day \n Remains af with normal wbc ct\n d/c foley as mental status clears\n SHOCK, CARDIOGENIC--cardiogenic in setting of a-fib with RVR and\n hypotension and severe AS, resolved\n mobilizing fluids, continue dig, BP stable\n > Hip pain--dose not seem source of infection, given pain have further\n evaluated with bone scan which was negative,\n continue lido patch, readdress pain level once extubated dilaudid\n ICU Care\n Nutrition:\n Comments: NPO, repeat speech and swallow\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments: PT consult\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU, possible floor transfer later if heart rate stable,\n given recurrent afib w/rvr\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318507,
"text": "Chief Complaint:\n 24 Hour Events:\n PRESEP CATHETER - STOP 12:06 PM\n ARTERIAL LINE - STOP 12:06 PM\n - all heparin products d/c'd for plts 40, HIT Ab sent\n - diuresing & developped A.Fib with RVR, BP stable, responded to IV\n bolus but required Metoprolol 5mg IV x 1 for rate control\n - MS , S/S recommended NPO till further evaluation\n Pt still confused this am, was awake most of the night.\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 08:00\n Metoprolol - 11:25 PM\n Other medications:\n Colace, Allopurinol, ISS, Lidocaine patch, Famotidine, Lasix prn,\n Olanzapine\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.9\nC (96.6\n HR: 89 (66 - 120) bpm\n BP: 111/36(56) {100/29(47) - 138/61(71)} mmHg\n RR: 24 (17 - 41) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n CVP: 11 (10 - 12)mmHg\n Total In:\n 2,050 mL\n 463 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,750 mL\n 463 mL\n Blood products:\n Total out:\n 3,275 mL\n 710 mL\n Urine:\n 3,275 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,225 mL\n -247 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GEN: NAD, confused, talking\n HEENT: anasarca, diffuse edema\n CV: RRR gr 3 SEM over LSB, does not radiate\n RESP: crackles bilaterally at bases, otherwise clear\n Abd: BS, NTTP, ND, edematous\n Extr: +2 pitting edema bilaterally\n Sacrum: skin tears, ecchymosis and diffuse intertriguin. rash\n Labs / Radiology\n 40 K/uL\n 8.3 g/dL\n 109 mg/dL\n 2.9 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 70 mg/dL\n 110 mEq/L\n 146 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n WBC\n 6.1\n Hct\n 25.4\n Plt\n 42\n 40\n Cr\n 2.9\n 2.9\n TCO2\n 27\n 25\n 24\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.8 mg/dL, Mg++:2.0 mg/dL, PO4:4.7 mg/dL\n Blood Cx NGTD \n Urine Cx NGTD \n C. Diff neg x 5\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis &\n extubated successfully on .\n #SEPSIS: resolved, presumed urosepsis with positive UA + for pan \n Pseudomonas, now day Zosyn. Pt was intubated on for\n worsening acidosis/MS changes, successfully extubated on . WBC\n trended down, afebrile, no recurrence of hypotension. Other infectious\n w/u neg to date, L chest U/S neg for abscess,Bone scan neg\n - Zosyn day today\n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n #CV: Pt with severe AS & CHF with EF 45%. Pt was aggressively diuresed\n and developped Afib with RVR again overnight, responded to IV bolus &\n BB. Pt with massive extravascular volume overload, will need to be\n slowly diuresed as pt is very preload dependant & tends to develop\n A.Fib with RVR when preload drops.\n - continue Digoxin 0.125mg every other day\n - no plan for systemic anticoagulation for intermittent A.Fib given\n daily risk of CVA low, may need to reconsider as outpt\n - Lasix 120mg IV prn for a goal of neg 1L/day\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation,\n more likely chronic changes to right sided pleurodeisis. Pt\n extubated successfully on and currently sating well on 2L NC.\n - continue with supplemental O2 & diuresis goal of neg 1L/day\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): s/p oliguric renal\n failure likely hypoperfusion vs ATN in setting of shock. UOP\n currently improving. Apprec renal recs, will admin Lasix 120mg IV to\n continue diuresis, avoid aggressive volume loss, appears to precipitate\n A. Fib with RVR. Monitor creatinine with diuresis\n - monitor i/os, goal net negative 1000cc/day\n - renally dose all \n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n - d/c foley as soon as possible, PT consulted to help mobilize patient\n # MS changes: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay.\n - d/c restraints when possible\n - continue Olanzapine \n - speech & swallow f/u eval prior to adv diet, high risk of aspiration\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. Not a septic joint on admission, but clearly painful on\n manipulation now. CT neg for joint effusion, bone scan neg for\n pathologic fracture/metastatic lesion\n -Tylenol standing to avoid MS \n - PT consulted\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts came up today at 58.\n Concern for HITs but suspician very low.\n -continue holding heparin products and f/u HIT Ab\n ICU Care\n Nutrition: NPO for now, pending s/s eval\n Glycemic Control: ISS\n Lines: Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: H2 blocker\n Code status: DNR (do not resuscitate)\n Disposition: possibly out to floor later today\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 318514,
"text": "Impaired Skin Integrity\n Assessment:\n Skin over both buttocks is reddened w/open area. Measuring 8x8.5cm\n stage 2 She also has an area 4.5cm x 1 deep tissue injury along the\n midline coccyx, gluteal cleft. Whole area drains yellow serosang. No\n odor. The perianal area is inflamed area fungal gluteals, posterior\n thighs, groin and medial thighs.\n Action:\n Place patient on kinair bed. Turn and reposition q 2 hrs and prn. If\n patient has loose stool try flexiseal device in order to protect the\n area\n Response:\n Plan:\n Wound care consult done: for coccyx, sacral pressure ulcer/deep tissue\n injury, cleanse with ns or wound cleanser pat dry , place aquacel\n dressing followed by dry gauze then softsorb secure with medipore soft\n cloth tape change qd. For fungal rash cleanse with gentle foam cleanser\n pat dry, apply thin layer of critic aid antifungal reapply every third\n cleansing\n Atrial fibrillation (Afib)\n Assessment:\n Afib with RVR\n Action:\n Replaced fluid and was given lopressor 5mg iv x1\n Response:\n Converted back to SR/ST w/ APC\ns & PVC\ns w/ 500cc NS w/ 1^st\n episode & 5mg IV lopressor w/2^nd episode. On\n tx with 500cc LR\n Plan:\n Continue to monitor.\n Delirium / confusion\n Assessment:\n Patient sundowned, speaking to people that were not there, reaching for\n things that were not present.\n Action:\n Given zyprexa .\n Response:\n Cleared as day progressed.\n Plan:\n Bed alarm. Keep bed low & locked. Orient patient prn.\n Urinary tract infection (UTI)\n Assessment:\n Afebrile. Urine clear. WBC:\n Action:\n Pseudomonas UTI treated w/zosyn IV.\n Response:\n Pseudomonas sensitive to zosyn\n Plan:\n Continue to give zosyn IV. Continue to check temperature.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318525,
"text": "86 yo F with severe AS, h/o renal cell and ovarian ca who presented\n with L hip pain and hypotension, with resolved pseudomonas urosepsis\n c/b A fib/RVR, ARF (ATN) and respiratory failure stable since\n extubation\n Atrial fibrillation (Afib)\n Assessment:\n Episodes of afib with RVR up to 144\n Action:\n Received 500cc LR x1, later had second episode of afib RVR received 5mg\n of iv lopressor\n Response:\n Patient went back into SR with occasional pvc and pac\n Plan:\n Lasix and diuril were discontinued, monitor urine output and cardiac\n rhythm\n Delirium / confusion\n Assessment:\n Alert to lethargic oriented to person, daughter but nothing else\n Action:\n Allowed time to rest, oriented frequently, on .olanzapine\n Response:\n Continues to be lethargic and disoriented\n Plan:\n Dilaudid discontinued, use Tylenol 650mg po q 6 round the clock for\n pain, olanzipine, allow rest periods, reorient frequently\n Impaired Skin Integrity\n Assessment:\n Has evidence of deep tissue injury to her sacral/coccyx area the\n entire breaddown measures 8x8.5cm. The area of DTI is deep purple\n along the midline coccyx, gluteal cleft. Measures 4.5x1cm. Moderate amt\n of serosang drainage no odor. Peri-anal area erythematous gluteals,\n posterior thighs, groin and medial thighs are fungal in appearance.\n Action:\n Pt was placed on a kinear bed. Wound RN consulted\n Response:\n .\n Plan:\n Kinear bed, apply thin layer of critic aid antifungal moisture barrier\n cream to affected tissue, reapply only after ery third cleansing,\n wound clean with wound cleaner or NS pat dry, place aquacel dressing\n followed by dry gauze then softsorb change qd, keep skin dry, turn q 2\n hrs and prn\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318587,
"text": "Impaired Skin Integrity\n Assessment:\n Patient\ns drsg injury @ coccyx is D&I.\n Action:\n Turned q 2 hrs. On kinair bed. Change drsg .\n Response:\n Patient has discomfort w/turning. Relieved once turning finished.\n Plan:\n Medicate w/Tylenol for ease w/turning.\n Delirium / confusion\n Assessment:\n Patient was alert in early evening & oriented X1. As she became more\n sleepy, she became more confused. Talked to herself for most of the\n night.\n Action:\n Unable to use bed alarm on kinair bed. Increased visibility by pulling\n curtains back. Bed locked & low. All siderails up as kinair bed is off\n the ground by a good amount even in low position. Checked patient\n frequently. Given zyprexa. Held off on feeding patient while she was\n so confused.\n Response:\n Patient continued to be confused.\n Plan:\n Orient patient . Check w/MD\ns re: plan to feed patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs sound clear @ upper lungs, crackles to diminished @ bases.\n RR20-35 O2 sat 93-99% on 2-3L NP. Desatted to 88% on room air. CXR\n am showed large R pleural effusion & suggestion of substantial\n pleural fluid on L as well.\n Action:\n Given 120mg IV lasix @ 2245.\n Response:\n Patient is 1L negative as of 0530 .\n Plan:\n Continue to monitor for resp distress. Continue to monitor O2 sats.\n Continue to minitor u/o.\n Atrial fibrillation (Afib)\n Assessment:\n Patient was in SR w/frequent PAC\ns & occasional PVC\ns until 0415.\n Converted to A-fib rate 128.\n Action:\n Given 5mg IV lopressor. Started on 12.5mg po lopressor . 1^st dose\n .\n Response:\n Converted back to SR in 70\ns-80\ns w/frequent PAC\ns & occasional PVC\n Plan:\n Give 5mg IV lopressor A-fib w/RVR\n This is an 86 yr old woman with c/o L hip pain, admitted w/urosepsis.\n Required fluid resuscitation & levophed. Also intubated. Extubated\n . Stable off pressors for days. Treated w/zosyn for pseudomonas in\n urine. Several episodes of conversion to A-fib w/RVR. Treated w/IVF &\n lopressor successfully.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318591,
"text": "Chief Complaint:\n 24 Hour Events:\n -- significantly more delerious\n -- 2 episodes of AF w/ RVR requiring iv metoprolol w/ improvement\n -- started on 12.5mg po metoprolol standing\n -- too delerious for swallow study, cont pleasure feeding w/ thickened\n diet, but recommended TF until resolves, patient too delerious to\n approach for NG tube placement\n -- completed zosyn course\n Pt delerious, not speaking in sentences or responding appropriately to\n questions\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 03:30 PM\n Furosemide (Lasix) - 10:59 PM\n Other medications:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.7\nC (96.3\n HR: 77 (63 - 143) bpm\n BP: 130/39(62) {101/19(41) - 134/70(78)} mmHg\n RR: 33 (16 - 41) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 1,577 mL\n 75 mL\n PO:\n 240 mL\n TF:\n IVF:\n 1,337 mL\n 75 mL\n Blood products:\n Total out:\n 2,240 mL\n 1,400 mL\n Urine:\n 2,240 mL\n 1,400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -663 mL\n -1,325 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n GEN: NAD, confused, anasarca improved, noncompliant with exam\n CV: harsh gr 3 SEM over LSB\n RESP:\n ABD: soft, NT, ND, BS:\n EXTR: edema still + pitting bilaterally\n Labs / Radiology\n 60 K/uL\n 8.5 g/dL\n 95 mg/dL\n 2.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 67 mg/dL\n 107 mEq/L\n 148 mEq/L\n 25.9 %\n 7.0 K/uL\n [image002.jpg]\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n WBC\n 6.1\n 5.7\n 7.0\n Hct\n 25.4\n 25.8\n 25.9\n Plt\n 42\n 40\n 58\n 60\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.5 mg/dL\n No new culture data\n RENAL Free water deficit 1.5L /day\n ASSESSMENT & PLAN:\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n urosepsis, s/p extubation on , intermitten A.fib with RVR and\n significant delirium.\n .\n #SEPSIS: resolved, presumed urosepsis with positive UA + for pan \n Pseudomonas, now day Zosyn. Pt was intubated on for\n worsening acidosis/MS changes, successfully extubated on . WBC\n trended down, afebrile, no recurrence of hypotension. Other infectious\n w/u neg, L chest U/S neg for abscess,Bone scan neg\n - completed 10 day of zosyn\n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n .\n #CV: Pt with severe AS & CHF with EF 45%. Pt was aggressively diuresed\n and developped Afib with RVR again overnight, responded to IV\n Lopressor. Started on Metoprolol 12.5mg . Pt with extravascular\n volume overload but intravascularly dry. (free water deficit, with\n rising Na) Pt should continue slow diuresis, very preload dependant &\n tends to develop A.Fib with RVR when preload drops.\n - continue Digoxin 0.125mg every other day, Metoprolol up titrate today\n - ?systemic anticoagulation for intermittent A.Fib\n - Lasix 80mg IV prn for a goal of neg 1L/day\n .\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): s/p oliguric renal\n failure likely hypoperfusion vs ATN in setting of shock. UOP\n currently improving. Apprec renal recs, will admin Lasix 120mg IV to\n continue diuresis, avoid aggressive volume loss, appears to precipitate\n A. Fib with RVR. Monitor creatinine with diuresis\n - monitor i/os, goal net negative 1000cc/day\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation,\n more likely chronic changes to right sided pleurodeisis. Pt\n extubated successfully on and currently sating well on 4L NC,\n pleural effusion? R\n -continue with supplemental O2 & diuresis goal of neg 1L/day\n .\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - completed Zosyn 10 day course\n - d/c foley as soon as possible, PT consulted to help mobilize patient\n .\n # MS changes: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay.\n - d/c restraints when possible\n - continue Olanzapine \n - speech & swallow f/u eval prior to adv diet, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. Not a septic joint on admission, but clearly painful on\n manipulation now. CT neg for joint effusion, bone scan neg for\n pathologic fracture/metastatic lesion\n -Tylenol standing to avoid MS \n - PT consulted\n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts came up today at 60.\n HITs but suspician very low.\n -continue holding heparin products and f/u HIT Ab\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Famotidine\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318572,
"text": "Impaired Skin Integrity\n Assessment:\n Patient\ns drsg injury @ coccyx is D&I.\n Action:\n Turned q 2 hrs. On kinair bed. Change drsg .\n Response:\n Patient has discomfort w/turning. Relieved once turning finished.\n Plan:\n Medicate w/Tylenol for ease w/turning.\n Delirium / confusion\n Assessment:\n Patient was alert in early evening & oriented X1. As she became more\n sleepy, she became more confused. Talked to herself for most of the\n night.\n Action:\n Unable to use bed alarm on kinair bed. Increased visibility by pulling\n curtains back. Bed locked & low. All siderails up as kinair bed is off\n the ground by a good amount even in low position. Checked patient\n frequently. Given zyprexa. Held off on feeding patient while she was\n so confused.\n Response:\n Patient continued to be confused.\n Plan:\n Orient patient . Check w/MD\ns re: plan to feed patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs sound clear @ upper lungs, crackles to diminished @ bases.\n RR20-35 O2 sat 93-99% on 2-3L NP. Desatted to 88% on room air. CXR\n am showed large R pleural effusion & suggestion of substantial\n pleural fluid on L as well.\n Action:\n Given 120mg IV lasix @ 2245.\n Response:\n U/o 300cc in 1 hr\n Plan:\n Continue to monitor for resp distress. Continue to monitor O2 sats.\n Continue to minitor u/o.\n Atrial fibrillation (Afib)\n Assessment:\n Patient was in SR w/frequent PAC\ns & occasional PVC\ns until 0415.\n Converted to A-fib rate 128.\n Action:\n Given 5mg IV lopressor. Started on 12.5mg po lopressor . 1^st dose\n .\n Response:\n Converted back to SR in 70\ns-80\ns w/frequent PAC\ns & occasional PVC\n Plan:\n Give 5mg IV lopressor A-fib w/RVR\n This is an 86 yr old woman with c/o L hip pain, admitted w/urosepsis.\n Required fluid resuscitation & levophed. Also intubated. Extubated\n . Stable off pressors for days. Treated w/zosyn for pseudomonas in\n urine. Several episodes of conversion to A-fib w/RVR. Treated w/IVF &\n lopressor successfully.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318573,
"text": "Impaired Skin Integrity\n Assessment:\n Patient\ns drsg injury @ coccyx is D&I.\n Action:\n Turned q 2 hrs. On kinair bed. Change drsg .\n Response:\n Patient has discomfort w/turning. Relieved once turning finished.\n Plan:\n Medicate w/Tylenol for ease w/turning.\n Delirium / confusion\n Assessment:\n Patient was alert in early evening & oriented X1. As she became more\n sleepy, she became more confused. Talked to herself for most of the\n night.\n Action:\n Unable to use bed alarm on kinair bed. Increased visibility by pulling\n curtains back. Bed locked & low. All siderails up as kinair bed is off\n the ground by a good amount even in low position. Checked patient\n frequently. Given zyprexa. Held off on feeding patient while she was\n so confused.\n Response:\n Patient continued to be confused.\n Plan:\n Orient patient . Check w/MD\ns re: plan to feed patient.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs sound clear @ upper lungs, crackles to diminished @ bases.\n RR20-35 O2 sat 93-99% on 2-3L NP. Desatted to 88% on room air. CXR\n am showed large R pleural effusion & suggestion of substantial\n pleural fluid on L as well.\n Action:\n Given 120mg IV lasix @ 2245.\n Response:\n Patient is 1L negative as of 0530 .\n Plan:\n Continue to monitor for resp distress. Continue to monitor O2 sats.\n Continue to minitor u/o.\n Atrial fibrillation (Afib)\n Assessment:\n Patient was in SR w/frequent PAC\ns & occasional PVC\ns until 0415.\n Converted to A-fib rate 128.\n Action:\n Given 5mg IV lopressor. Started on 12.5mg po lopressor . 1^st dose\n .\n Response:\n Converted back to SR in 70\ns-80\ns w/frequent PAC\ns & occasional PVC\n Plan:\n Give 5mg IV lopressor A-fib w/RVR\n This is an 86 yr old woman with c/o L hip pain, admitted w/urosepsis.\n Required fluid resuscitation & levophed. Also intubated. Extubated\n . Stable off pressors for days. Treated w/zosyn for pseudomonas in\n urine. Several episodes of conversion to A-fib w/RVR. Treated w/IVF &\n lopressor successfully.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318656,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt in NSR, HR low 50s-70s, freq difficult to see P waves on monitor, ?\n back into A-fib, but rate remained low. occ pvcs w couplets. SBP\n 90s-100s.\n Action:\n Metoprolol increased to 25mg .\n Response:\n HR dropped to 50s during sleep following Metoprolol.\n Plan:\n Monitor HR, BP, response to metoprolol.\n Delirium / confusion\n Assessment:\n Oriented x2 to person and place, but freq confusion. Very sleepy most\n of noc, complains whenever touched or turned to leave her alone.\n Grimaces w any movement but not able to articulate where pain is, says\nI have arthritis all over\n. Moaned when head was moved.\n Action:\n Held night dose of Olanzapine due to sleepiness. Tylenol q6hrs.\n Response:\n Slept most of noc. Talking when awakened but lethargic.\n Plan:\n Olanzapine dose reduced for day shift, ? if will require it. Monitor\n for pain. Reorient pt when awake.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Stable CRI per labs, cr 2.8. U/o cont low ~ 20mls/hr.\n Action:\n Receiving 75mls/hr D5W to be finished ~ 5am.\n Response:\n U/o cont low. Pt taking po flds fairly well.\n Plan:\n Will D/c D5W when liter finishes. If u/o falls below 20mls/hr, notify\n team and may give fld bolus.\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318746,
"text": "Chief Complaint:\n 24 Hour Events:\n - consult - decreased am dose of zyprexa to 2.5 mg, can use haldol\n prn\n In am:\n Pt developped AFib with RVR & became hypotensive during rounds. MS\n continued to be poor, ABg stable, unable to place A-Line, BP responded\n to multiple boluses of IVF & received 1u pRBCs. Family meeting took\n place to address goals of care & pt was made DNR/DNI\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Allopurinol, Tamoxifen, ISS, Digoxin, Colace, Tylenol, Metoprolol,\n Olanzapine, PPI\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 94) bpm\n BP: 95/26(44) {55/25(42) - 144/53(68)} mmHg\n RR: 25 (20 - 43) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 907 mL\n 907 mL\n PO:\n 160 mL\n 480 mL\n TF:\n IVF:\n 747 mL\n 427 mL\n Blood products:\n Total out:\n 2,490 mL\n 155 mL\n Urine:\n 2,490 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,583 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD, confused, not responded appropriately to questions\n HEENT: JVP elevated\n CV: irreg/irreg gr 3 harsh SEM over LSB (no appreciable diastolic\n murmur)\n RESP: CTAB no w/r apprec but not very compliant with exam\n ABD: soft/NT/ND/NABS\n EXTR: + pitting edema bilaterally\n Labs / Radiology\n 61 K/uL\n 7.3 g/dL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg]\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n WBC\n 6.1\n 5.7\n 7.0\n 8.5\n Hct\n 25.4\n 25.8\n 25.9\n 22.5\n Plt\n 40\n 58\n 60\n 61\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n Fluid analysis / Other labs: RPR pending\n Vit B 12 elev\n Folate WNL\n Imaging: Portable CXR \n In comparison with the study of , there is no significant change\n in the appearance of the heart and lungs. Bilateral pleural effusions\n with\n probable basilar atelectasis and some engorgement of the pulmonary\n vessels.\n Microbiology: NONE Pending\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n urosepsis, s/p extubation on , pt had recurrent A.fib with RVR\n this am, c/b hypotension that responded to repeat IV fluid boluses &\n continued delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 45%. Pt naturally diuresed\n >1.5L overnight and developped Afib with RVR again this am c/b\n hypotension responded to repeated IVF boluses. However, concern for\n worsening pulm edema & pt very delicate fluid balance with fixed aortic\n outflow obstruction. Concern for aggressive fluid resuscitation\n sending pt into pulm edema, likely to compromise resp status & possible\n require intubation. Family meeting regarding goals of care, pt\n currently DNR/DNI.\n - continue Digoxin 0.125mg every other day, holding Metoprolol for\n hypotension\n - f/u ABG\n - stat ECHO to r/o effusion/tamponade given hypotension, elev JVP &\n tachycardia (unable to assess pulsus)\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #Hypotension: Pt recently completed a 10 day course of Zosyn for\n pseudomonas urosepsis, successfully extubated on . WBC had trended\n down, afebrile. However, pt developed recurrent hypotension this am,\n likely cardiogenic but will rule out infectious causes & cover with\n empiric ABx until all Cx data negative at 48hrs\n - blood & urine Cx sent\n - starting Vanc/Zosyn renally dosed (follow up am Vanc level)\n - gentle bolus with LR prn\n .\n # RENAL FAILURE, ACUTE: Pt developed oliguric renal failure likely \n hypoperfusion vs ATN in setting of shock. UOP improved & responded well\n to Lasix diuresis. Na corrected with D5W but creatinine rose overnight\n to 3.1. Pt spontaneously diuresed 1.5L overnight) Today, UOP has\n dropped in setting of hypotension, avoiding volume overload/pulm edema,\n will bolus to maintain MAPs.\n - monitor creatinine\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed ?airspace\n disease in RLL likely chronic changes to h/o right sided\n pleurodeisis. Pt extubated successfully on and still maintaining\n sats on 2LNC, thought increased resp rate noted this am.\n - f/u stat ABG\n -continue with supplemental O2\n .\n # MS CHANGES: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed. All restraints have been removed, line\ns d/c\n -apprec Geripsych recs, continue Olanzapine 2.5mg qam & 5mg qhs\n - consider sitter, consider ECHO\n - NPO for now, per s/s recs, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing to avoid MS \n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts slightly increased\n today at 60. Suspician of HITS very low & specimen was never sent\n -continue holding heparin products for now\n .\n # Wound: sacral skin breakdown & intertriguinous rash.\n - kinair mattress with reg position changes\n - flexiseal prn loose stools\n - NS cleanser & apply criticaid with aquacel dressing\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n Code status: DNR/DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318747,
"text": "Chief Complaint:\n 24 Hour Events:\n - consult - decreased am dose of zyprexa to 2.5 mg, can use haldol\n prn\n In am:\n Pt developped AFib with RVR & became hypotensive during rounds. MS\n continued to be poor, ABg stable, unable to place A-Line, BP responded\n to multiple boluses of IVF & received 1u pRBCs. Family meeting took\n place to address goals of care & pt was made DNR/DNI\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Allopurinol, Tamoxifen, ISS, Digoxin, Colace, Tylenol, Metoprolol,\n Olanzapine, PPI\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 94) bpm\n BP: 95/26(44) {55/25(42) - 144/53(68)} mmHg\n RR: 25 (20 - 43) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 907 mL\n 907 mL\n PO:\n 160 mL\n 480 mL\n TF:\n IVF:\n 747 mL\n 427 mL\n Blood products:\n Total out:\n 2,490 mL\n 155 mL\n Urine:\n 2,490 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,583 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n GEN: NAD, confused, not responded appropriately to questions\n HEENT: JVP elevated\n CV: irreg/irreg gr 3 harsh SEM over LSB (no appreciable diastolic\n murmur)\n RESP: CTAB no w/r apprec but not very compliant with exam\n ABD: soft/NT/ND/NABS\n EXTR: + pitting edema bilaterally\n Labs / Radiology\n 61 K/uL\n 7.3 g/dL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg]\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n WBC\n 6.1\n 5.7\n 7.0\n 8.5\n Hct\n 25.4\n 25.8\n 25.9\n 22.5\n Plt\n 40\n 58\n 60\n 61\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n Fluid analysis / Other labs: RPR pending\n Vit B 12 elev\n Folate WNL\n Imaging: Portable CXR \n In comparison with the study of , there is no significant change\n in the appearance of the heart and lungs. Bilateral pleural effusions\n with\n probable basilar atelectasis and some engorgement of the pulmonary\n vessels.\n Microbiology: NONE Pending\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n urosepsis, s/p extubation on , pt had recurrent A.fib with RVR\n this am, c/b hypotension that responded to repeat IV fluid boluses &\n continued delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 45%. Pt naturally diuresed\n >1.5L overnight and developped Afib with RVR again this am c/b\n hypotension responded to repeated IVF boluses. However, concern for\n worsening pulm edema & pt very delicate fluid balance with fixed aortic\n outflow obstruction. Concern for aggressive fluid resuscitation\n sending pt into pulm edema, likely to compromise resp status & possible\n require intubation. Family meeting regarding goals of care, pt\n currently DNR/DNI.\n - continue Digoxin 0.125mg every other day, holding Metoprolol for\n hypotension\n - f/u ABG\n - stat ECHO to r/o effusion/tamponade given hypotension, elev JVP &\n tachycardia (unable to assess pulsus)\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #Hypotension: Pt recently completed a 10 day course of Zosyn for\n pseudomonas urosepsis, successfully extubated on . WBC had trended\n down, afebrile. However, pt developed recurrent hypotension this am,\n likely cardiogenic but will rule out infectious causes & cover with\n empiric ABx until all Cx data negative at 48hrs\n - blood & urine Cx sent\n - starting Vanc/Zosyn renally dosed (follow up am Vanc level)\n - gentle bolus with LR prn\n .\n # RENAL FAILURE, ACUTE: Pt developed oliguric renal failure likely \n hypoperfusion vs ATN in setting of shock. UOP improved & responded well\n to Lasix diuresis. Na corrected with D5W but creatinine rose overnight\n to 3.1. Pt spontaneously diuresed 1.5L overnight) Today, UOP has\n dropped in setting of hypotension, avoiding volume overload/pulm edema,\n will bolus to maintain MAPs.\n - monitor creatinine\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed ?airspace\n disease in RLL likely chronic changes to h/o right sided\n pleurodeisis. Pt extubated successfully on and still maintaining\n sats on 2LNC, thought increased resp rate noted this am.\n - f/u stat ABG\n -continue with supplemental O2\n .\n # MS CHANGES: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed. All restraints have been removed, line\ns d/c\n -apprec Geripsych recs, continue Olanzapine 2.5mg qam & 5mg qhs\n - consider sitter, consider ECHO\n - NPO for now, per s/s recs, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing to avoid MS \n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts slightly increased\n today at 60. Suspician of HITS very low & specimen was never sent\n -continue holding heparin products for now\n .\n # Wound: sacral skin breakdown & intertriguinous rash.\n - kinair mattress with reg position changes\n - flexiseal prn loose stools\n - NS cleanser & apply criticaid with aquacel dressing\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n Code status: DNR/DNI\n Disposition: ICU\n ------ Protected Section ------\n Hypotension/ UOP: will transfuse with 1u pRBCs now for hct drop\n overnight and transient hypotension\n - monitor i/os\n - f/u pm hct\n ------ Protected Section Addendum Entered By: , MD\n on: 21:34 ------\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318466,
"text": "This is an 86 yr old woman who presented to the EW w/L hip pain 0n\n . Tmax 100.1. Urine Cx positive for pseudomonas. Patient became\n hypotensive, requiring 5L IVF & levophed to suppoert her BP. Code\n sepsis started. Patient was intubated & transferred to MICU. She was\n extubated . Patient is stable off pressors.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318467,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318468,
"text": "This is an 86 yr old woman who presented to the EW w/L hip pain 0n\n . Tmax 100.1. Urine Cx positive for pseudomonas. Patient became\n hypotensive, requiring 5L IVF & levophed to suppoert her BP. Code\n sepsis started. Patient was intubated & transferred to MICU. She was\n extubated . Patient is stable off pressors.\n Atrial fibrillation (Afib)\n Assessment:\n Patient converted to A-fib w/RVR @ rate up to 150 @ 2100.\n Action:\n Given 500cc NS\n Response:\n Converted back to ST/SR w/ frequent APC\ns & occasional PVC\ns. Converted\n back to AF, w/rate up to 150 @ 2315, BP 120\ns/systolic. Given 5mg IV\n lopressor to convert back to SR.\n Plan:\n Consider dosing again w/5mg IV lopressor for A-fib w/RVR if BP\n tolerates.\n Altered mental status:\n Patient was A&OX1 (oriented to self). C/o hunger & thirst. She was\n able to be fed soft solids (jello & custard) & drink water through a\n straw this evening. Sat up @ 90 degrees. No choking. Took her pills\n crushed in apple sauce. As night progressed & patient became more\n tired, her mental status waned. She called out to people not present.\n She talked to herself constantly all night. Patient checked frequently.\n Bed alarm on. Bed low & locked. 3 side rails up. Curtains pulled back\n for increased visibility. Call light w/in easy reach.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318469,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 03:31 ------\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318634,
"text": "Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318453,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - EXTUBATED 03:43 PM\n - plts trending down 47>43\n - scheduled metolazone and lasix qam\n - diuresed well overnight (-2L)\n Pt sleeping comfortably & sating well on 2L NC. Pt still confused &\n disoriented\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Other ICU medications: Colace, Allopurinol, Tamoxifen, Insulin,\n Famotidine, Calcium, Digoxin, Lasix, Chlorthalidone\n Other medications:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 66 (66 - 83) bpm\n BP: 116/35(62) {100/32(54) - 152/51(83)} mmHg\n RR: 39 (17 - 42) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.2 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 513 mL\n 50 mL\n PO:\n TF:\n 345 mL\n IVF:\n 138 mL\n 50 mL\n Blood products:\n Total out:\n 2,720 mL\n 840 mL\n Urine:\n 2,720 mL\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,207 mL\n -790 mL\n Physical Examination\n GEN: NAD, sleeping comfortably, anasarca\n CV: RRR no m/r/g\n RESP: crackles bilaterally at bases, moving air well, no e/o resp\n ditress\n ABD: edematous, NTTP/NABS, soft\n EXTR: +2 pitting edema bilaterally\n Labs / Radiology\n CXR \n A single portable image of the chest was obtained and compared to\n prior examinations dated and . Allowing for slight\n differences in technique, there is no significant interval change. Mul\n tiple\n wires project over the left hemithorax. The endotracheal and nasogastr\n ic\n tubes and central venous catheter and Port-A-Cath are grossly unchanged\n and in\n satisfactory positions. The cardiomediastinal silhouette is grossly\n unchanged. A large right pleural effusion is seen. The left costophre\n nic\n angle is not included on the image, but there is a hazy opacity at the\n left\n base suggesting underlying effusion.\n IMPRESSION: Stable examination as above\n 40 K/uL\n 8.3 g/dL\n 91 mg/dL\n 2.9 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 69 mg/dL\n 109 mEq/L\n 142 mEq/L\n 25.4 %\n 6.1 K/uL\n [image002.jpg]\n 05:14 AM\n 07:41 PM\n 04:35 AM\n 04:47 AM\n 02:54 PM\n 04:08 PM\n 05:58 PM\n 07:52 PM\n 03:34 AM\n 03:54 AM\n WBC\n 7.4\n 6.1\n Hct\n 26.6\n 25.4\n Plt\n 47\n 42\n 40\n Cr\n 3.1\n 2.9\n TCO2\n 22\n 25\n 27\n 25\n 24\n 26\n 28\n Glucose\n 144\n 91\n Other labs: PT / PTT / INR:13.0/36.2/1.1, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n for presumed urosepsis, intubated on for worsening acidosis &\n extubated successfully on .\n #SEPSIS: resolved, presumed urosepsis with positive UA growing out pan\n Pseudomonas, now day Zosyn. Pt was intubation on for\n worsening acidosis/MS changes, successfully extubated. BP has been\n stable >72 hrs, WBC trending down, afebrile, no recurrence of\n hypotension. Other infectious w/u neg to date, L chest U/S neg for\n abscess,Bone scan neg\n - apprec ID consult, continue Zosyn day \n - bone scan- no lytic lesions or metastatic dz\n - Blood Cx NGTD, Urine culture + 2 diff pseudomonas, both pan\n sensitive. Sputum + yeast\n #SHOCK, CARDIOGENIC: resolved, pt with severe AS & CHF with EF 45%\n developed Afib with RVR and became hypotensive on . Pressure\n responded to IVF & pressors. Pt has been in/out of Afib but HR better\n controlled on digoxin. Pt with massive extravasc volume overload,\n currently being actively diuresed\n - continue Digoxin 0.125mg every other day, avoid CCB/BBs\n - no plan for systemic anticoagulation currently, daily risk of CVA\n very low\n - schedule metolazone and lasix daily, repeat in pm if volume up\n - EKG shows sinus with RBBB, frequent PACs.\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed possible\n airspace disease in , have been aspiration peri-intubation,\n more likely chronic changes to pleurodeisis. Pt extubated\n successfully on and currently sating well on 2L NC.\n - continue with supplemental O2 & diuresis\n # RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Pt with oliguric\n renal failure likely hypoperfusion vs ATN in setting of shock.\n Creatinine improved & having increased UOP. Apprec renal recs, will\n admin Lasix & Metolazone to continue diuresis. Improved urine output\n but Cr still well above baseline.\n - monitor i/os, goal net negative 1000cc/day\n - renally dose all meds\n # URINARY TRACT INFECTION (UTI): presumed source of infection with UA +\n pseudomonas, pan sensitive\n - continue Zosyn day renally dosed\n - d/c foley as soon as possible\n # MS changes: delirium likely secondary to intubation, polypharmacy &\n prolonged ICU stay\n - d/c lines & d/c restraints\n - start Olanzapine \n - speech & swallow eval prior to adv diet\n # LEFT HIP PAIN: Etiology unclear but not an infectious source. Not a\n septic joint on admission, but clearly painful on manipulation now. CT\n neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion\n - continue Fentanyl for pain control\n -Tylenol and dilaudid for pain prn\n - PT consult\n #Thrombocytopenia\n baseline 50-70s, trending down over last 24hrs,\n currently 40. Concern for HIT but suspician low.\n -holding all heparin products and sending HIT Ab today\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Presep Catheter - 07:05 PM- d/c today\n Arterial Line - 04:15 PM- d/c today\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318456,
"text": "This is an 87yr female who had presented to EW w/ L hip pain. Tmax\n 100.1 n EW and UCX positive for Pseudomonas. Pt then became hypotensive\n requiring 5L IVF and levophed. Code sepsis was initiated, pt required\n intubation and was treated in MICU. BP has now remained stable off\n pressors, respiratory status has improved and pt was extubated\n yesterday.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated previous shift.\n Action:\n Following respiratory status closely. FiO2 weaned to RA. Pt continues\n on abx as ordered. Also continues on Chlorothiazide followed by lasix\n daily.\n Response:\n BBS remain CTA to somewhat diminished at bilat basis. S/p Speech and\n swallow this am. Pt remains NPO for now pending further clearing of\n mental status, though S/S therapist reports swallow intact.SpO2 remains\n >95% on RA. Pt remains free of s/s distress. Pt remains afebrile and\n has diuresed well this shift.\n Plan:\n Continue to follow respiratory assessment closely. Continue abx as\n ordered. Continue chlorothiazide and lasix.\n"
},
{
"category": "Nursing",
"chartdate": "2163-01-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 318457,
"text": "This is an 87yr female who had presented to EW w/ L hip pain. Tmax\n 100.1 n EW and UCX positive for Pseudomonas. Pt then became hypotensive\n requiring 5L IVF and levophed. Code sepsis was initiated, pt required\n intubation and was treated in MICU. BP has now remained stable off\n pressors, respiratory status has improved and pt was extubated\n yesterday.\n Pt has remained A+OX1 this shift, though remains pleasant and\n cooperative t/o shift. MS seems to be improving t/o shift and pt has\n been started on zyprexa.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated previous shift.\n Action:\n Following respiratory status closely. FiO2 weaned to RA. Pt continues\n on abx as ordered. Also continues on Chlorothiazide followed by lasix\n daily.\n Response:\n BBS remain CTA to somewhat diminished at bilat basis. S/p Speech and\n swallow this am. Pt remains NPO for now pending further clearing of\n mental status, though S/S therapist reports swallow intact.SpO2 remains\n >95% on RA. Pt remains free of s/s distress. Pt remains afebrile and\n has diuresed well this shift.\n Plan:\n Continue to follow respiratory assessment closely. Continue abx as\n ordered. Continue chlorothiazide and lasix. Anticipate call out to\n floor in next several days.\n Impaired Skin Integrity\n Assessment:\n Pt w/ documented stage II pressure ulcer to coccyx area w/ Q3 day dsng\n changes in place. Duoderm dsng was changed overnoc per report; however,\n this dsng was falling over this afternoon. Several large skin tears\n noted beneath duoderm w/ black discoloration directly over\n sacrum/coccyx and red/excoriated rash to peri-rectal area. Pt has\n remained free of fecal incontinence this shift. Foley catheter in\n place.\n Action:\n Skin tears and coccyx washed w/ NS, Telfa non-stick dsng applied and\n covered w/ ABD dsng. Aloe-vesta anti-fungal ointment applied to\n surrounding tissue. , RN wound care nurse consulted and reports\n agreeing with current measures. Dr. notified and in to asses\n wound. Dr. reports black discoloration is likely eccymosis vs.\n necrosis. No further orders were given. Frequent side to side\n positioning maintained\n see flowsheet.\n Response:\n Pt has tolerated side to side positioning well .DSD remains CDI.\n Plan:\n Continue frequent side to side positioning and skin care measures.\n Anticipate PT consult in am. If pt w/ continue on bedrest, consider\n kinair bed; however, increase activity as tolerated. Wound care RN due\n in am to further assess pt.\n"
},
{
"category": "Nutrition",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 318688,
"text": "Subjective\n Patient extubated, confused\n Objective\n Pertinent medications: colace, pantoprazole\n Labs:\n Value\n Date\n Glucose\n 205 mg/dL\n 05:35 AM\n Glucose Finger Stick\n 256\n 06:00 AM\n BUN\n 71 mg/dL\n 05:35 AM\n Creatinine\n 3.1 mg/dL\n 05:35 AM\n Sodium\n 144 mEq/L\n 05:35 AM\n Potassium\n 3.7 mEq/L\n 05:35 AM\n Chloride\n 107 mEq/L\n 05:35 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 03:54 AM\n Albumin\n 2.1 g/dL\n 04:56 AM\n Calcium non-ionized\n 8.1 mg/dL\n 05:35 AM\n Phosphorus\n 4.6 mg/dL\n 05:35 AM\n Ionized Calcium\n 1.11 mmol/L\n 10:15 PM\n Magnesium\n 2.0 mg/dL\n 05:35 AM\n Current diet order / nutrition support: pureed with nectar thick\n liquids\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, stage II ulcer\n Specifics:\n 86 year old female presenting with left hip pain admitted to with\n urosepsis now s/p extubation on . Patient was unable to pass\n swallow evaluation. Diet advanced to pureed for pleasure until swallow\n evaluation repeated. Tube feedings have been held. Would suggest\n restarting at this time as patient not able to meet nutritional needs\n orally.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Restart tube feeding of Nutren Pulmonary to goal rate of\n 35ml/hr\n 2. Allow PO intake for pleasure when patient alert\n 3. Monitor skin integrity\n 10:08\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318671,
"text": "Chief Complaint:\n 24 Hour Events:\n - consult - decreased am dose of zyprexa to 2.5 mg, can use haldol\n prn\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 94) bpm\n BP: 95/26(44) {55/25(42) - 144/53(68)} mmHg\n RR: 25 (20 - 43) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 907 mL\n 907 mL\n PO:\n 160 mL\n 480 mL\n TF:\n IVF:\n 747 mL\n 427 mL\n Blood products:\n Total out:\n 2,490 mL\n 155 mL\n Urine:\n 2,490 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,583 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n Labs / Radiology\n 61 K/uL\n 7.3 g/dL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg]\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n WBC\n 6.1\n 5.7\n 7.0\n 8.5\n Hct\n 25.4\n 25.8\n 25.9\n 22.5\n Plt\n 40\n 58\n 60\n 61\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n Fluid analysis / Other labs: RPR pending\n Vit B 12 elev\n Folate WNL\n Imaging: Portable CXR \n In comparison with the study of , there is no significant change\n in the appearance of the heart and lungs. Bilateral pleural effusions\n with\n probable basilar atelectasis and some engorgement of the pulmonary\n vessels.\n Microbiology: NONE Pending\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n urosepsis, s/p extubation on , still having intermittent A.fib\n with RVR and delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 45%. Pt has been\n aggressively diuresed and developped Afib with RVR again overnight,\n responded to IV Lopressor. Started on Metoprolol 12.5mg . Pt with\n extravascular volume overload but intravascularly dry. (free water\n deficit of 2.5L, with rising Na) Pt very preload dependant & tends to\n develop A.Fib with RVR when preload drops. Holding diuresis today and\n watching resp status, will get CXR today to better eval lung fields.\n - continue Digoxin 0.125mg every other day, increase Metoprolol to 25mg\n today\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #SEPSIS/UTI: resolved, presumed urosepsis with UCx positive for\n Pseudomonas, completed 10/10 days of Zosyn. Pt was intubated on \n for worsening acidosis/MS changes, successfully extubated on . WBC\n down, afebrile, no recurrence of hypotension. Other infectious w/u\n neg, L chest U/S neg for abscess,Bone scan neg\n - Blood Cx NGTD, Urine culture was + 2 diff pseudomonas, both pan\n sensitive, s/p 10 days of Zosyn\n .\n # RENAL FAILURE, ACUTE: Pt developed oliguric renal failure likely \n hypoperfusion vs ATN in setting of shock. UOP improved & responded well\n to Lasix diuresis. Na corrected with D5W but creatinine rose overnight\n to 3.1 (all diuretics held & maintained approp urine outpt)\n - monitor i/os, goal net negative even\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed ?airspace\n disease in RLL likely chronic changes to h/o right sided\n pleurodeisis. Pt extubated successfully on and currently sating\n well on 2L NC.\n -continue with supplemental O2 & goal even i/os\n .\n # MS CHANGES: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed. All restraints have been removed, line\ns d/c\n -apprec Geripsych recs, continue Olanzapine 2.5mg qam & 5mg qhs (haldol\n prn)\n - consider sitter, consider ECHO\n - speech & swallow f/u eval prior to adv diet, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing to avoid MS \n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts slightly increased\n today at 60. Suspician of HITS very low & specimen was never sent\n -continue holding heparin products for now\n .\n # Wound: sacral skin breakdown & intertriguinous rash.\n - kinair mattress with reg position changes\n - flexiseal prn loose stools\n - NS cleanser & apply criticaid with aquacel dressing\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 318673,
"text": "Chief Complaint:\n 24 Hour Events:\n - consult - decreased am dose of zyprexa to 2.5 mg, can use haldol\n prn\n Allergies:\n Iodine\n Anaphylaxis;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Sulfonamides\n Rash;\n Morphine\n Nausea/Vomiting\n Codeine\n Nausea/Vomiting\n Levofloxacin\n Anaphylaxis;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 57 (57 - 94) bpm\n BP: 95/26(44) {55/25(42) - 144/53(68)} mmHg\n RR: 25 (20 - 43) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.8 kg (admission): 62 kg\n Height: 60 Inch\n Total In:\n 907 mL\n 907 mL\n PO:\n 160 mL\n 480 mL\n TF:\n IVF:\n 747 mL\n 427 mL\n Blood products:\n Total out:\n 2,490 mL\n 155 mL\n Urine:\n 2,490 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,583 mL\n 752 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///30/\n Physical Examination\n Labs / Radiology\n 61 K/uL\n 7.3 g/dL\n 205 mg/dL\n 3.1 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 71 mg/dL\n 107 mEq/L\n 144 mEq/L\n 22.5 %\n 8.5 K/uL\n [image002.jpg]\n 07:52 PM\n 03:34 AM\n 03:54 AM\n 12:00 PM\n 06:00 PM\n 09:55 PM\n 05:59 AM\n 03:09 PM\n 04:32 AM\n 05:35 AM\n WBC\n 6.1\n 5.7\n 7.0\n 8.5\n Hct\n 25.4\n 25.8\n 25.9\n 22.5\n Plt\n 40\n 58\n 60\n 61\n Cr\n 2.9\n 2.9\n 3.0\n 2.8\n 2.8\n 3.1\n TCO2\n 26\n 28\n Glucose\n 91\n 115\n 114\n 109\n 156\n 125\n 95\n 205\n Other labs: PT / PTT / INR:14.0/29.2/1.2, CK / CKMB /\n Troponin-T:39/8/0.11, ALT / AST:20/25, Alk Phos / T Bili:54/0.5,\n Differential-Neuts:91.2 %, Band:0.0 %, Lymph:4.2 %, Mono:4.5 %, Eos:0.1\n %, Fibrinogen:603 mg/dL, Lactic Acid:1.0 mmol/L, Albumin:2.1 g/dL,\n LDH:124 IU/L, Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:4.6 mg/dL\n Fluid analysis / Other labs: RPR pending\n Vit B 12 elev\n Folate WNL\n Imaging: Portable CXR \n In comparison with the study of , there is no significant change\n in the appearance of the heart and lungs. Bilateral pleural effusions\n with\n probable basilar atelectasis and some engorgement of the pulmonary\n vessels.\n Microbiology: NONE Pending\n Assessment and Plan\n 86 y/o F with PMHx of severe AS & CHF p/w Left hip pain, adm to \n urosepsis, s/p extubation on , still having intermittent A.fib\n with RVR and delirium.\n .\n # A.Fib/CV: Pt with severe AS & CHF with EF 45%. Pt has been\n aggressively diuresed and developped Afib with RVR again overnight,\n responded to IV Lopressor. Started on Metoprolol 12.5mg . Pt with\n extravascular volume overload but intravascularly dry. (free water\n deficit of 2.5L, with rising Na) Pt very preload dependant & tends to\n develop A.Fib with RVR when preload drops. Holding diuresis today and\n watching resp status, will get CXR today to better eval lung fields.\n - continue Digoxin 0.125mg every other day, increase Metoprolol to 25mg\n today\n - no plan for systemic anticoagulation currently for intermittent A.Fib\n given other co-morbidities\n .\n #SEPSIS/UTI: resolved, presumed urosepsis with UCx positive for\n Pseudomonas, completed 10/10 days of Zosyn. Pt was intubated on \n for worsening acidosis/MS changes, successfully extubated on . WBC\n down, afebrile, no recurrence of hypotension. Other infectious w/u\n neg, L chest U/S neg for abscess,Bone scan neg\n - Blood Cx NGTD, Urine culture was + 2 diff pseudomonas, both pan\n sensitive, s/p 10 days of Zosyn\n .\n # RENAL FAILURE, ACUTE: Pt developed oliguric renal failure likely \n hypoperfusion vs ATN in setting of shock. UOP improved & responded well\n to Lasix diuresis. Na corrected with D5W but creatinine rose overnight\n to 3.1 (all diuretics held & pt spontaneously diuresed 1.5L)\n - monitor i/os, goal net negative even\n - renally dose all \n .\n # RESP FAILURE: Pt was intubated on due to worsening acidosis & MS\n changes. CXR with effusions R>L & pulm edema. CT showed ?airspace\n disease in RLL likely chronic changes to h/o right sided\n pleurodeisis. Pt extubated successfully on and currently sating\n well on 2L NC.\n -continue with supplemental O2 & goal even i/os\n .\n # MS CHANGES: Pt with delirium likely secondary to intubation,\n polypharmacy & prolonged ICU stay. Sleep/wake cycles now very\n disturbed. All restraints have been removed, line\ns d/c\n -apprec Geripsych recs, continue Olanzapine 2.5mg qam & 5mg qhs (haldol\n prn)\n - consider sitter, consider ECHO\n - speech & swallow f/u eval prior to adv diet, high risk of aspiration\n .\n # LEFT HIP PAIN: Etiology unclear but unlikely due to infectious\n source. CT neg for joint effusion, bone scan neg for pathologic\n fracture/metastatic lesion. PT consulted.\n -Tylenol standing to avoid MS \n .\n #Thrombocytopenia\n pt has baseline plt ct 50-70s, trended down over\n last 2 days. Heparin products held & plts slightly increased\n today at 60. Suspician of HITS very low & specimen was never sent\n -continue holding heparin products for now\n .\n # Wound: sacral skin breakdown & intertriguinous rash.\n - kinair mattress with reg position changes\n - flexiseal prn loose stools\n - NS cleanser & apply criticaid with aquacel dressing\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n Indwelling Port (PortaCath) - 07:04 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Rehab Services",
"chartdate": "2163-01-27 00:00:00.000",
"description": "Physical Therapy Contact Note",
"row_id": 318681,
"text": "Physical Therapy/Rehabilitation Services\n PT attempted to evaluate patient for physical therapy this AM. Chart\n reviewed and upon PT arrival to pt\ns room pt was tachy to 150s and not\n medically appropriate at this time. PT will f/u as appropriate.\n"
}
] |
29,808 | 140,385 | This is a 59 yo woman with PMHx significant for Addison's disease on chronic steroids, COPD, chronic pain who presented to OSH with fever, cough, n/v/d, and lethargy. Found to be hypotensive and transferred to for further management of hypotension; concern for possible sepsis or adrenal crisis. . # Hypotension: Likely secondary to adrenal insufficiency and mild hypovolemia in the setting of not taking steroids and inadequate PO intake from nausea and vomiting. Patient was started on stress dose steroids (100 mg of Hydrocortisone) and received IV fluid boluses with subsequent improvement in her blood pressures. On admission she received broad antibiotics out of concern for sepsis; however, these were discontinued secondary to low clinical suspicion for bacterial illness and rapid improvement with hydration. Blood and urine cultures were negative. Endocrine was contact regarding steroid tapering and recommended Hydrocortisone 50 mg through , then decreasing to double her home dose for 3 days, then continuing her on home dose. Her blood pressures remained stable prior to transfer to the floor. On the medical floor, her steroids were tapered accordingly to Endocrine recommendations. However, as she developed a pneumonia (see below), she was discharged on 1 mg twice daily of Dexamethasone to be taken until her antibiotics are completed (higher dose kept in setting of current infection). At that time, she is to decrease her dose to 0.5 mg twice daily until follow-up with her primary endocrinologist. . # Adrenal insufficiency: This episode of hypotension was likely secondary to nausea/vomiting (secondary to viral illness) and relative adrenal insufficiency due to inability to take po steroids and concurrent stress. She responded quickly to IV fluids and stress-dose steroids. Her steroids were slowly weaned, however she was continued on a higher-dose (1 mg twice daily of dexamethasone) due to her concurrent pneumonia. She was instructed to taper to 0.5 mg twice daily afte completion of her antibiotics and to stay on this dose until follow-up with her endocrinologist. She recently had been hospitalized for another episode of hypotension at prior to this hospitalization; the etiology of this is not clear. Her BPs were stable during this hospitalization. . # Pneumonia, bacterial: Patient reported development of a cough and slight shortness of breath during her hospitalization. Initial CXR was negative for a PNA, however repeat CXR demonstrated progression of a RLL infiltrate. She was afebrile and concern for resistant organisms was very low, so she was started on Ciprofloxacin for a 7-day course. She had small bilateral pleural effusions on CXR; in discussion with pulmonary, these were too small to be tapped. She remained afebrile, with improvement in her respiratory symptoms. Her O2 sats were stable at 94-96%/RA. She would benefit from a repeat CXR next week to ensure no enlargement of the effusions. These effusions are likely secondary to her aggressive fluid resuscitation on arrival. . # Abdominal distension without obstruction - The patient complained of acute on chronic abd distension (for months, with worsening over the past few days), without n/v. She noted excess flatus chronically and irregular bowel bovements. Abd u/s was negative for ascites (slight perihepatic fluid only, likely secondary to her aggressive fluid resuscitation). KUB was read as obstruction, however upon review with the radiologist, the KUB was only significant for dilated bowel. A subsequent CT abd revealed NO evidence of obstruction. She was started on simethicone and miralax with improvement in her symptoms. She was tolerating a regular diet for several days without any difficulty. . # Hyponatremia - stable during her hospitalization . # COPD: continued on outpatient regimen of combivent and advair. . # Depression/Anxiety: continued on outpatient regimen. She was seen by SW during hospitalization as she does have many stressors in her family life. She would likely benefit from a neuropsych evaluation, as there is concern that this may be impacting her abilityto manage her medications and health on her own. . # Chronic Pain: continued on outpatient regimen. Initially, frequency of narcotics were reduced in setting of hypotension, but were restarted at her home dose during her hospitalization. She was recommended to taper these medications, as they can be contributing to her constipation and hypotension, however she notes that her pain is still at a constant and chronic level, requiring her current dose of medications. . # GERD - continued on PPI | Non-specific ST-T wave changes. Compared to the previous tracingof voltage remains low. | 1 | [
{
"category": "ECG",
"chartdate": "2173-04-24 00:00:00.000",
"description": "Report",
"row_id": 277546,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nof voltage remains low.\n\n"
}
] |
44,173 | 151,265 | -Likely brainstem small vessel disease -Initially admitted to NeuroICU due to hypertension | Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. Hypertension, benign Assessment: Pt SBP 180 on arrival. HR 80s V-paced Action: Pt given labetalol per orders. HR 80s V-paced Action: Pt given labetalol per orders. HR 80s V-paced Action: Pt given labetalol per orders. Study terminated early and could notbe completed.This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.LEFT VENTRICLE: Moderate symmetric LVH. Hypertension, benign Assessment: Pt SBP 180-198. Hypertension, benign Assessment: Pt SBP 180-198. Hypertension, benign Assessment: Pt SBP 180-198. !+"%D"{t"5#q#jw#C %w%D%UU%.&4&}&G)'-'8>'W'{'K(l(Sn(O)T)Ou)) +U+/+)+[+w+oy+.,KO,uz, -z-C-bb-u-F. .#.2/);/p;/60T~0O111>!1N5152Z`2 3R3S3Uh35Va5770797Au7M 8 8xS8Cq89?49? Response: Pt weaned off IV Labetalol. Response: Pt weaned off IV Labetalol. Response: Pt weaned off IV Labetalol. Started pt back on Labetalol drip. Started pt back on Labetalol drip. Started pt back on Labetalol drip. Suboptimal image quality - patient unable tocooperate.Conclusions:The left atrium and right atrium are normal in cavity size. Action: Pt started on labetalol drip per orders. Action: Pt started on labetalol drip per orders. Action: Pt started on labetalol drip per orders. L)*SN!T~eOx7;XVrg0% @\oM.DT>+i>mi*>Bu 9ZlkbSvttttt ? (gZh+ '',ba yCUn1ALB 8QN1j rf,N*sODf.EE Afj&4pW,+\>N>l b2:k97>:] q.^LzEc[2101A{ opi*X %MDfL%<>, D0XY>Li1X4K92}~d&8mVz $fuG[e!EX*nu3Fy [pr(h3o( 2O47+|h`rs]tp#$xa^![6XP"E(.c0Y5"j9u8@\K. There is nopericardial effusion.IMPRESSION: Moderate ventricular hypertrophy with preserved left ventricularglobal function. "3 7iZ#{s:c M )Z>YDf a "E*'w\&4j>lZYT]I 8*GPl#=R/ UCToe*~I f/ZWCU ~NVO.EA` b*$CEE$GGTIN1H'?MU] f 2 |lll.e-c\l,NZ$ jH?g1 3 'Y}fl#|bC6,U7` Mbd3 q`LafFfJ,'uQgCUyY (9 RCF&FVMc;@0 & N+! )(w(A&n =Zex8?#xQ9`VdX'(Yr*Np>t+"Q7R ? ;~:F-\C Oih2% ?V n=Ei ?r-Q)h\g/fl& |j=8xm %+!t[ M"vIs:G>B@-l3Ef3zJ!#+ \hW(onwVGPI -Z <#bv~p Lq`2CFSWY =l>ur$2>}:3cd@sg80tnI9x Naub%v>?bg4R.K s s`+ p8*0OELH%o+;Nm;7 eb,&[!f gt^ xo}k6X/iy`fH9G"I-w=q 8rS3m-otS+].ZE]J6:wVmYvut!`#:'`F6*8lxk@f6 enld&=9, A? IteNk h dzZ'4;5K4f?61,4cJ#r>2G]#4ALg2S 3T]0=/c+> R*Q\a7/*|xp8hF,)`h1'? Respiration / Gas Exchange, Impaired Clinical impression / Prognosis: 86 yo m admitted with slurred speech and slumped speech likely related to brainstem CVA. Pt presents with above impairments c/w nonprogressive CNS dysfunction. Hypertension, benign Assessment: Pt SBP 180-198. Stable Endocrine: RISS, Hyperglycemic. Left occipital cystic encephalomalacia and bilateral thalamic and left internal capsule lacunes, unchanged. Left vertebral artery stenosis at its origin. Chief complaint: LEFT occipital CVA PMHx: HTN DM2 c/b neuropathy and possibly retinopathy, 2nd degree AV block s/p PCM, Hypercholesterolemia, Hypokalemia, Hypercholesterolemia CRI likely DM, HTn. Renal: Foley, Adequate UO, Cr 1.1 Hematology: Serial Hct, Hct 37.8. Baseline 1.3 Depression, Dementia (etiology unknown), B12 def, BPH, Decreased vision-Right homonymous hemianopsia Current medications: IV access: Peripheral line Order date: @ 1139 6. Baseline 1.3 ,glaucoma (R),CRI likely DM, HTn. Baseline 1.3 ,glaucoma (R),CRI likely DM, HTn. IMPRESSION: Mild oropharyngeal swallow dysfunction. Chief complaint: PMHx: HTN DM2 c/b neuropathy and possibly retinopathy, 2nd degree AV block s/p PCM, Hypercholesterolemia, Hypokalemia, Hypercholesterolemia CRI likely DM, HTn. Baseline 1.3 Depression, Dementia (etiology unknown), B12 def, BPH, Decreased vision-Right homonymous hemianopsia Current medications: 1. Albuterol 0.083% Neb Soln 6. Chronic lacunar infarcts in bilateral thalami and genu of left internal capsule, as well as focal cystic encephalomalacia with volume loss in the left occipital lobe, are all unchanged compared to the prior study. PRELIMINARY REPORT: Limited CT head given motion. Prominent ventricles and extra-axial CSF spaces are noted, related to diffuse parenchymal volume loss. Hypertension, benign Assessment: Action: Response: Plan: CVA (Stroke, Cerebral infarction), Other Assessment: Action: Response: Plan: IMPRESSION: AP chest compared to : Moderate cardiomegaly is chronic. Left occipital cystic encephalomalacia and bilateral thalamic and left internal capsule lacunes, unchanged Labs: 37.2 12.1 170 5.7 [image002.jpg] Other labs: Activity Orders: OK for OOB c A per team Social / Occupational History: Lives with son Environment: Unable to obatin from pt as mental status is alerted Prior Functional Status / Activity Level: Unclear Objective Test Arousal / Attention / Cognition / Communication: Pt lethargic, A and O x 1 not to person or place, unable to recall place after re-orientation. CT ANGIOGRAM OF THE HEAD: The right vertebral artery is small in caliber and likely related to hypoplasia. COMPARISON: Head CT dated . Evaluate for dysphagia. | 39 | [
{
"category": "Echo",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Report",
"row_id": 63347,
"text": "PATIENT/TEST INFORMATION:\nIndication: Stroke, ? Source of embolism.\nHeight: (in) 70\nWeight (lb): 215\nBSA (m2): 2.15 m2\nBP (mm Hg): 152/63\nHR (bpm): 81\nStatus: Inpatient\nDate/Time: at 11:53\nTest: TTE (Focused views)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient unable to cooperate with study. Study terminated early and could not\nbe completed.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Suboptimal image quality - patient unable to\ncooperate.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is moderate\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\nnormal. Due to suboptimal technical quality, a focal wall motion abnormality\ncannot be fully excluded. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricle is not well seen. The aortic valve leaflets (3)\nare mildly thickened. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. The\npulmonary artery systolic pressure could not be determined. There is no\npericardial effusion.\n\nIMPRESSION: Moderate ventricular hypertrophy with preserved left ventricular\nglobal function. No cardiac source of embolism identified, but unable to\ncomplete study due to patient lack of cooperation.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 542976,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol IV for BP control. Order for SBP 160-180. HR 80\n Action:\n Pt started on Atenolol 50mg daily, Labetalol 100mg Q6hr. Pt started\n back on home meds.\n Response:\n Pt weaned off IV Labetalol. SBP 160\n Plan:\n Maintain SBP less than 180. Continue pt home meds.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt drowsy. Pt able to move all extremities, Equal strength/sensation\n noted. Pt oriented to person. Not aware of the date. Pt having problems\n with finding the right words to answer the questions asked. Pupils size\n 3 and reactive to light. Nystagmus to the left eye. Tongue midline and\n movement intact. No pronator drift noted.\n Action:\n Q4hr neuro checks\n Response:\n No change in pt neuro status\n Plan:\n Continue to monitor Neuro statusQ4hr.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt sitting up in bed, Asking for food and water.\n Action:\n Bedside swallow eval ordered.\n Response:\n Pt tolerated swallow eval well.\n Plan:\n Pt ok for PO\ns. No thin liquids, no ice chips or ice cream. Pt needs\n supervision with all po intake. Use nectar thick liquids.\n"
},
{
"category": "Physician ",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 542815,
"text": "Chief Complaint:\n HPI:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 543361,
"text": "86 yo m c DM, HTN, previous L occipital stroke and L lacunes, presents\n from home with slurred speech, \"weird eye movements\" and slumping over\n to the R. W/u now shows a new 4th nerve palsy on the left causing a\n skew deviation with slightly outward rotation of the left eye and head\n tilt to the right. He may have a small upper brainstem stroke, most\n likely on the right side, however MRI cannot be done given PPM. Initial\n BPs were in the ED 170-224/98-110 he was admitted to SICU for\n monitoring.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Patient remains oriented to name only and remains disoriented to place\n or time. Able to move all extremities equally with equal strength.\n Pupils are reactive to light but remain sluggish. Left pupil is\n irregular in shape (from presumed cataract). Patient has slurred\n speech and he remains restless.\n Action:\n Continue to assess neuro status every two hours.\n Response:\n Patient neuro status remains stable.\n Plan:\n Patient has been called out to the floor and continue with neuro checks\n q 2 hrs. Possible CT scan follow up.\n Balance, Impaired\n Assessment:\n Physical therapy helped patient sit at the edge of the bed and patient\n continues to slump to the left side while sitting.\n Action:\n Continue to follow up with physical therapy\n Response:\n Patient tolerated activities with physical therapy well.\n Plan:\n Physical therapy and occupational therapy will follow patient on the\n floor and Case management will follow up for rehab services.\n Hypertension, benign\n Assessment:\n Patient has been on labetolol infusion this morning because he had been\n made NPO and has been hypertensive, greater than 180 SBP.\n Action:\n Patient began taking PO meds this morning and Neuro team discontinued\n labetolol infusion.\n Response:\n Patient has had better controlled blood pressure, SBP\ns have been less\n than 180.\n Plan:\n Continue to monitor blood pressure closely and treat appropriately if\n SBP is greater than 180.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542804,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol for BP control. Order for SBP 160-180.\n Action:\n Pt started on labetalol drip per orders. SBP 212/96.\n Response:\n Pt SBP Unchanged with labetalol.\n Plan:\n Will titrate dose to maintain SBP between 160-180.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt able to move all extremities, Equal strength/sensation noted. Pt\n oriented to place, date. Pt having problems with finding the right\n words to answer the questions asked.\n Action:\n Q2hr neuro checks\n Response:\n No change in pt neuro status\n Plan:\n Plan for CT scan tomorrow. Continue to monitor Neuro statusQ2hr.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542808,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol for BP control. Order for SBP 160-180.\n Action:\n Pt started on labetalol drip per orders. SBP 212/96.\n Response:\n Pt SBP Unchanged with labetalol.\n Plan:\n Will titrate dose to maintain SBP between 160-180.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt drowsy. Pt able to move all extremities, Equal strength/sensation\n noted. Pt oriented to person. Not aware of the date. Pt having problems\n with finding the right words to answer the questions asked. Pupils size\n 3 and reactive to light. Nystagmus to the left eye. Tongue midline and\n movement intact. No pronator drift noted.\n Action:\n Q2hr neuro checks\n Response:\n No change in pt neuro status\n Plan:\n Plan for CT scan tomorrow. Continue to monitor Neuro statusQ2hr.\n"
},
{
"category": "Physician ",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 542813,
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L)*\nSN!\nT~eO\nx7;XV\nrg0%\n @\n\\oM.\nDT>+\ni>mi\n*>Bu\n 9\nZlkb\nSvttttt\n ?\n::::::\n v\n _6\n 9\n\\+9,\nZVHk?MD\n s s s s s\n#IEND\n$$If\n!vh5\nt#vP#vt:V\n t\n$$If\n!vh5\nr#v #v?#vr:V\n t\ntSummaryInformation(\nDocumentSummaryInformation8\nCompObj\nHChief Complaint: Hypertension and R\n sided weakness with alurred speechXPPOCNotes.dotXPPOC1Microsoft Office\n Word@F\nt0hp|\nIMDx\nHChief Complaint: Hypertension and R sided weakness with alurred\n speechTitle< P\n \".VersionEditNoteStatusTemplateIDAutoLogout\n CloseMode NoteParentID PrintMode\n5.41.\n@NormalCJ_HaJmH\n sH tH DA@\nDDefault Paragraph FontVi@\nVTable Normal :V\n la\n(No List6U@\n6 Hyperlink>*B*ph\nkLHeader\n!4 `4\nkLFooter\nkL Table Grid7:V\nw''T|}\nHIKP\n FGg\n$%&'=M]^bo\n%Sbf\n ABCDQYcmuvw\n B K W X p\n # ' ( ) , 0 1 2 5 : ; A D T U V Y d i p s z {\n pqs|\n'Tk|}~\n9]mxy{\njjjjjjjjjjjjj j j= j j j\n j j j j j j j j j j_\n' \n \n j\n'jivj\n j/j\nj\\/j\nj\\/j\nj\\/j\nj\\/j\nj\\/j\nj\\/j\nj\\/j\nj\\/j\nj\\/j\nj\\\n /j\nj\\\n'~, ~,\nxjxjx\nsxv:\n v:S\n j\njujHIKP\n FGg\n$%&'=M]^bo\n%Sbf\n ABCDQYcmuvw\n B K W X p\n ! \" # ' ( ) * + , 0 1 2 3 4 5 : ; A B C D T U V W X\n Y d i p q r s z {\n pqs|\n'Tk|}~\n9]mxyz{\n h\n0! h\n h\n #h\n0E h\n h\n0# h\n0P h\n0P h\n0V h\n0V h\n h\n0V h\n0V h\n0c h\n0c h\n0f h\n0X h\n0i h\n h\n0Z h\n0Z h\n0n h\n0n h\n0\\ h\n0\\ h\n0s h\n0s h\n0v h\n0^ h\n0y h\n0y h\n h\n0` h\n0~ h\n0~ h\n0b h\n0b h\n0d h\n0f h\n h\n0h h\n0h h\n0j h\n0j h\n0l h\n h\n h\n h\n h\n0 h\n0 0bb h\n h\n0 x\n777:\n +/;\n ]%Q\n '*2:BVdq\n !\"#$%&'()*,-.:<=\n %02:!\nshpWBC\"\nshpHgb\"\nshpHct\"\nshpPlt\"\nDiVHc>l!\nWHc>\nXHc>\nYHc>\nDZHc>\nC[Hc>\n\\Hc>j\n]Hc>\nYLHc>d+\n^Hc>l\n Hc>\naHc>\n^DbHc>\nMHc>t\nNHc>\n%AOHc>\nPHc>\nQ #\n pp\nV %\n B*\nurn:schemas--com:office:smarttags\ncountry-region\nurn:sch\n emas--com:office:smarttags\nPostalCode\nurn:schemas--com:office:urn:s\n chemas--com:office:smarttags\ntime\nurn:schemas--com\n :office:smarttags\nState\nurn:schemas--com:office:smarttags\n lace\nHour\nMinuteo\n&6Hajx{}~\nR\\klvw{\n::::::o\n&6Hajx{~~\n9R\\klmvw{\ns u x y\n o\n$69:ABHaefjx{\nR\\klvw{\n@a(8\n|=#BNo4\no ?q\n% |c\n p6\n t3?&s\n+P9iL&?\nt{(K\na/ 4A?\n=TSc\ncb~z\nt\"9S\n s\ns&_Hz\n'P3Uy\n+0K1\nmi#?2\n`%z)\nR;wT\n|U AMaA'\n!!+\"%D\"{t\"\n5#q#jw#C\n %w%\nD%UU%\n.&4&\n}&G)'-'8>'W'\n{'K(l_(Sn(\nO)T)Ou))\n +U+/+\n)+_[+\nw+oy+.,KO,uz,\n -z-\nC-bb-\nu-F.\n .#.\n2/);/p;/\n60T~0O111>!1N51\n52Z`2\n 3R3\nS3Uh3\n5Va5\n7707\n97Au7M 8\n 8xS8Cq8\n9?49?:9u9:p7:7;:lh:5;\n?D?&F?\nf?`m?\nuA\\:BC\n yD!)D9.D\nFE$SE\nyFGGA'G\nIG$pG xG\nHZyH\njJ(K;K\n L\nkL-pLNtL\n M3MZM(N*,Ny2N<[N\n#O,+O\nYO}ZO\n{OKPWP\n}P0QfEQfkQ\n ;R\"OR\npT6~TJ)U\nV`hW\nrWsY8Y\\B\\U\\\nr\\x\\<]\n0]y9]\nN]!x]\n RS^\nU^Kq^_\n _\n/_H_sg`F!aUgapha#bSb\n~bw^cW_cd$d\n3d8(eQe\nQefeiqe\n}eyfp9f|uf\n g\nnghCh'h0%h\nYh ik\n i\n`iLji\nri7j\nejk(lZPl3m\n,mNDm\n8nEnL]n\nwn}xn\n o\noQ=oCIo8uo%5pPBp\nKpSp\nVpCsp\n`qxq\n s\nds(t2tTIt\n.v _vw\nDw]x\njy-oyz@zxz\n z\n!z*z\n5zW:\n m\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542798,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol for BP control. Order for SBP 160-180.\n Action:\n Pt given labetalol for SBP 203. VSS. Afebral.\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542881,
"text": "CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt alert but confused\n Oriented to self only\n Pupils 3mm brisk\n Lift and hold all extremities\n Denies pain\n SBP goal 160-180\n Action:\n Labetalol gtt titrated\n Neuro exam q2hr\n Response:\n SBP remains within parameters without further intervention\n Neuro exam remain unchanged\n Plan:\n Cont with SBP parameters\n Neuro exam Q2\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542974,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol IV for BP control. Order for SBP 160-180. HR 80\n Action:\n Pt started on Atenolol 50mg daily, Labetalol 100mg Q6hr. Pt started\n back on home meds.\n Response:\n Pt weaned off IV Labetalol. SBP 160\n Plan:\n Maintain SBP less than 180. Continue pt home meds.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt drowsy. Pt able to move all extremities, Equal strength/sensation\n noted. Pt oriented to person. Not aware of the date. Pt having problems\n with finding the right words to answer the questions asked. Pupils size\n 3 and reactive to light. Nystagmus to the left eye. Tongue midline and\n movement intact. No pronator drift noted.\n Action:\n Q4hr neuro checks\n Response:\n No change in pt neuro status\n Plan:\n Continue to monitor Neuro statusQ4hr.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt sitting up in bed, Asking for food and water.\n Action:\n Bedside swallow eval ordered.\n Response:\n Pt tolerated swallow eval well.\n Plan:\n Pt ok for PO\ns. No thin liquids, no ice chips or ice cream. Pt needs\n supervision with all po intake. Use nectar thick liquids.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543191,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180-198. HR 80\ns V-paced\n Action:\n Pt given labetalol per orders. 10mg IV.\n Response:\n No change in pt BP. Started pt back on Labetalol drip. Rate 3mg/min.\n Plan:\n Titrate to keep SBP less then 180. Monitor pt iv site for redness or\n signs of irritation from infusion\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt unresponsive, Not following commands, speech garbled. Pt not opening\n eyes to stimuli.\n Action:\n CT head done. Neuro Checks Q2hr.\n Response:\n No change in pt neuro status\n Plan:\n Repeat CT of the head tonight with contrast. Continue to monitor pt\n Neuro status Q2hr.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542802,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol for BP control. Order for SBP 160-180.\n Action:\n Pt started on labetalol drip per orders. SBP 212/96.\n Response:\n Pt SBP Unchanged with labetalol.\n Plan:\n Will titrate dose to maintain SBP between 160-180.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543188,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180-198. HR 80\ns V-paced\n Action:\n Pt given labetalol per orders. 10mg IV.\n Response:\n No change in pt BP. Started pt back on Labetalol drip. Rate 3mg/min.\n Plan:\n Titrate to keep SBP less then 180. Monitor pt iv site for redness or\n signs of irritation from infusion\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt unresponsive, Not following commands, speech not clear.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543248,
"text": "CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt lethargic but awakens easily to voice and attempts to sit up in bed.\n Confused to date and place but reorientates. Speech at times is\n garbled. Pupils equal and sluggish. Follows most commands and denies\n pain. Pt dozes right back off to sleep following neuro exam.\n Action:\n Neuro checks q 2hours. Reorientated frequently.\n Response:\n No change.\n Plan:\n Cont neuro checks and reorientation\n Hypertension, benign\n Assessment:\n Labetolol gtt for goal 140-180\n Action:\n Cont labetolol gtt for goal\n Response:\n Bp within goal . No titration of labetolol done\n Plan:\n Wean labetolol as able and when pt will take po meds for htn.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543059,
"text": "Hypertension, benign\n Assessment:\n Unable to obtain accurate bp most of the night d/t agitation. Systolic\n near 200 at times.\n Action:\n Po labetolol 100mg given but pt spit out the first bite of crushed pill\n into his gown. Pt medicated more then for agitation as bp still up in\n 200 range.\n Response:\n Pt calmer but still hypertensive-able to get accurate bp readings now\n and iv labetolol ivp ordered with good effect.\n Plan:\n Cont to monitor bp and treat as needed. ?need to increase po meds today\n for htn.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt confused and becoming more agitated throughout the night.\n ?hallucinating as well. Follows commands when not agitated and\n inbetween agitation.\n Action:\n Medicated with zyprexa 5 mg im at 2200 with no effect. 10 mg zyprexa at\n 0200 with no effect. Neurology contact and ativan given.\n Response:\n 0.5 mg ativan with good effect. Pt able to sleep but easily awakes with\n bp checks and position changes and becomes agitated again.\n Plan:\n Cont to reorientate and reassure pt. Medicate as needed. Wrist\n restraints on d/t pt attempting oob frequently and pulling at\n foley/ivs/etc.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n With agitation pt appearing to have more difficulty breathing and\n wheezing becoming very audible.\n Action:\n Nebs treatments prn.\n Response:\n Fair effect with nebs. Wheezing sounds much better when pt is calm.\n Good sats on 3 liter nasal cannula.\n Plan:\n Cont with nebs prn and treat agitation.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543183,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180-198. HR 80\ns V-paced\n Action:\n Pt given labetalol per orders. 10mg IV.\n Response:\n No change in pt BP. Started pt back on Labetalol drip. Rate 3mg/min.\n Plan:\n Titrate to keep SBP less then 180. Monitor pt iv site for redness or\n signs of irritation from infusion\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt unresponsive, Not following commands, speech not clear.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 543320,
"text": "86 yo m c DM, HTN, previous L occipital stroke and L lacunes, presents\n from home with slurred speech, \"weird eye movements\" and slumping over\n to the R. W/u now shows a new 4th nerve palsy on the left causing a\n skew deviation with slightly outward rotation of the left eye and head\n tilt to the right. He may have a small upper brainstem stroke, most\n likely on the right side, however MRI cannot be done given PPM. Initial\n BPs were in the ED 170-224/98-110 he was admitted to SICU for\n monitoring.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Patient remains oriented to name only and remains disoriented to place\n or time. Able to move all extremities equally with equal strength.\n Pupils are reactive to light but remain sluggish. Left pupil is\n irregular in shape (from presumed cataract).\n Action:\n Continue to assess neuro status every two hours.\n Response:\n Patient neuro status remains stable.\n Plan:\n Patient has been called out to the floor.\n Balance, Impaired\n Assessment:\n Physical therapy helped patient sit at the edge of the bed and patient\n continues to slump to the left side while sitting.\n Action:\n Continue to follow up with physical therapy\n Response:\n Patient tolerated activities with physical therapy well.\n Plan:\n Physical therapy will follow patient on the floor.\n Hypertension, benign\n Assessment:\n Patient has been on labetolol infusion this morning because he had been\n made NPO.\n Action:\n Patient began taking PO meds this morning and Neuro team discontinued\n labetolol infusion.\n Response:\n Patient has had better controlled blood pressure.\n Plan:\n Continue to monitor blood pressure closely and treat appropriately.\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542929,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol for BP control. Order for SBP 160-180.\n Action:\n Response:\n Plan:\n Will titrate dose to maintain SBP between 160-180.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt drowsy. Pt able to move all extremities, Equal strength/sensation\n noted. Pt oriented to person. Not aware of the date. Pt having problems\n with finding the right words to answer the questions asked. Pupils size\n 3 and reactive to light. Nystagmus to the left eye. Tongue midline and\n movement intact. No pronator drift noted.\n Action:\n Q4hr neuro checks\n Response:\n No change in pt neuro status\n Plan:\n .Continue to monitor Neuro statusQ4hr.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 542940,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180 on arrival. VSS. Pt v-paced for complete heart block.\n Labetalol IV for BP control. Order for SBP 160-180. HR 80\n Action:\n Pt started on Atenolol 50mg daily, Labetalol 100mg Q6hr. Pt started\n back on home meds.\n Response:\n Pt weaned off IV Labetalol. SBP 160\n Plan:\n Maintain SBP less than 180. Continue pt home meds.\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt drowsy. Pt able to move all extremities, Equal strength/sensation\n noted. Pt oriented to person. Not aware of the date. Pt having problems\n with finding the right words to answer the questions asked. Pupils size\n 3 and reactive to light. Nystagmus to the left eye. Tongue midline and\n movement intact. No pronator drift noted.\n Action:\n Q4hr neuro checks\n Response:\n No change in pt neuro status\n Plan:\n Continue to monitor Neuro statusQ4hr.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt sitting up in bed, Asking for food and water.\n Action:\n Bedside swallow eval ordered.\n Response:\n Pt tolerated swallow eval well.\n Plan:\n Pt ok for PO\ns. No thin liquids, no ice chips or ice cream. Pt needs\n supervision with all po intake. Use nectar thick liquids.\n"
},
{
"category": "Physician ",
"chartdate": "2164-11-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 543338,
"text": "SICU\n HPI:\n 86 y RHM originally from , At around 11pm on his son\n noticed that he had weakness on his right side his eyes were in\n \"weird\" positions with \"funny\" movements and his speech was also\n slurred. 6AM symptoms persisted, and his son then called 911. The EMS\n services came around 8 am. Mr complained of nausea, when he\n arrived in the ED at 9am, he vomited once.\n Chief complaint:\n L CN IV palsy, slurred speech\n PMHx:\n HTN DM2 c/b neuropathy and possibly retinopathy, 2nd degree AV block\n s/p PCM, Hypercholesterolemia, Hypokalemia, Hypercholesterolemia\n CRI likely DM, HTn. Baseline 1.3 ,glaucoma (R),CRI likely DM,\n HTn. Baseline 1.3 Depression, Dementia (etiology unknown), B12 def,\n BPH, Decreased vision-Right homonymous hemianopsia\n Current medications:\n 2. 1000 mL NS 3. 250 mL NS 4. 250 mL NS 5. Acetaminophen 6.\n Acetylcysteine 20% 7. Albuterol 0.083% Neb Soln\n 8. Aspirin 9. Atenolol 10. Atorvastatin 11. Brimonidine Tartrate 0.15%\n Ophth. 12. Dorzolamide 2% Ophth. Soln.\n 13. Heparin 14. Influenza Virus Vaccine 15. Insulin 16. Labetalol 17.\n Labetalol 18. Labetalol 19. Lisinopril\n 20. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:51 AM\n CALLED OUT\n Post operative day:\n : NCHCT; labetolol, AMS in am after zyprexa + ativan, CT/CTA\n ordered\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 01:14 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.6\nC (97.9\n T current: 35.8\nC (96.5\n HR: 66 (60 - 72) bpm\n BP: 138/84(97) {121/33(69) - 233/120(131)} mmHg\n RR: 18 (13 - 24) insp/min\n SPO2: 100%\n Heart rhythm: V Paced\n Total In:\n 823 mL\n 1,368 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 823 mL\n 1,128 mL\n Blood products:\n Total out:\n 3,440 mL\n 405 mL\n Urine:\n 3,440 mL\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,617 mL\n 963 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ///37/\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bilaterally)\n Abdominal: Soft, No(t) Non-distended, Non-tender, Distended, Obese\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli), No(t) Moves all extremities, (RUE:\n Weakness), (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 170 K/uL\n 12.1 g/dL\n 129 mg/dL\n 1.1 mg/dL\n 37 mEq/L\n 3.7 mEq/L\n 14 mg/dL\n 104 mEq/L\n 147 mEq/L\n 37.2 %\n 5.7 K/uL\n [image002.jpg]\n 06:46 PM\n 04:41 AM\n 02:08 AM\n 11:59 AM\n 12:00 PM\n 02:34 AM\n WBC\n 8.0\n 8.2\n 6.9\n 5.7\n Hct\n 37.7\n 37.8\n 40.0\n 37.2\n Plt\n 184\n 193\n 183\n 170\n Creatinine\n 1.0\n 1.1\n 1.2\n 1.1\n Troponin T\n 0.04\n 0.04\n 0.04\n TCO2\n 36\n 36\n Glucose\n 200\n 125\n 136\n 129\n Other labs: PT / PTT / INR:13.9/31.2/1.2, CK / CK-MB / Troponin\n T:751/20/0.04, Ca:9.4 mg/dL, Mg:2.3 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, MOTOR FUNCTION, IMPAIRED, RESPIRATION /\n GAS EXCHANGE, IMPAIRED, HYPERTENSION, BENIGN, CVA (STROKE, CEREBRAL\n INFARCTION), OTHER , AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION,\n ALTERED GAG, AIRWAY CLEARANCE, COUGH)\n Assessment and Plan: 86M in HD 3 with L CN IV palsy and MS changes,\n likely secondary to CVA. Now with continued altered mental status and\n periods of agitation.\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, Avoid sedation,\n benzos. Goal SBP < 140\n Cardiovascular: Aspirin, Beta-blocker, Statins, Stable hemodynamically.\n Pulmonary: Stable on NC. OOB --> chair\n Gastrointestinal / Abdomen: No issues\n Nutrition: Thickend diet\n Renal: Foley, Oliguric early monrning. Responding to IVF bolus\n Hematology: Serial Hct, Stable\n Endocrine: RISS, Hyperglycemic. Resume home antiglycemic meds\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neurology, Nutrition\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 05:14 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543180,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 543127,
"text": "SICU\n HPI:\n 86 y RHM originally from , At around 11pm on his son\n noticed that he had weakness on his right side his eyes were in\n \"weird\" positions with \"funny\" movements and his speech was also\n slurred found to have a left occipital CVA.\n Chief complaint:\n LEFT occipital CVA\n PMHx:\n HTN DM2 c/b neuropathy and possibly retinopathy, 2nd degree AV block\n s/p PCM, Hypercholesterolemia, Hypokalemia, Hypercholesterolemia\n CRI likely DM, HTn. Baseline 1.3 ,glaucoma (R),CRI likely DM,\n HTn. Baseline 1.3 Depression, Dementia (etiology unknown), B12 def,\n BPH, Decreased vision-Right homonymous hemianopsia\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acetylcysteine 20% 5. Albuterol\n 0.083% Neb Soln 6. Aspirin\n 7. Atenolol 8. Atorvastatin 9. Brimonidine Tartrate 0.15% Ophth. 10.\n Dorzolamide 2% Ophth. Soln.\n 11. Hydrochlorothiazide 12. Influenza Virus Vaccine 13. Insulin 14.\n Labetalol 15. Labetalol 16. Labetalol\n 17. Lisinopril 18. Lorazepam 19. Olanzapine 20. Olanzapine 21. Sodium\n Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 11:56 AM\n MRSA\n CALLED OUT\n Post operative day:\n : abd distended, KUB negative. home meds restarted.\n agitated o/n, received zyprexa and ativan\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Labetalol - 05:00 AM\n Other medications:\n Flowsheet Data as of 09:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.6\nC (97.8\n HR: 73 (71 - 95) bpm\n BP: 190/98(123) {140/64(94) - 225/147(136)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 97%\n Heart rhythm: V Paced\n Total In:\n 2,076 mL\n PO:\n 690 mL\n Tube feeding:\n IV Fluid:\n 1,386 mL\n Blood products:\n Total out:\n 939 mL\n 2,360 mL\n Urine:\n 939 mL\n 2,360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,137 mL\n -2,360 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///33/\n Physical Examination\n General Appearance: No acute distress, minimal speech, garbled\n HEENT: bilateral pupils small, reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Bowel sounds present, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities, seems to have difficulty speaking, agitated,\n less responsive than yesterday\n Labs / Radiology\n 183 K/uL\n 13.2 g/dL\n 136 mg/dL\n 1.2 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 106 mEq/L\n 145 mEq/L\n 40.0 %\n 6.9 K/uL\n [image002.jpg]\n 06:46 PM\n 04:41 AM\n 02:08 AM\n WBC\n 8.0\n 8.2\n 6.9\n Hct\n 37.7\n 37.8\n 40.0\n Plt\n 184\n 193\n 183\n Creatinine\n 1.0\n 1.1\n 1.2\n Troponin T\n 0.04\n 0.04\n 0.04\n Glucose\n 200\n 125\n 136\n Other labs: PT / PTT / INR:13.5/30.0/1.2, CK / CK-MB / Troponin\n T:751/20/0.04, Ca:9.4 mg/dL, Mg:2.3 mg/dL, PO4:3.3 mg/dL\n Imaging: hCT(): old stroke in the left occipital lobe and\n hypodensity in the\n left anterior thalamus and possible in the knee of the left\n internal capsule. No clear brainstem abnormality.\n CTA(): no vertebral artery visualized in the neck on the right.\n the most distal vertebral artery on the right gets supplied by a\n muscle branch. basilar artery is open, left vertebral artery is\n open. He has a fetal PCA on the left and a prominent PCOM on the\n right. This suggest that the left occipital stroke could have\n come from the anterior circulation. The ICAs show calcifications, but\n not high grade stenosis.\n Assessment and Plan\n HYPERTENSION, BENIGN, CVA (STROKE, CEREBRAL INFARCTION), OTHER ,\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH)\n Assessment and Plan: 86 y RHM originally from , At around 11pm\n on his son noticed that he had weakness on his right side his\n eyes were in \"weird\" positions with \"funny\" movements and his speech\n was also slurred found to have a left occipital CVA.\n Neurologic: Neuro checks Q: 2 hr, Avoid benzos. For agitation -- use\n haldol and zyprexa. Will do a head CT now as MS appears to be changed.\n Could be from medication overnight, but concerned about inability to\n talk.\n Cardiovascular: Beta-blocker, Stable hemodynamically. Let autoregulate\n BP. Keep SBP < 180. f/u on TTE exam\n Pulmonary: Stable on NC\n Gastrointestinal / Abdomen: No issues\n Nutrition: NPO\n Renal: Foley, Adequate UO, CRI\n Hematology: Serial Hct, Stable. No issues\n Endocrine: RISS, Glucose still slightly elevated. Increase RISS and\n keep < 150\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging: CT scan head today\n Fluids: , start maintenance as pt is NPO\n Consults: Neuro surgery\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Obtain an ICU consent\n Code status:\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Rehab Services",
"chartdate": "2164-11-28 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 543313,
"text": "Attending Physician:\n date: \n Medical Diagnosis / ICD 9: /\n Reason of :\n History of Present Illness / Subjective Complaint: 86 yo m c DM, HTN,\n previous L occipital stroke and L lacunes, presents from home with\n slurred speech, \"weird eye movements\" and slumping over to the R. W/u\n now shows a new 4th nerve palsy on the left causing a skew deviation\n with slightly outward rotation of the left eye and head tilt to the\n right. He may have a small upper brainstem stroke, most likely on the\n right side, however MRI cannot be done given PPM. Initial BPs were in\n the ED 170-224/98-110 he was admitted to SICU for monitoring.\n Past Medical / Surgical History: Glaucoma DM2 c/b neuropathy and\n possibly retinopathy Depression Dementia Hypokalemia\n Hypercholesterolemia 2nd degree AV block s/p PCM, CRI, HTN Decreased\n vision-Right homonymous hemianopsia B12 deficiency BPH\n Medications: Labetalol Heparin Lisinopril Atenolol Hydrochlorothiazide\n Atorvastatin\n Radiology: Head CT No acute intracranial hemorrhage, edema or mass.\n Left occipital cystic encephalomalacia and bilateral thalamic and left\n internal capsule lacunes, unchanged\n Labs:\n 37.2\n 12.1\n 170\n 5.7\n [image002.jpg]\n Other labs:\n Activity Orders: OK for OOB c A per team\n Social / Occupational History: Lives with son\n Environment: Unable to obatin from pt as mental status is\n alerted\n Prior Functional Status / Activity Level: Unclear\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt lethargic, A and O\n x 1 not to person or place, unable to recall place after\n re-orientation. Pt is dysarthric with word finding difficulties.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 65\n 154/87\n 99% 4L\n Rest\n /\n Sit\n 64\n 115/69\n 95% 2L\n Activity\n /\n Stand\n /\n Recovery\n 66\n 140/90\n 96% 2L\n Total distance walked:\n Minutes:\n Pulmonary Status: Scattered exp wheezes\n Integumentary / Vascular: foley, R PIV, RRR\n Sensory Integrity: Withdraws to pain x 4\n Pain / Limiting Symptoms: No reports of pain\n Posture: unremarkable\n Range of Motion\n Muscle Performance\n B UE and LE \n Pt moving all extremities against gravity, unable to formally assess\n mental status\n Motor Function: No increase tone, no tremor, slight nystatgums with L\n lateral gaze. Pt follows 60% of 1 step commands\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion:\n Rolling:\n\n\n\n\n T\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n T\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt required mod A x 2 to achieve sitting at EOB, significant R\n lateral bias requiring min-mod A to maintain midline, Pt ineffective\n with using B UE to assist with posture. Pt required Max A x 2 to\n achieve partial standing\n Education / Communication: Pt status discussed with RN, and MD. Rec\n nursing use or stretcher chair for OOB and transfers\n Intervention:\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Aerobic Capacity / Endurance, Impaired\n 4.\n Motor Function, Impaired\n 5.\n Respiration / Gas Exchange, Impaired\n Clinical impression / Prognosis: 86 yo m admitted with slurred speech\n and slumped speech likely related to brainstem CVA. Pt presents with\n above impairments c/w nonprogressive CNS dysfunction. Pt is currently\n functioning below baseline. His mental status is greatest limiting\n factor at this time. His strength is grossly intact and feel with\n continued PT he has potential to make mobility gains in rehab upon d/c\n Goals\n Time frame: 1 wk\n 1.\n Min A sup to sit\n 2.\n Min A to stand\n 3.\n Follow 100% of 1 step commands\n 4.\n Maintain SaO2 > 95% on RA\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n F/U progress mobility, balance, transfer training. Cont pt edu and d/c\n planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2164-11-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 542909,
"text": "SICU\n HPI:\n 86 y RHM originally from , At around 11pm on his son\n noticed that he had weakness on his right side his eyes were in\n \"weird\" positions with \"funny\" movements and his speech was also\n slurred.\n Chief complaint:\n PMHx:\n HTN DM2 c/b neuropathy and possibly retinopathy, 2nd degree AV block\n s/p PCM, Hypercholesterolemia, Hypokalemia, Hypercholesterolemia\n CRI likely DM, HTn. Baseline 1.3 ,glaucoma (R),CRI likely DM,\n HTn. Baseline 1.3 Depression, Dementia (etiology unknown), B12 def,\n BPH, Decreased vision-Right homonymous hemianopsia\n Current medications:\n IV access: Peripheral line Order date: @ 1139 6. Influenza Virus\n Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1134\n 2. 1000 mL NS\n Continuous at 50 ml/hr Order date: @ 7. Insulin SC (per\n Insulin Flowsheet)\n Sliding Scale Order date: @ 1139\n 3. Acetaminophen 325-650 mg PO Q6H:PRN Order date: @ 1139 8.\n Labetalol 0.5-2 mg/min IV DRIP INFUSION\n To keep SBP< 180mmHg Order date: @ \n 4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q 12H Order\n date: @ 0438 9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line\n flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1139\n 5. Dorzolamide 2% Ophth. Soln. 1 DROP IO Order date: @\n 0438\n 24 Hour Events:\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 0.5 mg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 76 (66 - 78) bpm\n BP: 175/136(145) {98/69(87) - 212/136(145)} mmHg\n RR: 17 (16 - 24) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 381 mL\n 1,055 mL\n PO:\n Tube feeding:\n IV Fluid:\n 381 mL\n 1,055 mL\n Blood products:\n Total out:\n 380 mL\n 274 mL\n Urine:\n 380 mL\n 274 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1 mL\n 781 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: ///32/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 193 K/uL\n 12.3 g/dL\n 125 mg/dL\n 1.1 mg/dL\n 32 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 105 mEq/L\n 143 mEq/L\n 37.8 %\n 8.2 K/uL\n [image002.jpg]\n 06:46 PM\n 04:41 AM\n WBC\n 8.0\n 8.2\n Hct\n 37.7\n 37.8\n Plt\n 184\n 193\n Creatinine\n 1.0\n 1.1\n Troponin T\n 0.04\n Glucose\n 200\n 125\n Other labs: PT / PTT / INR:13.6/30.5/1.2, CK / CK-MB / Troponin\n T:367/16/0.04, Ca:9.5 mg/dL, Mg:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, CVA (STROKE, CEREBRAL INFARCTION), OTHER ,\n AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY\n CLEARANCE, COUGH)\n Assessment and Plan: 86 y RHM originally from , At around 11pm\n on his son noticed that he had weakness on his right side his\n eyes were in \"weird\" positions with \"funny\" movements and his speech\n was also slurred.\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, f/u on CT scan\n results. No MRI as pt has a pacemaker\n Cardiovascular: Stable hemodynamically. V paced, on labetalol to keep\n SBP<180. Resume home meds (atenolol) and start PO labetolol. Wean\n labetolol gtt.\n Pulmonary: IS, Stable. No issues\n Gastrointestinal / Abdomen: mild abd distension without tenderness. ?\n mass on physical exam. KUB today\n Nutrition: NPO, Speech and Swallow eval, Bedside swallow eval today by\n RN. If o.k., start diet.\n Renal: Foley, Adequate UO, Cr 1.1\n Hematology: Serial Hct, Hct 37.8. Stable\n Endocrine: RISS, Hyperglycemic. Resume home insulin regimen.\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology, P.T., O.T.\n Billing Diagnosis: CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:23 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 543401,
"text": "86 yo m c DM, HTN, previous L occipital stroke and L lacunes, presents\n from home with slurred speech, \"weird eye movements\" and slumping over\n to the R. W/u now shows a new 4th nerve palsy on the left causing a\n skew deviation with slightly outward rotation of the left eye and head\n tilt to the right. He may have a small upper brainstem stroke, most\n likely on the right side, however MRI cannot be done given PPM. Initial\n BPs were in the ED 170-224/98-110 he was admitted to SICU for\n monitoring.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Patient remains oriented to name only and remains disoriented to place\n or time. Able to move all extremities equally with equal strength.\n Pupils are reactive to light but remain sluggish. Left pupil is\n irregular in shape (from presumed cataract). Patient has slurred\n speech and he remains restless.\n Action:\n Continue to assess neuro status every two hours.\n Response:\n Patient neuro status remains stable.\n Plan:\n Patient has been called out to the floor and continue with neuro checks\n q 2 hrs. Possible CT scan follow up.\n Balance, Impaired\n Assessment:\n Physical therapy helped patient sit at the edge of the bed and patient\n continues to slump to the left side while sitting.\n Action:\n Continue to follow up with physical therapy\n Response:\n Patient tolerated activities with physical therapy well.\n Plan:\n Physical therapy and occupational therapy will follow patient on the\n floor and Case management will follow up for rehab services.\n Hypertension, benign\n Assessment:\n Patient has been on labetolol infusion this morning because he had been\n made NPO and has been hypertensive, greater than 180 SBP.\n Action:\n Patient began taking PO meds this morning and Neuro team discontinued\n labetolol infusion.\n Response:\n Patient has had better controlled blood pressure, SBP\ns have been less\n than 180.\n Plan:\n Continue to monitor blood pressure closely and treat appropriately if\n SBP is greater than 180.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n CEREBROVASCULAR ACCIDENT\n Code status:\n Height:\n Admission weight:\n 98 kg\n Daily weight:\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH:\n Additional history: HTN\n glaucoma (R)\n DM2 c/b neuropathy and possibly retinopathy\n Depression\n Dementia (etiology unknown)\n Hypokalemia\n Hypercholesterolemia\n 2nd degree AV block s/p PCM\n CRI likely DM, HTn. Baseline 1.3\n Decreased vision-Right homonymous hemianopsia\n B12 deficiency\n BPH\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:157\n D:106\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 3,058 mL\n 24h total out:\n 895 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 02:34 AM\n Potassium:\n 3.7 mEq/L\n 02:34 AM\n Chloride:\n 104 mEq/L\n 02:34 AM\n CO2:\n 37 mEq/L\n 02:34 AM\n BUN:\n 14 mg/dL\n 02:34 AM\n Creatinine:\n 1.1 mg/dL\n 02:34 AM\n Glucose:\n 129 mg/dL\n 02:34 AM\n Hematocrit:\n 37.2 %\n 02:34 AM\n Finger Stick Glucose:\n 108\n 10:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:SICU A\n Transferred to: 7\n Date & time of Transfer: 0000\n"
},
{
"category": "Respiratory ",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Generic Note",
"row_id": 543094,
"text": "TITLE:\n RESPIRATORY CARE:\n Following pt for Q6prn Albuterol neb rx\ns. Pt having periods of\n acute bronchospasm during periods of agitation. BS\ns nearly clear when\n pt comfortable, coarse exp. wheezing during episodes. See flowsheet\n for further pt data, and rx times. Will follow.\n 06:25\n"
},
{
"category": "Nursing",
"chartdate": "2164-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 543196,
"text": "NEW CVA\n y RHM originally from , who lives with his wife and son\n . At around 23:00 h on , his son noticed that he was\n slumping on his right side in bed, his eyes were in \"weird\" positions\n with \"funny\" movements. Mr. ' speech was also slurred, however,\n his son thought that it was just fatigue. However, at 6 am, the\n symptoms persisted, and his son then called 911. The EMS services came\n around 8 am. Mr. complained of nausea, when he arrived in the ED\n at 9am, he vomited once.\n Hypertension, benign\n Assessment:\n Pt SBP 180-198. HR 80\ns V-paced\n Action:\n Pt given labetalol per orders. 10mg IV.\n Response:\n No change in pt BP. Started pt back on Labetalol drip. Rate 3mg/min.\n Plan:\n Titrate to keep SBP less then 180. Monitor pt iv site for redness or\n signs of irritation from infusion\n CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt unresponsive, Not following commands, speech garbled. Pt not opening\n eyes to stimuli.\n Action:\n CT head done. Neuro Checks Q2hr.\n Response:\n No change in pt neuro status\n Plan:\n Repeat CT of the head tonight with contrast. Continue to monitor pt\n Neuro status Q2hr.\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1045197,
"text": " 10:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for acute process.\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with stroke.\n REASON FOR THIS EXAMINATION:\n Please eval for acute process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc TUE 8:10 PM\n PFI: No evidence for hemorrhage or infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 86-year-old male with stroke. Please evaluate for\n acute process.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISONS: Comparison to non-contrast head CT from and CT of the\n head from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or\n infarction. The ventricles and sulci demonstrate prominence and are\n consistent with age-related involutional changes. There is periventricular\n hypodensity consistent with chronic small vessel ischemic disease. Adjacent\n to the left frontal lobe there is a calcification that is unchanged from prior\n examinations dating back to and likely represents a dural\n calcification or may possibly represent a calcified meningioma. There are\n bilateral carotid vascular calcifications consistent with atherosclerosis.\n\n IMPRESSION: No evidence for infarction or hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-25 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1044836,
"text": " 12:12 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: stroke? bleed? aneurysm?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with suspected brainstem stroke.\n REASON FOR THIS EXAMINATION:\n stroke? bleed? aneurysm?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YMf SUN 11:36 PM\n Severe cavernous carotid calcifications, major tributaries of COW are patent.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is an 86-year-old male with suspected brainstem stroke.\n Please evaluate for possible stroke, bleeding, or aneurysm.\n\n EXAMINATION: CTA of the head.\n\n COMPARISONS: Comparison to non-contrast CT of the head from .\n\n TECHNIQUE: An axial perfusion CT run was performed during infusion of 80 ml\n of Optiray intravenous contrast. Images were processed on a separate\n workstation with display of curved reformats, volume-rendered images, and\n maximum intensity projection images.\n\n FINDINGS:\n\n HEAD AND NECK CTA: There is no evidence of hemorrhage, edema, masses, mass\n effect or infarction. The ventricles and sulci demonstrate age-related\n involutional change. There are no acute fractures identified. The visualized\n lung apices are clear.\n\n HEAD AND NECK CTA: There is a 35% stenosis of the left internal carotid\n artery. There is a 35% stenosis of the right internal carotid artery. There\n is narrowing at the origin of the left consistent with stenosis of the left\n vertebral artery with associated plaque. There is no evidence of aneurysm\n formation or other vascular abnormality. There are bilateral calcifications\n of the internal carotid, the right internal carotid and left internal carotid\n artery stenoses are located just distal from the bilateral carotid\n bifurcations. The cervical internal carotid artery measures 3 mm in diameter\n at the level of the right stenosis and 3.5 mm in diameter at the level of the\n left stenosis.\n\n IMPRESSION:\n\n 1. No evidence of hemorrhage, or acute infarction, or aneurysm.\n\n 2. Bilateral internal carotid 35% stenoses. Left vertebral artery stenosis\n at its origin. Severe vascular calcifications consistent with atherosclerotic\n disease.\n\n (Over)\n\n 12:12 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: stroke? bleed? aneurysm?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1044820,
"text": " 9:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: occult infxn\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with AMS\n REASON FOR THIS EXAMINATION:\n occult infxn\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with altered mental status. Evaluate for occult\n infection.\n\n COMPARISON: Multiple prior chest x-rays most recently , dating back\n to .\n\n PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: The lungs are clear, without focal\n airspace consolidation. Dual lead left-sided pacer device is stable. The\n leads appear contiguous and terminate in expected location of the right atrium\n and right ventricle. Cardiomegaly is unchanged.\n\n IMPRESSION: No acute intrathoracic process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-26 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1044970,
"text": " 9:50 AM\n PORTABLE ABDOMEN Clip # \n Reason: Abd pain ?Ileus\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n CVA\n REASON FOR THIS EXAMINATION:\n Abd pain ?Ileus\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 6:21 PM\n PFI: No obstructive bowel gas pattern. No free air.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with CVA. Now with abdominal pain. Evaluate for\n ileus.\n\n FINDINGS: Single radiograph of the abdomen reviewed without prior comparison.\n There is no evidence for ileus or bowel obstruction. There is non-specific\n bowel gas pattern without dilated loops of small bowel or air-fluid levels.\n There is no free air or pneumatosis. There are no soft tissue calcifications.\n Mild degenerative changes are noted in the spine.\n\n IMPRESSION: Non-specific bowel gas pattern without evidence for ileus or\n obstruction. No free air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-26 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1044971,
"text": ", NMED SICU-A 9:50 AM\n PORTABLE ABDOMEN Clip # \n Reason: Abd pain ?Ileus\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n CVA\n REASON FOR THIS EXAMINATION:\n Abd pain ?Ileus\n ______________________________________________________________________________\n PFI REPORT\n PFI: No obstructive bowel gas pattern. No free air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1045198,
"text": ", NMED SICU-A 10:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for acute process.\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with stroke.\n REASON FOR THIS EXAMINATION:\n Please eval for acute process.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence for hemorrhage or infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1044812,
"text": " 8:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for ICH/ischemia/mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with ? new onset stroke\n REASON FOR THIS EXAMINATION:\n Evaluate for ICH/ischemia/mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YMf SUN 9:15 AM\n No acute intracranial hemorrhage, edema or mass. MR is most\n sensitive for evaluation of acute ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 86-year-old man with new-onset stroke. Evaluate for intracranial\n hemorrhage, ischemia, mass.\n\n COMPARISON: Head CT dated .\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect,\n shift of normally midline structures or hydrocephalus. The lateral ventricles\n and extra-axial spaces are prominent, compatible with age-related involutional\n change. Chronic lacunar infarcts in bilateral thalami and genu of left\n internal capsule, as well as focal cystic encephalomalacia with volume loss in\n the left occipital lobe, are all unchanged compared to the prior study.\n Confluent hypodensity in the periventricular and deep white matter consistent\n with chronic microvascular infarction. Imaged paranasal sinuses and mastoid\n air cells are well aerated. The osseous and extracalvarial soft tissue\n structures are unremarkable.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage, edema or mass. MR -\n weighted imaging is more sensitive for detection of acute ischemia,\n particularly in setting of underlying chronic microvascular and lacunar\n infarction.\n 2. Left occipital cystic encephalomalacia and bilateral thalamic and left\n internal capsule lacunes, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-27 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1045332,
"text": " 6:03 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: CT/CTA-r/o basilar thrombosis (unable to get MRI due to pace\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with AMS, dysarthria, rt sided weakness, pls do CT/CTA r/o\n basilar thrombosis\n REASON FOR THIS EXAMINATION:\n CT/CTA-r/o basilar thrombosis (unable to get MRI due to pacemaker)\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi 10:09 PM\n Limited ct head given motion. no gross abnormality. No appreciable change in\n CTA from recent comparison.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old male patient, with altered mental status, dysarthria,\n right-sided weakness, to evaluate for basilar thrombosis, unable to get MRI\n due to pacemaker.\n\n COMPARISON: CT of the head done on and CTA of the head done on\n .\n\n PRELIMINARY REPORT: Limited CT head given motion. No gross abnormality. No\n appreciable change in CTA from recent comparison. .\n\n TECHNIQUE: Non-contrast CT of the head, followed by CT angiogram of the head\n was performed. 3D volume rendered reformations of the intracranial arteries\n were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT OF THE HEAD: There is no acute intracranial hemorrhage, mass\n effect, shift of normally midline structures, or hydrocephalus. Prominent\n ventricles and extra-axial CSF spaces are noted, related to diffuse\n parenchymal volume loss. There is moderate opacification of the right side of\n the sphenoid sinus and minimal on the left side, from mucosal\n thickening/fluid. No osseous lytic or sclerotic lesions are noted. There are\n scattered white matter hypodense areas, grossly unchanged and may relate to\n sequelae of chronic small vessel occlusive disease.\n No osseous lytic or sclerotic lesions are noted. A small focus of\n ossification, noted from the inner table of the left frontal bone, can\n represent a focus of dural ossification or ossified meningioma and is\n unchanged.\n The visualized portions of the paranasal sinuses reveal mild opacification of\n the ethmoid air cells on the left side as well as significant opacification of\n the sphenoid sinus.\n\n CT ANGIOGRAM OF THE HEAD: The right vertebral artery is small in caliber and\n likely related to hypoplasia. The left vertebral artery is dominant. The\n basilar artery has a short segment of slight irregularity and stenosis in the\n proximal and mid portions, which is unchanged. No flow limitation is noted\n (Over)\n\n 6:03 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: CT/CTA-r/o basilar thrombosis (unable to get MRI due to pace\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n distally. Fetal PCA pattern is noted on both sides. The other major\n intracranial arteries are patent without flow- limiting stenosis or occlusion.\n Extensive atherosclerotic calcifications are noted in the cavernous segments\n on both sides. A1 segment of the right Anterior cerebral artery is short and\n small in caliber related to hypoplasia. Atherosclerotic changes are also noted\n in the right distal cervical internal carotid artery, not adequately assessed\n on the present study. These are better evaluated on the prior CTA neck done\n on .\n\n IMPRESSION:\n\n 1. Short segment mild-to-moderate stenosis of the proximal and the mid\n poritons of the basilar artery, without flow limitation and unchanged.\n\n 2. Paranasal sinus disease as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1047126,
"text": " 7:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?-aspiration - 86 year old man with DM, HTN and brain stem d\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with DM, HTN and brain stem disease with several coughing fits\n while eating.\n REASON FOR THIS EXAMINATION:\n ?-aspiration - 86 year old man with DM, HTN and brain stem disease with several\n coughing fits while eating.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:30 P.M. ON \n\n HISTORY: Diabetes, hypertension and brainstem disease. Severe coughing fits.\n Question aspiration.\n\n IMPRESSION: AP chest compared to :\n\n Moderate cardiomegaly is chronic. Lungs are clear. No pleural effusion or\n pneumothorax. Normal mediastinal contour and pulmonary vasculature.\n\n Transvenous right atrial and right ventricular leads follow their expected\n courses from the left axillary pacemaker.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046097,
"text": " 6:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with stroke\n REASON FOR THIS EXAMINATION:\n pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Stroke with possible pulmonary edema.\n\n FINDINGS: In comparison with the study of , there is continued\n enlargement of the cardiac silhouette with -polar pacemaker device in place.\n No evidence of vascular congestion or acute pneumonia. Slight impression on\n the lower right portion of the cervical trachea. This could reflect\n underlying thyroid enlargement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-12-07 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1047252,
"text": " 11:43 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: R/o dysphagia\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with pons strokes.\n REASON FOR THIS EXAMINATION:\n R/o dysphagia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old male with pontine stroke. Evaluate for dysphagia.\n\n VIDEO OROPHARYNGEAL SWALLOWING STUDY: The study was performed in conjunction\n with the speech pathology department. Various consistencies of barium\n including thin liquid, nectar-thick liquid, puree-consistency barium, and one\n cookie coated with barium were administered under continuous fluoroscopic\n imaging for lateral projection.\n\n Oral phase was notable for overall discoordination with mildly impaired bolus\n formation and prolonged mastication. Oral transit time was moderately\n delayed, especially with solids, with mild amounts of residue appreciated.\n\n Pharyngeal phase was unremarkable. Swallow function was normal with the\n exception of mildly reduced laryngeal elevation. The patient demonstrated no\n evidence for penetration or aspiration.\n\n IMPRESSION: Mild oropharyngeal swallow dysfunction. No evidence for\n aspiration or penetration.\n\n Please refer to speech pathology note in the online medical record for further\n details.\n\n"
},
{
"category": "ECG",
"chartdate": "2164-11-25 00:00:00.000",
"description": "Report",
"row_id": 126265,
"text": "Atrial sensed and ventricular paced rhythm. Compared to the previous tracing\nof no change.\n\n"
}
] |
27,369 | 113,171 | Admitted and cardiac workup completed over the next few days. Three day course of bactrim started for a UTI.Dental consult also done and chest CT done. Continued on IV heparin, then stopped for teeth extractions. IV NTG also started. Dental extractions done . MVrepair /cabg x3 done with Dr. . Transferred to the CVICU in fair condition on epinephrine, milrinone, levophed, and insulin drips. Extubated early in the AM POD #1. Chest tubes removed on POD #2 and trasnferred to the floor to begin increasing her activity level. Pacing wires removed on POD #3. Beta blockade titrated and she was gently diuresed toward her preop weight. Cleared for discharge to rehab, but pt. refused discharge over the weekend. Bed available and discharged to rehab on POD #6. Pt. is being covered with SSI and is to make all rehab appts. as per discharge instructions. | Mild (1+) MR. LV inflow pattern c/w impairedrelaxation. Mild (1+)mitral regurgitation is seen. Normal descending aorta diameter. The ascending aorta is mildlydilated. Normal ascending aorta diameter. Mild mitral annularcalcification. Normal interatrial septum. Moderate (2+) MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Milrinone and Levophed gtts weaned off. Normal aortic arch diameter. ANESTHESIA REPORTED THAT PACER WORKS. PALPABLE AND DOPPLERABLE PULSES.RESP: CS DIMINISHED IN BASES. Mildly dilated aortic arch. LS clear and diminished at bases. Mild mitralannular calcification. CT'S PATENT FOR MINIMAL SERO-SANG DRAINAGE. CT x2 to LWS draining scant serosang. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ]LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal -hypo; mid inferoseptal - hypo; mid anterolateral - hypo; anterior apex - hypo;septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The mitral valve leaflets are mildlythickened. The aortic arch is mildly dilated. IMPRESSION: Minimal interval decrease in size of bilateral moderate-sized pleural effusions. A-line d/c'd. Given percocet x1 with minimal effect. Focal calcifications inascending aorta. Pulmonary vascularity is within normal limits. There is blunting of the left costophrenic angle consistent with a small left pleural effusion. Mild thickening of mitral valve chordae. IMPRESSION: Small left pleural effusion. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Thin section reformatted images and lung reformats are provided. FINDINGS: In comparison with study of , there is now an endotracheal tube in place with its tip 4.7 cm above the carina. Thepatient appears to be in sinus rhythm. Protonix for GI prophylaxis.Endo: RISS per CVICU protocol; restarted glyburide .Skin: intact. LV inflow pattern c/w restrictive filling abnormality, withelevated LA pressure.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. NoASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness and cavity size. This is consistent with bilateral pleural fluid, probably associated with some atelectatic change. Aorta is intact post decannulation.4. There are focal calcifications inthe aortic arch. afebrile.Resp: LS clear, dim at bases. K REPLEATED.CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. The left ventricular inflow pattern suggestsimpaired relaxation. Normal PA systolicpressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Sinus rhythm. Also on glyburide. HR 90s-110s SR/ST, rare PVC. foley to bedside drainage. A mitral valve annuloplasty ring is well seated. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. Mild atelectatic changes at the left base. There is no pericardial effusion.Impression: profound global left ventricular systolic dysfunction withrestrictive filling pattern; mild mitral regurgitation Swan-ganz in place, tip in MPA. Normal tricuspidvalve supporting structures. FINDINGS: In comparison with study of , the left chest tube has been removed. TITRATE IV LEVOPHED TO KEEP S B/P ^ 100. TITRATING IV LEVOPHED TO KEEP S B/P ^ 100. Moderate-severeregional left ventricular systolic dysfunction. left basilar atelectasis. Mitral valve disease.Height: (in) 66Weight (lb): 170BSA (m2): 1.87 m2BP (mm Hg): 135/70Status: InpatientDate/Time: at 09:42Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The cardiac silhouette is slightly less prominent as noted on the prior examination. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated ascending aorta. Start lopressor when levophed requirements lessen. Focal calcifications inaortic root. HR continues to be tachycardic with a rare PVC. updated on POC. Neuro) Pt. Calcified tipsof papillary muscles. Focal calcifications in ascendingaorta. IMPRESSION: Standard appearance following cardiac surgery. Palp. Possible prior anterior myocardialinfarction. PERRLA. Encouraged to C&DB and using I.S. Leg incision c/d/i. BP stable. No 2Dor Doppler evidence of distal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). soft with positive bowel sounds, no BM. Good resp. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for CABG, MVR, ?LVADHeight: (in) 66Weight (lb): 160BSA (m2): 1.82 m2Status: InpatientDate/Time: at 13:51Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. responded well to IV lasix this AM. The heart and pericardium appear otherwise unremarkable. Complaining of feeling slightly nauseous and reglan given with some effect. Ace to L leg changed. Right ventricular chamber size and free wall motion are normal.4. The estimated pulmonary arterysystolic pressure is normal. Reglan 5mg IV given with good results.GU) adequate huo.Skin) Sternal Dsg without drng.Surgi-bra in place. Thetricuspid valve leaflets are mildly thickened. Linear opacity at in left lung suggests scar. BUN/Creat WNL. Lungs clear but slightly dim. Central airways appear patent. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. Reversal of right and left arm lead electrodes.Possible anterior myocardial infarction of indeterminate age, possibly acute.Non-specific lateral repolarization changes. Compared to the previous tracing of leads are now placedproperly. Right bundle-branch block. OG IN PLACE, PLACEMENT CHECKED. PSERL. Physiologic TR. (+) BS, (-) BM. NGT in stomach. Endotracheal tube, nasogastric tube, right Swan-Ganz catheter, and mediastinal drains have all been removed. [Intrinsic left ventricular systolic function is likely moredepressed given the severity of valvular regurgitation.]3. Trace MRis seen. effort.GI) c/o nausea when extubated. IMPRESSION: 1. Complex (>4mm) atheroma in thedescending thoracic aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Dense coronary arterial calcifications. COMPARISON: No prior CT. Focal calcifications in aortic arch. A 2-mm triangular opacity present in the lower right middle lobe (4:158). Pt. Left ventricular wall thicknesses and cavity size are normal. RV function is preserved.3. PO Lopressor started. HEART RATE NSR WITH OCC. There ismoderate to severe regional left ventricular systolic dysfunction withhypokinesis of the inferoseptal, anteroseptal, anterior and anterolateralwalls. FRONTAL AND LATERAL CHEST RADIOGRAPHS Cardiac and mediastinal contours appear unremarkable. There is poor definition of both hemidiaphragms with hazy opacification at the bases and preservation of pulmonary markings. | 14 | [
{
"category": "Radiology",
"chartdate": "2152-01-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1002602,
"text": " 3:01 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluation of effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p mvr, cabg\n REASON FOR THIS EXAMINATION:\n evaluation of effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for effusion.\n\n FINDINGS: Two views of the chest were obtained and compared to the prior\n examination dated . There are persistent bilateral pleural effusions\n that have slightly decreased since the prior examination. There is a\n persistent left retrocardiac opacity likely secondary to underlying\n atelectasis, although a superimposed pneumonia cannot be entirely excluded.\n The patient is status post mitral valve replacement, CABG and median\n sternotomy. The cardiac silhouette is slightly less prominent as noted on the\n prior examination.\n\n IMPRESSION: Minimal interval decrease in size of bilateral moderate-sized\n pleural effusions. Otherwise, no significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-01-15 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1001406,
"text": " 9:39 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for calcification in aorta\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman pre-op CABG\n REASON FOR THIS EXAMINATION:\n eval for calcification in aorta\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op CABG, evaluate for aortic calcification.\n\n COMPARISON: No prior CT.\n\n TECHNIQUE: Axial MDCT images were obtained through the chest without\n intravenous contrast. Thin section reformatted images and lung reformats are\n provided.\n\n CONTRAST: No contrast.\n\n CT CHEST WITHOUT INTRAVENOUS CONTRAST: There are no pathologically enlarged\n mediastinal, hilar, or axillary lymph nodes. Dense and extensive coronary\n artery calcifications are present in the left anterior descending, circumflex,\n and right coronary arteries. The heart and pericardium appear otherwise\n unremarkable. There are atheromatous calcifications in the brachiocephalic\n artery, left subclavian artery, along the aortic arch and within the\n descending aorta, consistent with atheromatous disease. Central airways\n appear patent.\n\n There are no pleural effusions, and there is no pneumothorax. A 3-mm nodule\n is present in the right upper lobe (4:76). An additional 4 mm sub-fissural\n nodule is present in the right middle lobe (4:121). A 2-mm triangular opacity\n present in the lower right middle lobe (4:158). In the imaged portion of the\n upper abdomen, calcifications are seen at the origin of the celiac and\n superior mesenteric arteries, within the splenic artery, and involving the\n imaged portion of the upper abdominal aorta. The imaged portion of the liver,\n spleen and splenule, adrenal glands, upper poles of the kidneys and pancreas\n appear unremarkable.\n\n BONE WINDOWS: No lesions worrisome for osseous metastatic disease are\n identified.\n\n IMPRESSION:\n\n 1. Dense coronary arterial calcifications.\n\n 2. Aortic mural calcification consistent with atherosclerotic disease.\n\n 3. Right upper and middle lobe pulmonary nodules up to 4 mm in diameter.\n Followup CT in one year is recommended.\n\n (Over)\n\n 9:39 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval for calcification in aorta\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002111,
"text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx s/p ct removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p mvr cabg\n REASON FOR THIS EXAMINATION:\n ? ptx s/p ct removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG after chest tube removal.\n\n FINDINGS: In comparison with study of , the left chest tube has been\n removed. No evidence of pneumothorax. Endotracheal tube, nasogastric tube,\n _____ right Swan-Ganz catheter, and mediastinal drains have all been removed.\n There is poor definition of both hemidiaphragms with hazy opacification at the\n bases and preservation of pulmonary markings. This is consistent with\n bilateral pleural fluid, probably associated with some atelectatic change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-01-20 00:00:00.000",
"description": "Report",
"row_id": 1620356,
"text": "CVICU B NPN:\nNEURO: A&Ox3. Complaining of incisional pain and back pain but reluctant to take pain meds. Given percocet x1 with minimal effect. MAE in bed and helps with turning.\nCV: Afeb. HR 90s-110s SR/ST, rare PVC. BP stable. Pacer wires intact but pacer turned off and not tested due to tachycardia. Palp. pedal pulses bilat.\nRESP: Continues on 4L O2 Sat with O2 Sat 90-96%. LS clear and diminished at bases. Encouraged to C&DB and using I.S. CT x2 to LWS draining scant serosang. drainage, no leak or creptius noted.\nGI/GU: Abd. soft with positive bowel sounds, no BM. Complaining of feeling slightly nauseous and reglan given with some effect. Blood glucose high and covered per CVICU ss. Also on glyburide. Na low this am and will restrict free water intake. Foley draining clear yellow urine >30cc/hr.\nSKIN: Cordis intact. A-line d/c'd. #20G to R arm. Sternal and mediastinal dsgs intact with no drainage. Ace to L leg changed. Leg incision c/d/i.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-01-19 00:00:00.000",
"description": "Report",
"row_id": 1620354,
"text": "Neuro) Pt. able to gesture and make letters in the palm of my hand to communicate words while intubated. Once extubated, speaks freely and coherently. moves all extr. with good strength. Assists with repositioning.\n\nCV) SVO2 60-70's while CI improving to >2.5. Milrinone remains at .5mcq/ Levophed titrated for MAP >60. HR continues to be tachycardic with a rare PVC. Little response in reducing HR by giving additional 1000cc NS. Pacer in off mode: not tested for pacing due to HR.\n\nPulm) Extubated to NC @5l. SAo2 93%: additional aerosol O2 at 50% with NC at 4l. Sao2 ~96%. Pt. c/o having phlegm in back of throat but very dry cough. Lungs clear but slightly dim. @ bases. Good resp. effort.\n\nGI) c/o nausea when extubated. Reglan 5mg IV given with good results.\n\nGU) adequate huo.\n\nSkin) Sternal Dsg without drng.Surgi-bra in place. Left leg vein graft sites with steri strips. Ace bandage changed.\n\nEndocrine) insulin drip off when BS 87. Protocol in place and blood sugars checked as per protocol.\n\nID) afebrile. Vanco for peri-op period x4 doses.\n\nPlan) wean levophed. Start lopressor when levophed requirements lessen. Wean milrinone to keep CI >2. Monitor lytes and replete prn.\nManage blood sugars per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-01-19 00:00:00.000",
"description": "Report",
"row_id": 1620355,
"text": "NPN 0700-1900\nNeuro: awake, A&O x 3. MAEW. PERRLA. c/o incisional pain and back pain. given percocet and morphine with good effect. pt sleeping in long naps majority of day.\n\nCV: ST no ectopy noted. SBP 90-120. MAP > 60. Milrinone and Levophed gtts weaned off. PO Lopressor started. Captopril due this evening. 2 A-wires, 2 V-wires. pacer not checked d/t HR > 100. palpable pedal pulses. afebrile.\n\nResp: LS clear, dim at bases. non productive cough. Chest tubes draining serosanguinous drainage 20 - 50 cc/hr. no leak noted. O2 sats\n92-96% on 40% FiO2 via FM and 4L NC.\n\nGI/GU: abd soft, non tender. (+) BS, (-) BM. foley to bedside drainage. responded well to IV lasix this AM. BUN/Creat WNL. Protonix for GI prophylaxis.\n\nEndo: RISS per CVICU protocol; restarted glyburide .\n\nSkin: intact. see careview for complete documentation.\n\nSocial: family visited. updated on POC. supportive.\n\nPlan: start captopril this evening if BP tolerates. increase diet/activity as pt tolerates, wean O2 as pt tolerates. pain management. pulmonary hygiene. Deline and transfer to 6 tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-01-18 00:00:00.000",
"description": "Report",
"row_id": 1620352,
"text": "~1635 PATIENT ADMITTED FROM THE OR. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. IV MILRANONE/LEVOPHED/INSULIN INFUSING. PSERL. OG IN PLACE, PLACEMENT CHECKED. PACER OFF. HEART RATE NSR WITH OCC. PAC. CT'S PATENT FOR MINIMAL SERO-SANG DRAINAGE. FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE. PALPABLE RT /DOPPLERABLE LEFT PULSES.\nNO INTERACTION WITH FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-01-18 00:00:00.000",
"description": "Report",
"row_id": 1620353,
"text": "NEURO: FOLLOWING COMMANDS, MAE, FINGER WRITING ON MY PALM.\n\nCARDIAC: HEART RATE NSR-ST WITH OCCASSIONAL PAC'S, RARE PVC'S. CO/CI ACCEPTABLE WITH 3 LITERS CRYSTALLOID. TITRATING IV LEVOPHED TO KEEP S B/P ^ 100. MILRANONE REMAINS AT .5 M/K/M. PACER OFF, UNABLE TO TEST PACER DUE TO ^ HEART RATE. ANESTHESIA REPORTED THAT PACER WORKS. 2 UNITS PACKED CELLS GIVEN. K REPLEATED.CT'S PATENT FOR SMALL AMT SERO-SANG DRAINAGE. PALPABLE AND DOPPLERABLE PULSES.\n\nRESP: CS DIMINISHED IN BASES. ATTEMPTING TO WEAN TO EXTUBATE.\n\nGI: OG IN PLACE, PATENT FOR BILIOUS. PATIENT C/O NAUSEA, MEDICATED WITH IV REGLAN.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE.\n\nENDO: INSULIN GTT INFUSING, FOLLOWING PROTOCOL.\n\nPAIN: MEDICATED X 1 WITH IV MORPHINE FOR PROBABLE INCISIONAL PAIN, NODDED YES WHEN ASKED IF SHE HAD PAIN, AND NODDED YES WHEN ASKED IF IT WAS IN HER CHEST. NODDED NO WHEN ASKED IF THE PAIN WAS IN HER THROAT.\n\nFAMILY: NO INTERACTION.\n\nPLAN: MONITOR HEMODYNAMICS. REPLEATE LAB WORK AS NEEDED. MAINTAIN CI ^ 2. NEEDS HCT AFTER 2ND UNIT CELLS INFUSED. MEDICATE FOR PAIN AS NEEDED. TITRATE IV LEVOPHED TO KEEP S B/P ^ 100.\n"
},
{
"category": "Echo",
"chartdate": "2152-01-18 00:00:00.000",
"description": "Report",
"row_id": 85126,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for CABG, MVR, ?LVAD\nHeight: (in) 66\nWeight (lb): 160\nBSA (m2): 1.82 m2\nStatus: Inpatient\nDate/Time: at 13:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate-severe\nregional left ventricular systolic dysfunction. Severely depressed LVEF.\n[Intrinsic LV systolic function likely depressed given the severity of\nvalvular regurgitation.]\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal -\nhypo; mid inferoseptal - hypo; mid anterolateral - hypo; anterior apex - hypo;\nseptal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the\naortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data The\npost-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler.\n2. Left ventricular wall thicknesses and cavity size are normal. There is\nmoderate to severe regional left ventricular systolic dysfunction with\nhypokinesis of the inferoseptal, anteroseptal, anterior and anterolateral\nwalls. Overall left ventricular systolic function is severely depressed (LVEF=\n20-25 %). [Intrinsic left ventricular systolic function is likely more\ndepressed given the severity of valvular regurgitation.]\n3. Right ventricular chamber size and free wall motion are normal.\n4. There are complex (>4mm) atheroma in the aortic arch. There are complex\n(>4mm) atheroma in the descending thoracic aorta.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly\nthickened. Moderate (2+) mitral regurgitation is seen.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including Milrinone and Norepinephrine, Epinephrine and is being AV\npaced.\n1. A mitral valve annuloplasty ring is well seated. No is seen. Trace MR\nis seen. Mean gradient across the valve is 8mm of Hg with a CO of 5.5.\n2. LV function is slightly improved. RV function is preserved.\n3. Aorta is intact post decannulation.\n4. Other findings are unchanged\n\n\n"
},
{
"category": "Echo",
"chartdate": "2152-01-14 00:00:00.000",
"description": "Report",
"row_id": 85127,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease.\nHeight: (in) 66\nWeight (lb): 170\nBSA (m2): 1.87 m2\nBP (mm Hg): 135/70\nStatus: Inpatient\nDate/Time: at 09:42\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severe global LV hypokinesis. TDI\nE/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta. Focal calcifications in ascending\naorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Mild (1+) MR. LV inflow pattern c/w impaired\nrelaxation. LV inflow pattern c/w restrictive filling abnormality, with\nelevated LA pressure.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Physiologic TR. Normal PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thicknesses are normal.\nThere is severe global left ventricular hypokinesis (LVEF = 20 %). Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). There is no ventricular septal defect. Right ventricular\nchamber size and free wall motion are normal. The ascending aorta is mildly\ndilated. The aortic arch is mildly dilated. There are focal calcifications in\nthe aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. The left ventricular inflow pattern suggests\nimpaired relaxation. The left ventricular inflow pattern suggests a\nrestrictive filling abnormality, with elevated left atrial pressure. The\ntricuspid valve leaflets are mildly thickened. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\nImpression: profound global left ventricular systolic dysfunction with\nrestrictive filling pattern; mild mitral regurgitation\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-01-13 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1001223,
"text": " 9:43 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with CAD pre-op CABG\n REASON FOR THIS EXAMINATION:\n baseline pre-op study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old woman with CAD, pre-op for CABG.\n\n COMPARISON: None.\n\n FRONTAL AND LATERAL CHEST RADIOGRAPHS\n\n Cardiac and mediastinal contours appear unremarkable. Pulmonary vascularity\n is within normal limits. There are no focal consolidations. There is\n blunting of the left costophrenic angle consistent with a small left pleural\n effusion. Linear opacity at in left lung suggests scar.\n\n IMPRESSION: Small left pleural effusion.\n\n jr\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-01-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1001849,
"text": " 5:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p CABG, MV Repair\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n WET READ: DSsd TUE 6:30 PM\n No ptx. ETT 4.7 cm above carina. Swan-ganz in place, tip in MPA. Multiple\n pleural drains in place. NGT in stomach. left basilar atelectasis. -.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG and MVR repair.\n\n FINDINGS: In comparison with study of , there is now an endotracheal tube\n in place with its tip 4.7 cm above the carina. Right IJ Swan-Ganz catheter\n extends to the proximal right pulmonary artery. Left chest tube is in place\n with no evidence of pneumothorax. Nasogastric tube extends well into the\n stomach. Mild atelectatic changes at the left base.\n\n IMPRESSION: Standard appearance following cardiac surgery.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2152-01-18 00:00:00.000",
"description": "Report",
"row_id": 215239,
"text": "Sinus rhythm. Right bundle-branch block. Possible prior anterior myocardial\ninfarction. Compared to the previous tracing of leads are now placed\nproperly. Right bundle-branch block is newly appreciated.\n\n"
},
{
"category": "ECG",
"chartdate": "2152-01-13 00:00:00.000",
"description": "Report",
"row_id": 215240,
"text": "Normal sinus rhythm, rate 75. Reversal of right and left arm lead electrodes.\nPossible anterior myocardial infarction of indeterminate age, possibly acute.\nNon-specific lateral repolarization changes. No previous tracing available for\ncomparison.\n\n"
}
] |
76,633 | 181,802 | NEURO/PAIN: Mr. was admitted post-op from right parotidectomy and right neck dissection with right abdominal fat grafting performed. His post-op pain was controlled initially with Acetaminophen and Percocet, then he was switched to PO Dilaudid with more adequate control achieved. Unfortunately, he developed some hallucinations with his pain medication on HOD#8 requiring a switch to Propoxyphene, without issue. His home dose of Citalopram 30 mg PO daily was resumed on HOD#7. His home dose of Trazadone was held post-operatively. | Comparedto the previous tracing of -109 T wave inversion in lead V3 is slightlyless marked. Normal sinus rhythm with atrial premature beats. Normal sinus rhythm with atrial premature beats and ventricular prematurebeats. Non-specific ST-T wave abnormalities mostmarked in the inferior leads. Previously noted right parotid mass is not assessed on the present study. Unchanged retrocardiac atelectasis, unchanged right perihilar lower lobe opacity. Sinus bradycardia with atrial premature beats. There appears to be some decrease in the perihilar lower lobe opacity on the right. Non-specific ST-T wave abnormalities. Non-specific ST-T wave abnormalities. Elevation of the right hemidiaphragmatic contour persists. Non-specificST-T wave abnormalities. Premature ventricular contractions.Borderline first degree A-V block. TECHNIQUE: Bilateral lower extremity venous ultrasound. FINDINGS: In comparison with the study of , the endotracheal tube has been removed. A small hypodense focus in the left Sylvian fissure posteriroly is more prominent form prior and may relate to volume loss. Poor R wave progression ofuncertain significance. Unchanged size of the cardiac silhouette. Within limitations above, no large intraparenchymal hemorrhage. Otherwise, lung fields, cardiomediastinal silhouette, hilar silhouette, and pleural surfaces remain unchanged. Poor R wave progression of uncertainsignificance. Non-specific ST-T wave abnormalities most marked in the inferiorleads. Borderline first degree A-V block. Borderline first degree A-V block. Visualized portion of the upper abdomen is otherwise unremarkable. Sinus bradycardia with sinus arrhythmia. Otherwise, no diagnostic change.TRACING #1 Borderline first degreeA-V block. Borderline first degreeA-V block. On the left, the hemidiaphragm is well seen with some continued retrocardiac and infrahilar opacification that most likely represents some atelectasis. Evidence of right heart strain. Evidence of right heart strain. There is flattening of the intraventricular septum and enlargement of the right ventricle relative to the left suggestive of right ventricular heart strain. TECHNIQUE: Chest radiograph was obtained. FINDINGS: Evaluation for small foci of acute intracranial hemorrhage is limited on this study due to recent administration of IV contrast. Bilateral maxillary sinus disease. Otherwise, no diagnostic change.TRACING #3 FINDINGS: As compared to the previous radiograph, the patient has been intubated. FINDINGS: Grayscale and color Doppler images of bilateral common femoral, superficial femoral, and popliteal veins were performed. Evaluation is limited for mass but no mass effect. Evaluation is limited for mass but no mass effect. Evaluation is limited for mass but no mass effect. COMPARISON: Chest radiograph of . Compared to the previous tracing of ventricular premature beats are new.TRACING #2 Cardiac size is top normal. Early precordial R wave transition of uncertain significance. Evaluate for DVT. FINDINGS: Left subclavian PICC with the catheter tip at the body of the right atrium. Within this limiation, there is no large intraparenchymal or extra-axial hemorrhage. Normal sinus rhythm. New right lower lobe and left lower lobe opacities right greater than left are most likely due to atelectasis. Small mediastinal nodes do not meet CT criteria for pathologic enlargement. Polypoid mucosal thickening/ retention cysts is noted in the bilateral maxillary and ethmoid sinuses. The remainder of visualized paranasal sinuses and mastoid air cells are well aerated. (Over) 1:10 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: CTA for PE Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA Field of view: 36 Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) 3. REASON FOR THIS EXAMINATION: Please eval ET tube placement FINAL REPORT CHEST RADIOGRAPH INDICATION: Recent intubation, evaluation of endotracheal tube placement. The presence of minimal overhydration cannot be excluded. REASON FOR THIS EXAMINATION: pls eval for pulm edema, infiltrate FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Acute respiratory distress. IMPRESSION: Left subclavian PICC with the catheter tip in the right atrium. COMPARISONS: Comparison is made to prior radiograph from . There is normal compressibility, flow, and augmentation. There is patchy consolidation at the bilateral lung bases medially which may represent atelectasis; however, aspiration or infection are also considerations. Bilateral acute pulmonary emboli with possible right heart strain. Evaluate for pulmonary embolus. Left axis deviation. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Compared totracing #4 no diagnostic change.TRACING #5 Compared to the previoustracing axis has shifted more leftward. (Over) 3:07 AM CT HEAD W/O CONTRAST Clip # Reason: eval for brain mets, site of bleeding Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA FINAL REPORT (Cont) No evidence of pulmonary vascular congestion at this time. Coronal and sagittal reformats and maximum intensity projection oblique images are displayed. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. A filling defect is also noted in the left lingular branches and subsegmental branches of the left lower and upper lobes. Otherwise, no interval change. Bibasilar consolidative opacities may represent atelectasis, aspiration or infection. No pericardial effusion. | 14 | [
{
"category": "Radiology",
"chartdate": "2160-07-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1146978,
"text": " 1:10 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CTA for PE\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chest pressure and increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n CTA for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 2:32 AM\n Multiple pulmonary arterial filling defects compatible with acute pulmonary\n embolus. Evidence of right heart strain. Patchy consolidation at the lung\n bases could represent atelectasis, but aspiration or infection should also be\n considered, and clinical correlation is advised.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year old male status post neck dissection with new-onset chest\n pressure and increasing O2 requirement. Evaluate for pulmonary embolus.\n\n COMPARISON: Chest radiograph of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest before\n and after the administration of 100 cc IV Optiray contrast per the CT\n pulmonary angiogram protocol. Coronal and sagittal reformats and maximum\n intensity projection oblique images are displayed.\n\n CT PULMONARY ANGIOGRAM: There are numerous filling defects within the\n pulmonary arterial vasculature, notably in the right upper pulmonary artery\n extending into the segmental branches. A filling defect is also noted in the\n left lingular branches and subsegmental branches of the left lower and upper\n lobes. There is flattening of the intraventricular septum and enlargement of\n the right ventricle relative to the left suggestive of right ventricular heart\n strain.\n\n There is patchy consolidation at the bilateral lung bases medially which may\n represent atelectasis; however, aspiration or infection are also\n considerations. No pleural effusion or mass is present. No pericardial\n effusion. Small mediastinal nodes do not meet CT criteria for pathologic\n enlargement. No axillary or hilar lymphadenopathy is noted.\n\n Fatty infiltration of the liver is noted. Visualized portion of the upper\n abdomen is otherwise unremarkable.\n\n IMPRESSION:\n\n 1. Bilateral acute pulmonary emboli with possible right heart strain.\n\n 2. Bibasilar consolidative opacities may represent atelectasis, aspiration or\n infection.\n\n (Over)\n\n 1:10 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CTA for PE\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Fatty liver.\n\n Findings discussed with Dr. at 2:10 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1146979,
"text": ", A. ENT 12R 1:10 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: CTA for PE\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with chest pressure and increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n CTA for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Multiple pulmonary arterial filling defects compatible with acute pulmonary\n embolus. Evidence of right heart strain. Patchy consolidation at the lung\n bases could represent atelectasis, but aspiration or infection should also be\n considered, and clinical correlation is advised.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1147100,
"text": " 12:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval ET tube placement\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with recent intubation, PEs.\n REASON FOR THIS EXAMINATION:\n Please eval ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recent intubation, evaluation of endotracheal tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the tube projects 6 cm above the carina, the tube could\n be advanced by 1-2 cm.\n\n Unchanged retrocardiac atelectasis, unchanged right perihilar lower lobe\n opacity. Unchanged size of the cardiac silhouette. The presence of minimal\n overhydration cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1146990,
"text": " 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for brain mets, site of bleeding\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with PE and H and N cancer in need of heparinization\n REASON FOR THIS EXAMINATION:\n eval for brain mets, site of bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 6:16 AM\n Evaluation for SAH is limited given recent adminstration of IV contrast, but\n no large intracranial hemorrhage. Evaluation is limited for mass but no mass\n effect. If there is concern for metastatic disease, MRI should be obtained\n for further evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with pulmonary embolus and head and neck cancer\n in need needed heparinization. Evaluate for brain mets.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast. Please note that the patient received a contrast load for the PE\n study earlier the same day.\n\n FINDINGS: Evaluation for small foci of acute intracranial hemorrhage is\n limited on this study due to recent administration of IV contrast. Within this\n limiation, there is no large intraparenchymal or extra-axial hemorrhage. No\n mass effect or edema is noted. -white matter differentiation is\n preserved. Ventricles and sulci are normal in size and appearance. Basilar\n cisterns are preserved. A small hypodense focus in the left Sylvian fissure\n posteriroly is more prominent form prior and may relate to volume loss.\n Polypoid mucosal thickening/ retention cysts is noted in the bilateral\n maxillary and ethmoid sinuses. The remainder of visualized paranasal sinuses\n and mastoid air cells are well aerated. No osseous abnormality is identified.\n\n IMPRESSION:\n\n 1. Within limitations above, no large intraparenchymal hemorrhage.\n\n 2. Evaluation is limited for mass but no mass effect. If there is concern\n for metastatic disease, MRI should be obtained for further evaluation, if not\n contra-indicated.\n\n 3. Bilateral maxillary sinus disease.\n Previously noted right parotid mass is not assessed on the present study.\n (Over)\n\n 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for brain mets, site of bleeding\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1146991,
"text": ", A. ENT 3:07 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for brain mets, site of bleeding\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with PE and H and N cancer in need of heparinization\n REASON FOR THIS EXAMINATION:\n eval for brain mets, site of bleeding\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Evaluation for SAH is limited given recent adminstration of IV contrast, but\n no large intracranial hemorrhage. Evaluation is limited for mass but no mass\n effect. If there is concern for metastatic disease, MRI should be obtained\n for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1147692,
"text": " 3:41 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pls assess tip of 60cm brachial LEFT PICC, call #37\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with new left picc\n REASON FOR THIS EXAMINATION:\n pls assess tip of 60cm brachial LEFT PICC, call # w/ wet read\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of PICC placement.\n\n TECHNIQUE: Chest radiograph was obtained.\n\n COMPARISONS: Comparison is made to prior radiograph from .\n\n FINDINGS: Left subclavian PICC with the catheter tip at the body of the right\n atrium. Repositioning via retraction by 4 cm is recommended. Otherwise, lung\n fields, cardiomediastinal silhouette, hilar silhouette, and pleural surfaces\n remain unchanged. There are no pleural effusions. There is no pneumothorax.\n\n IMPRESSION: Left subclavian PICC with the catheter tip in the right atrium.\n Retraction by 4 cm is recommended. Otherwise, no interval change.\n\n These findings were discussed with the PICC nurse 4 p.m. on\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-13 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1147050,
"text": " 12:08 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p parotidectomy with new PE\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n WET READ: IPf SUN 1:37 PM\n -no evidence of DVT in bilateral CFV, SFV, and .\n -veins of calf not seen, unable to image.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old man status post parotidectomy, with new PE. Evaluate for\n DVT.\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound.\n\n FINDINGS:\n Grayscale and color Doppler images of bilateral common femoral, superficial\n femoral, and popliteal veins were performed. There is normal compressibility,\n flow, and augmentation.\n Veins of the calf were not seen bilaterally, unable to image, given suboptimal\n evaluation.\n\n IMPRESSION:\n 1. No evidence of deep venous thrombosis in bilateral common femoral vein,\n superficial femoral vein, and popliteal veins.\n 2. The veins of the calf bilaterally were not seen, unable to image, given\n suboptimal evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1146973,
"text": " 11:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for pulm edema, infiltrate\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with acute resp distress.\n REASON FOR THIS EXAMINATION:\n pls eval for pulm edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Acute respiratory distress.\n\n Comparison is made with prior study .\n\n New right lower lobe and left lower lobe opacities right greater than left are\n most likely due to atelectasis. There is no evident pneumothorax or pleural\n effusion. Cardiac size is top normal.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2160-07-13 00:00:00.000",
"description": "Report",
"row_id": 125927,
"text": "Normal sinus rhythm with atrial premature beats and ventricular premature\nbeats. Borderline first degree A-V block. Poor R wave progression of\nuncertain significance. Non-specific ST-T wave abnormalities. Compared to\ntracing #4 no diagnostic change.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2160-07-13 00:00:00.000",
"description": "Report",
"row_id": 125928,
"text": "Normal sinus rhythm with atrial premature beats. Borderline first degree\nA-V block. Left axis deviation. Poor R wave progression of uncertain\nsignificance. Non-specific ST-T wave abnormalities. Compared to the previous\ntracing axis has shifted more leftward. Heart rate has increased slightly.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2160-07-12 00:00:00.000",
"description": "Report",
"row_id": 125929,
"text": "Normal sinus rhythm. Borderline first degree A-V block. Non-specific\nST-T wave abnormalities. Compared to the previous tracing of heart\nrate has increased. Otherwise, no diagnostic change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2160-07-12 00:00:00.000",
"description": "Report",
"row_id": 125930,
"text": "Sinus bradycardia with sinus arrhythmia. Premature ventricular contractions.\nBorderline first degree A-V block. Non-specific ST-T wave abnormalities most\nmarked in the inferior leads. Compared to the previous tracing of \nventricular premature beats are new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2160-07-11 00:00:00.000",
"description": "Report",
"row_id": 125931,
"text": "Sinus bradycardia with atrial premature beats. Borderline first degree\nA-V block. Non-specific ST-T wave abnormalities most marked in the inferior\nleads. Early precordial R wave transition of uncertain significance. Compared\nto the previous tracing of -109 T wave inversion in lead V3 is slightly\nless marked. Suggest clinical correlation. Otherwise, no diagnostic change.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-07-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1147256,
"text": " 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change infiltrate\n Admitting Diagnosis: RIGHT PAROTID TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with mucoepidermoid R parotid CA s/p surgery now with bilateral\n PE\n REASON FOR THIS EXAMINATION:\n Interval change infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative pulmonary embolism, to assess for change.\n\n FINDINGS: In comparison with the study of , the endotracheal tube has been\n removed. Elevation of the right hemidiaphragmatic contour persists. There\n appears to be some decrease in the perihilar lower lobe opacity on the right.\n On the left, the hemidiaphragm is well seen with some continued retrocardiac\n and infrahilar opacification that most likely represents some atelectasis. No\n evidence of pulmonary vascular congestion at this time.\n\n\n"
}
] |
3,332 | 151,345 | Will continue tomonitor.FEN: Received infant NPO. PIVinfusing D10W. Settles well after cares. BS clear= with mild retractions. A&A with caresand settles well in between. Rest well inbetween cares. Settleswell when held. BP stable.#2Infant remains NPO. Maintain NPO for now. Continue toencourage PO's as tolerated.3. to support po/breast feedings and monitorwt.#3- O/A: In OAC, swaddled with stable temps. Placed inisolette at second cares. A: Appropriatefor gestational age. Abd benign. Tolerating well thus far. Will be inlater for cares.#7 As/Bs: No spells so far this shift. Continue to support andkeep up to date.A/Bs - No spells noted thus far. Nursing Progress NOte#2- O/A: Min. and L+D course. Follow D/S and daily wts. Suckles wellon pacifier. NPN#1Infant continues in RA with sats mid-high 90s. Continue to support PO feeding.DEV - Temps remain stable swaddled in OAC. of 130/kilo of BM/ 24- 44ccq4h. Updated and oriented to unit. Wakingfor feedings q4h. Well-perfused. Updated at bedside by this RN. P: Cont. P: Cont. P: Cont. P: Cont. Good perfusion noted.No spells noted. Updatedat bedside by this RN. Alt PO/PGfeedings. Abd exam benign as noted flow sheet. Doeswell with pacifier. Independent with infant cares and bottle feeding eachof them. Independent withinfant's cares and bottling. MOMcompletely independent with cares and asking appropriatequestions. Desitin applied prn for min. Rest well inbetween cares. Desitin applied w/diaperchanges. Min asp. AFOF sutures approximated, eyes clear, nares patent, MMMPChest is clear, equal bs, comfortableCV: RRR, no murmur, pulses+2=Abd: soft,a ctive bsGU: immature femaleEXT: , Neuro: active with symmetric tone and relfexes. to support breast/pofeedings and monitor wt.#3- O/A: Swaddled in OAC with stable temps. Abd.exam benign. Updated at bedside bythis RN. Nursing Progress Note#2- O/A: Min. 1 spell w/feed, see flowsheet. Updated at bedside. All PO for24hrs. D/Cprep teaching done. Improving PO intake.PLANS:- Continue as at present.- Monitor for spells.- Monitor PO intake. Voiding and stooling normally.Temp stable in open cirb.A&P33-2/7 week GA with feeding immaturity-Continue current management as detailed above Abdomen exam benign. Plan to cont tomonitor. Abd benign. A:Appropriate for gestational age. Current feeds & supps meeting weaned recs for kcal/pro/vits/mins. Alt PO/PGfeedings. abd benign, vdg and stoolingguiac neg stools. independent w/cares, asking appropriate questions.updated. Parenting: were in at start of shift but left atapprox. CUrrent feeds + supps meeting recs for kcals/pro/vits and mins. O/Pt remains on TF of 150cc/k/d of BM24/ SC24po/pngt. Appears tobe tolerating present feeding regimen at this time. Updated at bedside. No further contact thus far this shift.Loving and invovled . Voiding and stooling normally.Temp stable in open crib.A&P33-2/7 week GA with feeding immaturity-Continue current management as detailed above Willcontinue to update and support. A: still prematurebehaviours P: cont to support developmentally#4 O: mom here for day, dad in earlier and will be back thisevening. attempting po qofeed, takingonly small amts this morning before tiring. Settles well between cares. Ferinsol as ordered, desitin to butt forirritation.#3 O: see above re: feeds, temp stable in open crib. Abdomen is soft, pink, active bowel sounds, noloops, AG stable. P: Continue to support andupdate . Abdomenexam benign. thus far this shift.Fluid and NutritionInfant's wt. : in for AM cares, updated at bedside by thisRN. Settles well in between cares. updatedat bedside by this RN. in Resp. in Resp. Temp. Abd benign. Wakesfor feedings q3-4h. temps stable afsf. A: Appropriate for gestational age. Well coordinated today w/playtex bottle. REmainder of fluids as D10 w/ lytes via PIV. LSclear/=. Tolerating gradual advancement of enteral feeds. Lytes 141/4.2/110/18.GI: Bili 6.4/0.3 this am.DEV: In isolette.Exam: comfortable, responsive to exam. NPN 0700-1900F/N: Remains on TF min 130cc/kg/day BM/ 24. Abdomen soft/flat, good bs, girth stable.D10 infusing via PIV. See flowsheet.Voiding q.s., stooling meconium.DevelopmentInfant awake and alert with care periods, and sleeps quietlybetween cares. Abdomen soft/round, good bs, girth stable,V&S. soft, no loops, B.S.(+).Abd. girth stable. girth stable. Rest IVF. Asked appropriatequestions. Stable in RA. Infant bottling48-70 cc q3-4h. Voiding 3.4 cc/kg/hr and stooling normally. P: Continue to support andupdate .4. On servomode for heating; temp.stable. alt po/pg. P: Continue to monitor/support FEN.DEV: Maintaining stable temps swaddled in OAC. P: D/C lightwed. Updated at the beside on infant'sprogress by this RN. I>130 cc/kg/day + BF.uop and stool wnl.FeTemp stable, alert. Remainder byNGT. Min asp. Rebound thurs am. Wakesfor all care times. Abd benign. Abd benign. Abd benign. Abd benign. Abd benign. Abd benign. PG'd remainder. Rehab/OTReviewed worksheet for activities birth through one. A:Appropriate for gestational age. A: REsolving bili P: Followlevels. maintained in air controlledisolette.A:Appropriate for GA.P:Cont. to assess resp. D-stick 78. Bilidrawn this AM, pending. A: AGA P: Cont to support G+D. Voiding well; stooledheme(-). AGstable. Mom . A+A w/cares. A+A w/cares. In air isolette with stable temp. Abdomen exam benign. AGA. Updated by thisRN, asking appropriate questions. A: AGA P:cont to support dev needs. Tol well. Remains under singlephoto therapy. Now day count. AG stable. A: Hyperbili improved. MAEW. Remains in RA. Mom BF independently. A: Tol currentfeeding plan P: Adv 15cc/k as tol. Asking appropquestions. 1 spit. Infant had 1 A/B this am QSR. Wakes for feeds. BW=1775g. BP 72/42 (53).Bilirubin to 8.4/0.2 under single phototherapy.Wt 1690 (+35) on TFI 120 cc/kg/day BM20, tolerating well. A:AGA P: present care.#4 O: here for first 2 cares. abd benign, vdgand stooling . Ferinsol as ordered. Baseline mild sc rtxns. , check d/s with next feed.#3- O/A: Nested in servo isolette with stable temps. P: present care. A&A withcares and settles well in between. Continue tomonitor. AGA.Passed hearing screen this shift. P/cont. P/cont. alert w/cares, pacifier for pg feeds and to settle. Fontanels soft andflat, MAEW. Continue to support.Continue to prepare for D/C.A/Bs - No spells noted thus far. AGA.Support G&D.4. P: Cont. P: Cont. P: Cont. Brings hands to face and sucks on pacifier.Kangarooed x 1hr and tolerated well. on pacifier. Abd benign. V&S. Check results of bili. updated. independent, lovingw/babies. IVF dc'd d/t PIV puffy in appearance,team aware. BBS =/clear. Continue to supportdevelopmental growth.PAR - Mom called x1, updated by RN. to support developmental needs ofinfant.#4- O/A: Mom up for all cares thus far, independent withdiaper change and temp taking. A/Appearsto be tolerating present feeding regimen. Nursing Progress Note2. Neonatology Attending NoteDay 9, PMA 34 4RA. | 103 | [
{
"category": "Nursing/other",
"chartdate": "2177-07-11 00:00:00.000",
"description": "Report",
"row_id": 1726850,
"text": "NICU Admission Note\n\nO: Baby Girl , #1, admitted from L+D to NICU at 1600 after C/S delivery at 33 wks gestation. Please see above note for maternal hx. and L+D course. Apgars 9 at 1 min and 9 at 5 min. On admission infant pink in RA, active and alert with appropriate tone. Placed on open warmer servo control with cardio, resp, and sat monitors on, with alarms set and audible. Wt-1775 gms. VS as noted on careview flowsheet. HR's 130's-160's RR- 30's-60's. Sats 98-100. Breath sounds are clear and = with very mild SC retractions. D/S=61. CBC and BC drawn and sent. PIV placed in R hand. D10W commenced at 80cc/kg=5.9cc/hr. Baby care given. Dad in to see infant. Updated and oriented to unit. Infant has voided, no stool yet. Presently resting comfotable on sheepskin nest with boundaries in place.\nA: 33 wks w/o resp. compromise at present\nP: Continue close observation and monitoring of resp. status and VS. Maintain NPO for now. Follow D/S and daily wts. Keep parents updated and informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-12 00:00:00.000",
"description": "Report",
"row_id": 1726851,
"text": "NPN\n\n\n#1\nInfant continues in RA with sats mid-high 90s. No desats\nnoted. BS clear= with mild retractions. Color is pink and\nslightly ruddy. Murmer not audible. Good perfusion noted.\nNo spells noted. BP stable.\n\n#2\nInfant remains NPO. TF=80cc/k of D10W infusing via a patent\nPIV. DS=86. Abd is soft and flat; active BS. No stool.\nVoiding well. NGT placed in right nare for feedings to be\nstarted later this am.\n\n#3\nInfant remains on an open warmer nested in sheepskin with\nboundaries. Temp has been stable. Infant is alert and\nfiesty with cares; sucks on the pacifier; brings hands to\nface. Bath given. To be transferred into an isolette later\nthis am.\n\n#4\nDad was by to visit last evening, per report. No contact\nduring the night from either parent.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-12 00:00:00.000",
"description": "Report",
"row_id": 1726852,
"text": "NNP Physical Exam\nPE: pink, well perfused, AFOF, breath sounds clear/equal with easy WOB, no murmur, +2/= pulses, abd soft, non distanded, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-12 00:00:00.000",
"description": "Report",
"row_id": 1726853,
"text": "Neonatology Attending Progress Note\n\nNow day of life 1, CA 3/7 weeks.\nIn RA with RR 30-60s, O2 sats 98-100%\nNo apnea and bradycardia.\n\nHR 120-160s BP 63/33 43\n\nWt. 1775gm on 80ml/kg/d of TF IV - D10W\nNPO\nDS 61-86\nUO 2.9ml/kg/hr - no stool yet\n\nID - cbc unremarkable, blood culture no growth\n\nAssessment/plan:\nVery nice progress overall.\nWill continue to monitor cardiorespiratory status.\nFeedings to start today with SC and MM when available.\nLytes with bili tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-12 00:00:00.000",
"description": "Report",
"row_id": 1726854,
"text": "NPN 0700-1900\n\n\nRESP: Remains in room air, LS clear/=, mild IC/SC\nretractions. No spells or desats thus far. Will continue to\nmonitor.\n\nFEN: Received infant NPO. Enteral feeds started at\n30cc/kg/day of BM/SC 20. Tolerating well thus far. PIV\ninfusing D10W. Abdomen soft/flat, good bs, girth stable,\nvoiding, no stool thus far.\n\nG/D: Received infant nested on radiant warmer. Placed in\nisolette at second cares. Temp remains stable. Infant\nkangaroo'd with Mom x 60 minutes - tolerated well. Brings\nhands to face and sucks on pacifier for comfort.\n\nPARENTS: Both parents and family in to visit throughout day.\nUpdated by this RN, asking appropriate questions. Mom took\ntemp and changed diaper. Plan to return for third cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-29 00:00:00.000",
"description": "Report",
"row_id": 1726927,
"text": "NPN 7p-7a\n\n\n#2 FEN: Infant weight grams with a gain of 10 grams. TF\nmin 130 cc/kg of BM or Similac 24 (44 cc q4h). Infant\nbottling 48-53 cc q4h. Took 138 cc/kg/24hr. One large spit.\nAbdomen pink and soft with active bowel sounds and no loops.\nVoiding and heme negative stool. On iron. A: Infant bottles\nwell but has occasional choking-no brady with bottles. P:\nContinue with current plan.\n\n#3 Dev: Infant swaddled in an open crib, temp stable. Alert\nand active during cares and sleeps well in between. Waking\nfor feedings q4h. Settles well after cares. A: Appropriate\nfor gestational age. P: Continue to support developmental\nneeds.\n\n#4 : Mom called at 2200 and was updated. Will be in\nlater for cares.\n\n#7 As/Bs: No spells so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-29 00:00:00.000",
"description": "Report",
"row_id": 1726928,
"text": "Attending Note\nDay of life 18 PMA 35 \nin room air RR 20-40 no spells overnigth HR to 79 with a feeds\nHR 160-170 BP 75/38 mean 50\nweight up 10 grams on min 120 cc/kg/day took 162 cc/kg/day of BM or SC 24 cal/oz\non iron\nin open air crib\n\nImp-stable making progress\nwill continue to monitor for spells\nwill consider transfer to if space available\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-29 00:00:00.000",
"description": "Report",
"row_id": 1726929,
"text": "Attending Note\nPhysical Exam\nGen well appearing in no distress\nlugns clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds no masses\nGU normal female\nExt warm well perfused brisk cap refill\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-29 00:00:00.000",
"description": "Report",
"row_id": 1726930,
"text": "Nursing Progress NOte\n\n\n#2- O/A: Min. of 130/kilo of BM/ 24- 44ccq4h. Infant has\ntaken 60cc at both feeds thus far using Playtex nursers with\ngood coordination. Abdomen benign, no spits. Voiding and\npassing sm. yellow stools w/each diaper. Desitin to bottom.\nOn Fe. P: Cont. to support po/breast feedings and monitor\nwt.\n\n#3- O/A: In OAC, swaddled with stable temps. Alert and\nactive with cares, waking for feeds. Brings hands to face\nand sucks on pacifier. Fontanels soft and flat. Potential\ntransfer to on . pending open beds. P: Cont. to\nsupport dev. needs of infant and contact Hospital on\n.\n\n#4- O/A: Mom and Dad in this am, independent with cares and\nbottling. Updated at bedside by this RN. Asking approriate\nquestions. MOm staying for day. P: Cont. to support and\neducate family.\n\n#7- O/A: No a/b's thus far this shift. P: Cont. to monitor\nand support.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-30 00:00:00.000",
"description": "Report",
"row_id": 1726931,
"text": "NPN 7p -7a\n\n\nFEN - Wt 2.035 up 15g. TF min 130cc/k/d of BM/ 24 = 44cc\nq4h. Infant tolerating feeds well with no spits thus far.\nWell coordinated with the playtex slow flow nipple, with\noccasional choking episodes which are QSR with removal of\nbottle. Abd is benign with no visible loops and good BS.\nV&S. Continue to support PO feeding.\n\nDEV - Temps remain stable swaddled in OAC. A&A with cares\nand settles well in between. Wakes for some feeds. Brings\nhands to face and sucks on pacifier for comfort. Settles\nwell when held. Continue to support developmental growth.\n\nPAR - Mom called x1, updated by RN. Continue to support and\nkeep up to date.\n\nA/Bs - No spells noted thus far. Day 2 of 5 spell\ncountdown. Continue to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-11 00:00:00.000",
"description": "Report",
"row_id": 1726847,
"text": "Admission Note\nthis infant is getting IVF at 80 cc/kg/day not the 60 listed above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-11 00:00:00.000",
"description": "Report",
"row_id": 1726848,
"text": "Admission Note\nthis infant is getting IVF at 80 cc/kg/day not the 60 listed above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-11 00:00:00.000",
"description": "Report",
"row_id": 1726849,
"text": "Admission Note\nOb-\nPedi- at Pediatrics in \n\nBaby girl girl I is the 1775 grams product of an IVF tri-tri triplet 33 week gestation (EDC ) born to a 35 yo G1 P0 mom with PNS blood type A positive, antibody negative, Hep B negative, RPR NR, Rubella Immune. This pregnancy was complicated by gestational diabetes treated with NPH insulin and cholestatis treated with ursodiol.\n\nThis infant is born by C-section with Apgar scores of 9 (1 min) 9 (5 min). She was dried and suctioned in the delivery room.\n\nExam-gen active well appearing infant in no distress\nweight 1775 grams (50%) length 43 cm(50%) HC 30.5 cm (25%)\ntemp 98.3 HR 166 RR 60 sat 97% BP 60/41 mean 48 D stick 61\nskin pink\nHEENT normocephalic atraumatic ant font open and flat red reflex present bilaterally palate intact\nneck supple\nlungs clear bilaterally\nCV regular rate and rhythm 1/6 systolic murmur femoral pulse 2+ bilaterally\nAbd soft with active bowel sounds no masses or distention\nGU normal preterm female\nAnus patent\nHips stable\nNeuro good tone moved all extremities equally\nExt warm well perfused brisk cap refill\n\n\nImp-33 week infant born because of materal indications in stable condition\nCV-murmur present likely transitional will follow clincically\nRESP-stable in room air no respiratory distress will monitor for apnea\nFEN-will keep NPO for now will begin IVF at 60 cc/kg/day. Will consider pg feeds later today if stable in room air\nID-no sepsis risk factors. will draw cbc and blood culture will not begin abx unless there is other clinical concern or a shifted cbc\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-27 00:00:00.000",
"description": "Report",
"row_id": 1726918,
"text": "NPN 1900-0730\n\n\n2. Wt up 40gm to 2015gm. TF 150cc/k/d BM/ 24. Able to\ntake 2 whole bottles thus far. PO TF intake yesterday=\n154cc/k/d. Abdomen benign. Voiding and stooling.\nTolerating PO's with one spit and no aspirates. Continue to\nencourage PO's as tolerated.\n\n3. Temp stable swaddled in open crib. Alert and active,\nwaking for feeds. Rest well inbetween cares. Suckles well\non pacifier. MAE, brings hands to face and mouth. Continue\nto promote development.\n\n4. No parental contact thus far.\n\n7. In RA, no oximeter. Lungs clear. RR 30-60's. No A&B's\nthus far. Stable in RA. Continue to monitor for A&B's.\nLast brady was with noon feed yesterday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-27 00:00:00.000",
"description": "Report",
"row_id": 1726919,
"text": "Neonatology Attending\nDOL 16 / PMA 35-4/7 weeks\n\nRemains in room air with no distress. One feeding-associated bradycardia yesterday, none overnight.\n\nNo murmur. Well-perfused. BP 71/31 (49).\n\nWt (+40) on TFI 150 cc/kg/day BM/Sim24, tolerating well with full PO overnight and intake 154 cc/kg/day. Abd benign. Voiding and stooling normally.\n\nTemp stable in open crib\n\nA&P\n33-2/7 week GA with respiratory and resolving feeding immaturity\n-Continue to await maturation of respiratory drive\n-In order to facilitate oral feeding, will decrease minimum TFI to 130 cc/kg/day\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-28 00:00:00.000",
"description": "Report",
"row_id": 1726922,
"text": "NICU\n\n\nNPN#2 O= WT= down 5gms, TF min 130cc/kg/d of BM24/\nSim24 q4hrs..infant bottling for 50-60cc q feed, tol well,\nno spits, abd exam softly rounded & benign, voiding &\nstooling, cont on Fe supps as ordered, took 139cc/kg/d\nyesterday A= tol feeds, wt down/ TF decreased P= cont plan\nof care/ enc po's follow wt\n\nNPN#3 O= temp stable in open crib swaddled, waking for\nfeeds, active & alert with cares, good tone, hands to face,\nAF soft & flat A= behaviors app for GA P= cont to assess &\nsupport dev needs\n\nNPN#4 O= no contact from thus far this shift A/P=\ncont to teach/ update & support \n\nNPN#7 O= infant remains in RA , rr=30's-40's, LS clear &\nequal bilat, no spells thus far overnight ( x2 in last\n24hrs) A= occ spells/ no overnight P= cont to monitor &\ndocument all spells\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-28 00:00:00.000",
"description": "Report",
"row_id": 1726923,
"text": "Attending Note\nPhysical Exam\nGen well appearing no distress\nlungs clear bilaterally\npalate intact\nneck supple\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused brisk cap refill\nNeuro normal tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-28 00:00:00.000",
"description": "Report",
"row_id": 1726924,
"text": "Attending Note\nDay of life 17 PMA 35 \nin room air RR 30-40 no retractions\ntwo bradys with feeds yesterday\nHR 140-160 BP 71/52 mean 59\nweight down 5 grams on min 130 cc/kg/day took in 139 cc/kg/day BM/SC 24\nall po\nvoiding and stooling no spits\non iron\nin open air crib\nalert and active\n\nImp-stable making progress\nwill monitor for spells\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-28 00:00:00.000",
"description": "Report",
"row_id": 1726925,
"text": "Nursing Progress Note\n\n\n#2- O/A: Min. 130cc/kilo of /BM 24 (made with \npowder)- 44cc q4h. Infant taking 51-60cc with each feed\nusing Playtex nurser with fair coordination; had one choking\nbrady. Abdomen benign, no spits. Voiding and stooling (heme\nneg) w/every diaper. On Fe. P: Cont. to support breast/po\nfeedings and monitor wt.\n\n#3- O/A: Swaddled in OAC with stable temps. Alert and active\nwith cares, occ. waking for feeds. Brings hands to face and\nsucks on pacifier. Fontanels soft and flat. Potential\ntransfer to when beds available, ? tomorrow. P:\nCont. to support developmental needs of infant, call\n hospital tomorrow.\n\n#4- O/A: Mom in for day as off 12pm cares. Independent with\ninfant's cares and bottling. Updated at bedside by this RN.\nAsking approriate questions. P: Cont. to support and\neducate.\n\n#7- O/A: Infant had one brady with feeding, 79 requiring\nmild stim. P: Cont to monitor and support as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-29 00:00:00.000",
"description": "Report",
"row_id": 1726926,
"text": "NPN 7p-7a\nCorrection: Infant took 162 cc/kg/24 hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-27 00:00:00.000",
"description": "Report",
"row_id": 1726920,
"text": "NPN 0700-1900\n\n\nFEN: TF decr'd today from 150 to TF min of 130cc/kg/day;\nBM/ 24. Infant waking early/demanding feeds. Bottled 50\nand 60cc Q4hrs thus far this shift and showed improved\ncoordination. 1 spell w/feed, see flowsheet. Abdomen exam\nbenign. No spits. Voiding qs; stooled heme(-). Continues on\nIron. P: Continue to monitor and support FEN status.\n\nDEV: Maintaining stable temps swaddled in OAC. A&A w/her\ncares and sleeps well bwtn. Brings hands to face to comfort\nself and loves to suck on binki. Desitin applied w/diaper\nchanges. AFSF. MAEW. P: Continue to promote optimal G&D.\n\nParenting: Mom in for all three care/feeding times. Updated\nat bedside by this RN. Teaching done in prep for d/c. MOM\ncompletely independent with cares and asking appropriate\nquestions. Continues to have concerns about milk supply and\nBF at home; mom set up to meet with LC this Wed.\nand also to meet with for contact # for a LC\nresource in area. Bath done with this at\n1200 today and pt tol well; Mom now independent w/ bath\n(this was her 3rd time). P: Continue to update and support.\n\nA's and B's: Pt had one brady to 71 today with her 0800\nfeeding. No bradys at rest, =3 in 24hrs (all w/feeds). P:\nContinue to monitor pt for apnea and bradycardia.\n\nsee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-27 00:00:00.000",
"description": "Report",
"row_id": 1726921,
"text": "NP NOTE\nPE: small growing preterm infant swaddled in open crib. Pink well erfused in RA. Mottles with care. AFOF sutures approximated, eyes clear, nares patent, MMMP\nChest is clear, equal bs, comfortable\nCV: RRR, no murmur, pulses+2=\nAbd: soft,a ctive bs\nGU: immature female\nEXT: , \nNeuro: active with symmetric tone and relfexes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-26 00:00:00.000",
"description": "Report",
"row_id": 1726914,
"text": "NPN 1900-0730\n\n\n2. Wt up 15gm to 1975gm. TF 150cc/k/d BM/ 24. Able to\ntake 2 whole bottles thus far. Abdomen benign. Voiding and\nhaving heme negative stools. Tolerating bottles without\naspirates. Having small to medium spits after feeds.\nContinue to monitor ability to take bottles.\n\n3. Temp stable swaddled in open crib. Alert, active,\nwaking for some feeds. Rest well inbetween cares. MAE,\nbrings hands to face. Suckles well on pacifier. Continue\nto promote development.\n\n4. Mom called and updated on plan of care. Continue to\nsupport, update, and educate .\n\n7. In RA without oximeter. Lungs clear. RR 30-60's. No\nA&B's thus far. Last spell was on . Continue to\nmonitor for A&B's.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-26 00:00:00.000",
"description": "Report",
"row_id": 1726915,
"text": "Neonatology\nDOL #15, CGA 35 wks.\n\nCVR: Remains in RA, comfortable, RR 30-60s. Occasional spells with feeds. No spells at rest (day ). Hemodynamically stable, no murmur.\n\nFEN: Wt , up 15 grams. TF 150 cc/kg/day, BM/ 24, PO/PG, all PO overnight. Voiding/stooling.\n\nDEV: In open crib.\n\nIMP: Former 33+ wk , doing well. Stable in RA. Occasional spells. Improving PO intake.\n\nPLANS:\n- Continue as at present.\n- Monitor for spells.\n- Monitor PO intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-26 00:00:00.000",
"description": "Report",
"row_id": 1726916,
"text": "NPN 0700-1900\n\n\nFEN: TF 150cc/kg/day BM/Similac 24 =49cc Q4hrs. All PO for\n24hrs. 2 spells w/feed today but usually coordinated with\nfeeds using Playtex bottle. Took 50-60cc Q4hrs today. Abd.\nexam benign. +BS. No spits. No residual. Voiding qs; stooled\nheme(-). Continues on Iron. P: Cont to monitor FEN status.\n\nDEV: Remains swaddled in OAC; temps stable; A&A with cares\nand sleeps well bwtn. Brings hands to face to comfort self\nand loves her pacifier. Wakes early demanding feeds. AFSF.\nMAEW. Will need Hep B this week. P: COntinue to support.\n\n: Mom and Dad in 0800 to 1400. Updated at bedside by\nthis RN. Maternal step-Grandmother visited 1200-1400. Mom\nand Dad independent w/ cares; asking appropriate questions.\nBath done with (#3) and teaching continued in prep\nfor d/c. experienced with detecting when infant is\napneic w/bottle & respond/intervene quickly & appropriately.\nMom will return in AM. P: Continue to support family.\n\nA's/B's: Pt continues to have occ spells w/ feedings only.\nRemains slightly uncoordinated w/ bottle feeding but is\nimproving each day. 2 spells today- see flowsheet. P:\nContinue to monitor pt for apnea and bradycardia.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-26 00:00:00.000",
"description": "Report",
"row_id": 1726917,
"text": "NP NOTE\nPE: small growing preemie swaddled in open crib. Pink well perfused in RA.\nAFOF sutures approximated, eyes clear, ng in lace, MMMP\nChest is clear, equal bs\nCV: RRR, no murmur, pulses+2=\nAbd: soft active bs, cord healing\nGU: immature female, buttocks improved\nEXT: , \nNeuro: active with symmetric tone and relfexes\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-25 00:00:00.000",
"description": "Report",
"row_id": 1726909,
"text": "NPN 7p-7a\n\n\n#2 FEN: Infant weight grams with a gain of 25 grams. TF\n150 cc/kg of BM or Special Care 24 (49 cc q4h gavaged over 1\nhr). Po/pg based on cues. Bottling 25-50 cc q4h, remaining\nvolume gavaged. One large spit. Min asp. Abdomen pink and\nsoft with active bowel sounds and no loops. Voiding and heme\nnegative stool. On iron. A: Infant well coordinated with\nbottling but tires at times. P: Continue with current plan\nand encourage po feedings as tolerated.\n\n#3 Dev: Infant swaddled in an open crib, temp stable. Alert\nand active during cares and sleeps well in between. Does\nwell with pacifier. Wakes for some feedings. PKU sent. A:\nAppropriate for gestational age. P: Continue to support\ndevelopmental needs.\n\n#4 : in at with grandparents for CPR and\nwere updated. A: Appropriate and independent. P: Continue to\nsupport and educate. Possible transfer to in the\nnear future if beds are available.\n\n#7 As/Bs: No spells so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-25 00:00:00.000",
"description": "Report",
"row_id": 1726910,
"text": "Attending Note\nDay of life 14 PMA 35 \nin room air RR 30-60 no retractions\nlast spells 7/11\nHR 140-160\nweight up 20 on 150 cc/kg/day of BM or SSC 24 cal/oz taking some pg but mostly po feeds\none spit\nmin residual\nvoiding and stooling heme negative\nalert and active\n\nImp-stable making progress\nwill continue current calories\nwill continue to encouarge po feeds\nwill increase iron dose\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-25 00:00:00.000",
"description": "Report",
"row_id": 1726911,
"text": "Attending Note\nwill change to 24 cal/oz\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-25 00:00:00.000",
"description": "Report",
"row_id": 1726912,
"text": "NP NOTE\nPE: small growing preterm infant swadsdled in open crib. PInk well perfused in AR\nAFOF sutures approximated, eyes clear, ng in place. Miuld jaundice.\nChest is clear, equal bs, comfortable\nCV: RRR, no murmur, pulses+2=\nAbd: soft active bs\nGU: immature fema;e\nEXT: , \nNeuro: active with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-25 00:00:00.000",
"description": "Report",
"row_id": 1726913,
"text": "NPN 0700-1900\n\n\nF/N: TF 150cc/kg/day BM/ 24 (using powder for BM).\n=48cc Q4hrs. Mostly PO's. Bottled 43cc; 43cc and 40cc Q4hrs\nthis shift w/remainder by NGT. Abdomen exam benign. +BS.\nVoiding qs; stooled heme(-). One spit. No residuals. Cont.\non Fe. P: Continue to monitor and encourage PO's as tol.\n\nDev: Remains swaddled in OAC; temps stable; A&A w/her cares\nand sleeps well bwtn. Brings hands to mouth; loves binki.\nAFSF. MAEW. AGA. Desitin applied prn for min. redness to\nbottom. P: Continue to monitor and support G&D.\n\nParenting: MOm in from 0800 to 1500. Updated at bedside. D/C\nprep teaching done. Recipe card reviewed and given to mom.\nMOm completely independent w/ cares and asking appropriate\nquestions. P: Continue to update and support family.\n\nA/B's: No apnea or bradycardias since . P: Continue to\nmonitor pt for A's and B's.\n\nSee flowsheet for details.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-23 00:00:00.000",
"description": "Report",
"row_id": 1726903,
"text": "NPN days\n\n\nNutrition: TF 150cc/k/d of BM24 or SC24cal/oz. Alt PO/PG\nfeedings. When gavage fed, infusion given over 75min.\nBottled well, coordinated, no choking, tired after 27cc.\nAbdomen is soft, pink ,active bowel sounds, no loops,\nvoiding and stooling. No spits, min residuals. tolerating\nfeedings well, improving po skills. will continue to\nmonitor closely for signs or symptoms of feeding\nintolerance, encourage po feedings.\n\nDEV: Temps are stable,swaddled in crib. Infant is active\nand alert with cares, moving all extremities well. brings\nhands to face,sucks on pacifier/hands. Fontonelles are soft\nand flat. will continue to support developmental needs.\n\nParenting: both in this am, updated at bedside.\nMother in all day, independant with infants cares. Holding,\nbottling , follows infants cues well. Will continue to\nsupport and update family.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-24 00:00:00.000",
"description": "Report",
"row_id": 1726904,
"text": "NPN\n\n\n#2 TF 150cc/k/d of BM24/SC24=48cc Q4hrs on pump over 75\nmin. Abd soft, +BS, no loops. No spits, min asp. Infant\nbottled 46cc x1 tonight. Voiding and stooling. Wt\n(+40gms).\n\n#3 Infant active and alert with cares. Occasionally\nirritable during gavage feeding. Temp stable on open crib.\nCo-bedded with sister. Sucks on pacifier. Brings hands to\nface.\n\n#4 No contact from overnight.\n\n#7 No bradys in past 24hrs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-24 00:00:00.000",
"description": "Report",
"row_id": 1726905,
"text": "Neonatology Attending\nDOL 13 / PMA 35-1/7 weeks\n\n remains in room air with no cardiorespiratory events.\n\nNo murmur.\n\nWt (+40) on TFI 150 cc/kg/day BM24/SC24, tolerating well by gavage over 75 minutes for reflux. Bottled full volume x 2 last night. Abd benign. Voiding and stooling normally.\n\nTemp stable in open cirb.\n\nA&P\n33-2/7 week GA with feeding immaturity\n-Continue current management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-24 00:00:00.000",
"description": "Report",
"row_id": 1726906,
"text": "Nursing Progress Note\n\n\nFEN: TF 150cc/kg/d BM/SC 24. Tolerating feedings, no\nspits. Abd exam benign as noted flow sheet. Offered bottle\nwith both feedings infant taking about volume PO.\nVoiding QS, passing green guiac neg stools.\n\nDev: Temp stable swaddled in crib. Infant is alert and\nactive with cares. Swaddled in crib with had and blanket\nover. Plan to cont to support dev needs.\n\n: in this am, mother in for remainder of\nday. Independent with infant cares and bottle feeding each\nof them. Mother pumping .5-3 hrs to try to increase\nsupply. Plan for CPR tonight. Plan to cont to monitor.\n\nA's and B's: No spells thus far this shift. Plan to cont to\nmonitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-24 00:00:00.000",
"description": "Report",
"row_id": 1726907,
"text": "Neonatology - NNP PRogress Note\n\nInfant is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable in room air, breath sounds clear and equal. She is tolerating enteral feeds, abd soft, active bowel sounds, voiding/stooling. Improving on po feeding skills. Stable temp in open crib. Please refr to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-24 00:00:00.000",
"description": "Report",
"row_id": 1726908,
"text": "CPR Note\n\n\nBoth and maternal grandparents in for CPR class.\nEveryone participated by watching video, practicing on\nmanniquin and asking questions. Reviewed infant CPR &\nchoking, back to sleep, and bulb syringe use. Poster given\nto to take home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-21 00:00:00.000",
"description": "Report",
"row_id": 1726891,
"text": "Nursing Progress Note\n\n\n#2 TF 150cc/k/d BM24/SSC24. attempting po qofeed, taking\nonly small amts this morning before tiring. tol pg well over\n75min/mod spit this morning. abd benign, vdg and stooling\nguiac neg stools. Ferinsol as ordered, desitin to butt for\nirritation.\n#3 O: see above re: feeds, temp stable in open crib. waking\non own for feeds but still not able to sustain full volume.\nalert w/cares but tires easily. A: still premature\nbehaviours P: cont to support developmentally\n#4 O: mom here for day, dad in earlier and will be back this\nevening. independent w/cares, asking appropriate questions.\nupdated. P: cont to support and teach.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-22 00:00:00.000",
"description": "Report",
"row_id": 1726897,
"text": "NPN days\n\n\nalt in Nutrition: Tf 150cc/k/d of Bm24/SC24. Alt PO/PG\nfeedings. Took 26cc via bottle today, well coordinated -\ntired after 10-15min. When gavage feed feeding given over\n75min. Abdomen is soft, pink, active bowel sounds, no\nloops, AG stable. No spits, min residuals. Voiding and\nstooling guiac neg stools. Tolerating feeds well.\nImproving po skills. will continue per current feeding plan\nand monitor for signs or symptoms of feeding intolerance.\nEncourage po feeds.\n\nDEV: Temps are stable in crib , swaddled with hat on.\nInfant is active and alert with cares, moving all\nextremities . Brings hands to face. sucks on pacifier at\ntimes for comfort. AGA. will continue to support\ndevelopmental needs.\n\nParenting: in this am, mom in for day, indepandant\nwith cares, feeding infants. Kangarood with infant this\nafternoon during gavage feeding. Updated at bedside. Will\ncontinue to update and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-22 00:00:00.000",
"description": "Report",
"row_id": 1726898,
"text": "Neonatology Attending\nDOL 11\n\nInfant remains in room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 77/33 (44)\n\nWt 1880 (+35) on TFI 150 cc/kg/day BM/SC24 PO/PG, tolerating well. Voiding and stooling normally.\n\nTemp stable in open crib.\n\nA&P\n33-2/7 week GA with feeding immaturity\n-Continue current management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-22 00:00:00.000",
"description": "Report",
"row_id": 1726899,
"text": "Neonatology NP Note\nPE\nswaddled in opencrib\nAFOF\nminimal subcostal retractions in room air, lungs clear/=\nRRr, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nface jaundiced\nactive with goodt one\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-23 00:00:00.000",
"description": "Report",
"row_id": 1726900,
"text": "NPN 1900-0700\n\n\nFEN: Tolerating full enteral feeds well, no spits or\naspirates. Alternating PO/PG - infant took first full bottle\nthis shift. Abdomen soft/round, good bs, V&S. Continues on\nIron & Desitin.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Brings hands to face and sucks on pacifier\nand fingers for comfort.\n\n: No contact thus far.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-21 00:00:00.000",
"description": "Report",
"row_id": 1726892,
"text": "Neonatology Attending Progress Note\n\nNow day of life 10, CA 5/7 weeks.\nIn RA with RR 30-60s.\nO2 sat 97-100%\nHR 140-160s BP 66/48 55\n\nWt. 1845gm up 55gm on 150ml/kg/d of MM or SSC24\nFeedings tolerated well by slow gavage over 75 minutes - attempting some po too.\nNormal urine and stool output.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-21 00:00:00.000",
"description": "Report",
"row_id": 1726893,
"text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures approximated\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nface and trunk jaundiced\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-22 00:00:00.000",
"description": "Report",
"row_id": 1726894,
"text": "PCA note 1900-0700\nI have examined Baby and agree with the above note written by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-22 00:00:00.000",
"description": "Report",
"row_id": 1726895,
"text": "PCA note 1900-0700\n\n\n1. FEN: TF 150cc/kg BM 24 SC 24. Infant's current weight is\n1880 up 35 grams. At gavaged 46 cc over 75 minutes. At\n00 infant bottled 30 cc and gavaged 17cc. Pt tolerating\nfeeds well; abdomen benign, stable girth, minimal aspirates,\nand no spits. No spells thus far this shift. Voiding and\nstooling heme negative. Destin applied to bottom. P:\nContinue to support nutritional needs.\n\n2. G/D: Temps stable and swaddled in crib. Alert and active\nwith cares. Settles well between cares. MAE well. AFSF. AGA.\nP: Continue to support developmental needs.\n\n3. Parenting: were in at start of shift but left at\napprox. 19:30. No further contact thus far this shift.\nLoving and invovled . P: Continue to support and\nupdate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-22 00:00:00.000",
"description": "Report",
"row_id": 1726896,
"text": "Clinical Nutrition\nO:\n~35 wk CGA BG on DOL 11.\nWT: 1880 g (+35)(~25th %Ile); birth wt: 1775 g. Average wt gain over past wk ~14 g/kg/day.\nHC: 30 cm(~10th to 25th %ILe); last: 30.5 cm\nLN: 43.5 cm (~25th %Ile); last: 43 cm\nMeds include Fe\nLabs not needed\nNutrition: 150 cc/kg/day BM/SSC 24, po/pg over 75 min feeds. Infant is slow bottler, taking only ~ of volume when po fed. Projected intake over next 24hrs ~120 kcal/kg/day and ~3.2 to 3.3 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. Learning feeding skills. Labs not needed. CUrrent feeds + supps meeting recs for kcals/pro/vits and mins. Growth is not meeting recs for any parameter yet, but feeds were just recently increased to goal, and daily wt gains have been adequate over past several days, so anticipate improvement in growth. WIll continue to follow w/team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-23 00:00:00.000",
"description": "Report",
"row_id": 1726901,
"text": "Neonatology Attending\nDOL 12 / PMA 35 weeks\n\n remains in room air with no distress and only one bradycardia.\n\nNo murmur. BP 69/44 (53).\n\nWt 1895 (+15) on TFI 150 cc/kg/day BM/SC24, tolerating well. Alternating PO/PG with two full bottles last night!. Abd benign. Voiding and stooling normally.\n\nTemp stable in open crib.\n\nA&P\n33-2/7 week GA with resolving respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Awaiting bed availability at Hospital\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-23 00:00:00.000",
"description": "Report",
"row_id": 1726902,
"text": "Neonatology Fellow Note\nSee Attending Note for details\nPhysical Examination:\nHEENT: Moist oral mucosa, no lesions. AFOF. PERLA and normal red reflex B/L.\nResp: Stable RA. RR 40-60s, CTA and mild SC retractions\nCardiac: HR 140-160s, Normal S1 and S2 with no added sounds. Full femoral pulses B/L.\nGI: Soft non distended abdomen, no masses and BS present\nNeuro: Alert, in a crib. Normal tone and good neonatal reflexes\nExtrem: Warm and mild jaundice. Good cap refill and stable hips\nGU: Normal no rashes\nSpine; normal\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726943,
"text": "Clinical Nutrition:\nO:\n~36 week CGA BG on DOL 21.\nWT: 2115g(+55)(10-25th %ile); BWT: 1775g. Average wt gain over past week ~22g/day.\nHC: 30.5cm(10-25th %ile); last: 30cm\nLN: 44.5cm(~25th %ile); last: 43.5cm\nMeds include Fe.\nLabs not needed.\nNutrition: Adlib/Min. 130cc/kg/day as BM/Similac 24 (4kcal/oz Similac powder if BM); all po's + breastfeeds. Average of past 3-day intake ~146cc/kg/day (117kcal/kg/day & ~1.9-2.4g pro/kg/day plus unquantified amounts from breastfeeding).\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; all po's. Labs not needed. ON day 4 of 5 for spell countdown. Current feeds & supps meeting weaned recs for kcal/pro/vits/mins. Growth is meeting recs for WT/HC/LN gains. Will cont. to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726944,
"text": "Case Management Note\nI have contact many for a home visit. Currently, there are no Maternal-Child care VNA's that have any availability for home visits. I have a call into () to see if they would have any availabity even at end of next week. Currently looks doubtful, but they will get back to me. They definitely can not do weekend or Monday or Tuesday visit next week I have called Partners care and they have no MCH availability in . Healthcare has no MCH capability. Care was called to 2 branches & they do not service . Centrus does not either. Healthcare & do not go to . There are other VA that do service , but can not do babies. I have shared possibilty of no home care with Dr & mom. aware to arrange Pedi follow up appts soon after the actual d'c of each .\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-18 00:00:00.000",
"description": "Report",
"row_id": 1726881,
"text": "Neonatology NP Note\nPe\nswaddled in open crib\nAFOf, sutures approximated\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\nface and trunk jaundiced\n\nmet with mother regarding lactation, gave her a small nipple shield, infant latched briefly but never effectively moved milk. mother demonstrates excellent positioning. also reviewed methods to increase milk supply.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-19 00:00:00.000",
"description": "Report",
"row_id": 1726882,
"text": "Nursing NICU Note\n\n\n2. F.N. O/Pt remains on TF of 150cc/k/d of BM24/ SC24\npo/pngt. Please refer to flowsheet for examinations of pt\nfrom this shift. voiding. Stooling. Pt appears eager to feed\nat care times: Actively rooting. Offered bottle twice thus\nfar this shift. A/Showing interest in po feeding. Appears to\nbe tolerating present feeding regimen at this time. P/ Cont.\nto monitor for s/s of feeding intolerance.\n\n3. Dev. O/Temp remains stable swaddled in a crib, with an\nextra blanket and a hat on. Waking prior to care time. Awake\nand very alert at care times and sleeping well in between.\nHeld by this nurse. on pacifier.\nA/Alt. in G/D. P/Cont. to support pt's growth and dev.\nneeds.\n\n4. . O/No contact from this shift. A/Unable\nto fully assess involvement at this time. P/Cont. to\nsupport and educate and encourage parent\nparticipation.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-19 00:00:00.000",
"description": "Report",
"row_id": 1726883,
"text": "Neonatology Attending Progress Note:\nDOl #8\nPMA 34 3/7 weeks\nremains in RA, RR=30-50's, clear/equal, mild sc retx.\nno bradys or desats. no murmur, HR=130-160's, BP 70/41 (mean=51)\nwt=1765g (inc 40g), TF=150cc/kg/d. BM or SC 24\npo/pg\nvoiding, stooling\nImp/Plan: premie infant learning to po feed\n--monitor weight, encourage po feeding\n--continue rest of present management\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-19 00:00:00.000",
"description": "Report",
"row_id": 1726884,
"text": "npn 7a-7p\n\n\n2.) FEN: TF at 150cc/kg/d. of bm/sc24. alt po/pg. min asp.\nsm spits. voiding/stooling with each diaper change. abd pink\nand soft, no loops. desitin ordered for sl reddened bottom.\nwill apply with diaper changes prn. continue to support fen.\n\n3.) G/D: Infant swaddled in oac. A/A with cares. sleeps well\ninbetween. temps stable afsf. aga.continue to monitor and\nsupport dev needs.\n\n4.) PARENTING: mom and dad both in to visit. both very\nindependent and actively involved with baby cares of infant\ntriplets. mom doing well with breastfeeding. updated\nat bedside by this RN. are in good spirits with\ntriplets progress. continue to educate and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-14 00:00:00.000",
"description": "Report",
"row_id": 1726859,
"text": "Neonatology Attending\nDOL 3 / PMA 33-5/7 weeks\n\nRemains in room air with no distress. One bradycardia in 24 hours.\n\nNo murmur. BP 46/36 (39).\n\nWt 1655 (-70) on TFI 100 cc/kg/day including enteral feeds BM20 at 90 cc/kg/day, tolerating well. Abd benign. Voiding 3.4 cc/kg/hr and stooling normally. D-stick 67.\n\nBilirubin 10.4/0.2 this morning; phototherapy started.\n\nTemp stable in servo isolette.\n\nA&P\n33-2/7 week GA with respiratory and feeding immaturity, hyperbilirubinemia\n-Continue to monitor for respiratory maturity\n-Advance feeds cautiously as tolerated\n-Continue phototherapy and repeat bilirubin in 24 hours\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-14 00:00:00.000",
"description": "Report",
"row_id": 1726860,
"text": "CLinical Nutrition\nO:\n33 wk gestational age BG, AGA, now on DOL 3.\nBirth wt: 1775 g (~25th to 50th %Ile); current wt: 1655 g (-70)(down ~7% from birth wt)\nHC at birth: 30.5 cm (~25th to 50th %Ile); current HC: 30.5 cm\nLN at birth: 43 cm (~25th to 50th %ILe); current LN: 43 cm\nLabs not due yet\nNutrition: 120 cc/kg/day TF. Feeds were started on DOL 1; currently @ 90 cc/kg/day BM/SSC 20, increasing 15 cc/kg/. REmainder of fluids as D10 w/ lytes via PIV. Projected intake for next 24hrs from feeds ~60 kcal/kg/day, ~0.9 to 1.6 g pro/kg/day.\nGI: Abdomen benign; passing large meconium\n\nA/goals:\nTolerating feeds without GI problems so far; advancing slowly and monitoring closely for tolerance. Labs not due yet. INitial goal for feeds is ~150 cc/kg/day BM/SSC 24, providing ~120 kcal/kg/day and ~3.2 to 3.3 g pro/kg/day. Further increases in feeds as per growth and tolerance. Appropriate to add Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain,and ~ 1 cm/wk for LN gain. WIll follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-14 00:00:00.000",
"description": "Report",
"row_id": 1726861,
"text": "NP NOTE\nPE: well appearing preterm infant nestled in isolette under photoherapy. PInk, mildly jaundiced over face and trunk.\nAFOF sutures approximated, eyes clear, ng in lpace, MMMP\nChest is clear, equal bs, comfortable\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs cord dry\nGU: immature female\nEXT: PIV in right hand,MAE\nNeuro: active with symmetric tone and relfexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-31 00:00:00.000",
"description": "Report",
"row_id": 1726938,
"text": "Attending Note\nDay of life 20 PMA 36 \nin room air RR 30-50 no retractions day 3/5\nHR 140-150 BP 70/36 mean 48\nweight 2065 up 25 grams on min 130 cc/kg/day of BM or 24 cal/oz taking more than minimum and breast fed\nvoiding and stooling heme negative\nstable temp in open crib\n visit daily\n\nImp-stable currently\nwill monitor for spells\nwill plan discharge teaching\nwill have a car seat test\nwill give Hep B today\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-18 00:00:00.000",
"description": "Report",
"row_id": 1726880,
"text": "NPN 0700-1900\n\n\nFEN: Tolerating full enteral feeds well, no spits or\naspirates. Learning to PO feed, takes bottle with good\ncoordination. Abdomen soft/round, good bs, girth stable,\nV&S. Started on Iron supplements today.\n\nG/D: Temp stable swaddled in open crib. A&A w/cares, sleeps\nwell in between. Brings hands to face and sucks on pacifier\nfor comfort.\n\nPARENTS: Both parents in for first cares. Updated by this\nRN, asking appropriate questions. Mom in throughout day -\nindependent with cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-31 00:00:00.000",
"description": "Report",
"row_id": 1726939,
"text": "NPN 0700-1900\n\n\nF/N: Remains on TF min 130cc/kg/day BM/ 24. Needs 45cc\nQ4hrs. All PO >48hrs. Wakes for feeds on own and took full\nbottles today in addition to breasfeeding well. Meeting req\nTF intake. Well coordinated today w/playtex bottle. Abdomen\nexam benign. Voiding/stooling. One sm spit. Cont. on Fe.\nDesitin to bottom. P: Continue to monitor/support FEN.\n\nDEV: Maintaining stable temps swaddled in OAC. A&A w/cares;\nwaking for feeds on own. Sleeps well bwtn. Brings hands to\nface for comfort and loves her pacifier. AFSF. MAEW. AGA. Pt\ncould possibly go home Sunday when 5 days brady free; and\nwill need car seat and hearing screens. Also receive Hep B\nthis evening. P: COntinue to monitor and support G&D.\n\n: in for AM cares, updated at bedside by this\nRN. MOM at bedside and pumping bwtn cares and here for all\nfeedings today. Independent w/cares and asking lots of\nappropriate questions. LOving/invested family. P: COntinue\nto update, educate and support NICU family.\n\nA's and B's: No A's or B's noted thus far this shift. Pt.\nhad now been brady free for 3 days of 5. P: Continue w/five\nday spell countdown.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726940,
"text": "NPN 7p-7a\n\n\n#2 FEN: Infant weight 2115 grams with a gain of 55 grams. TF\n min 130 cc/kg of BM/ 24 (46 cc q4h). Infant bottling\n48-70 cc q3-4h. Took 150 cc/kg/24 hr plus breast feeding\nwell x 1. One medium spit. Abdomen pink and soft with active\nbowel sounds. Voiding and one stool. On iron. A:Infant\nbottles well and is gaining weight. P: Continue with current\nplan.\n\n#3 Dev: Infant swaddled in an open crib, temp stable. Alert\nand active during cares and sleeps well in between. Wakes\nfor feedings q3-4h. A: Appropriate for gestational age. P:\nWill give Hep B vacc at next cares.\n\n#4 : Mom called and was updated.\n\n#7 As/Bs: No spells so far this shift. Now day count.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726941,
"text": "Neonatology Attending Progress Note:\nDOL #21\nPMA 36 2/7 weeks\nremains in RA, RR=30-40's, clear/equal, day # spell free\nno murmur, HR=140-160's, bp overnight mean=51\nwt=-2115g (inc 55g), feeding ad lib with min of 130cc/kg/d BM/ 24\ntook 150c/kg/d and breast feeding\nvoiding, stooling\nHep B last night\nImp/Plan: premie infant with spell countdown\n--monitor for spells\n--d/c planning--needs hearing screen, needs car seat test, Hep B given, VNa to be called. pedi appointment on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-13 00:00:00.000",
"description": "Report",
"row_id": 1726855,
"text": "NICU Nursing Note 1900-0700\n\nRespiratory\nInfant remains stable in room air. RR stable, O2 sats high\n90's-100% as per flowsheet, LSC=, no signs of resp. distress\nnoted. Mild intercostal/subcostal retractions noted.\nNo apnea, bradycardia or desats. thus far this shift.\n\nFluid and Nutrition\nInfant's wt. 1725gms (-50). Total fluids 80cc/k/day; feeds\nincreased to 45cc/k/day; infant tol. increase well. No\nspits, no aspirates, abdomen soft, bowel sounds (+), no\nloops. Voiding q.s. no stool. Blood sugar 58 prior to feed.\nLytes drawn/sent to lab. Abd. girth stable. IVF's infusing\nwithout incident via PIV in (R) hand; currently at\n35cc/k/day. Infant's feeding plan is to increase feedings by\n15cc/k/day Q12hrs as tol.\n\nDevelopment\nInfant awake, alert and active, MAE with care periods.\nNested in sheepskin in a heated, covered isolette. On servo\nmode for heating; temp.stable. All cares clustered.\nBrings hands to face, sucks on pacifier. AFOF.\n\nParenting\nInfant's dad in briefly to drop off breastmilk earlier in\nthe evening and was updated on the babies' status by this\nnurse.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-13 00:00:00.000",
"description": "Report",
"row_id": 1726856,
"text": "Neonatology\nDOL #2, CGA 33 wks.\n\nCVR: Remains in RA, RR 30-50s, O2sats 96-100%. No spells/desats. Hemodynamically stable.\n\nFEN: Wt 1725, down 50 grams. TF 80 cc/kg/day; enteral feeds at 60 cc/kg/day, BM/SC20, advancing 15 . Rest IVF. Dstik 58. Voiding, no stool. Lytes 141/4.2/110/18.\n\nGI: Bili 6.4/0.3 this am.\n\nDEV: In isolette.\n\nExam: comfortable, responsive to exam. Skin warm, dry, mildly juandiced. Fontanelles soft and flat. Chest well-aerated, clear. Cardiac RRR, no m. Abdomen soft, no HSM, no mass, active BS. Tone and activity appropriate.\n\nIMP: Former 33 wk , doing well. Stable in RA. No significant apnea. Tolerating gradual advancement of enteral feeds. Mild hyperbili.\n\nPLANS:\n- Continue monitoring in RA.\n- Continue advancing enteral feeds.\n- Increase TF to 100.\n- Bili in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-13 00:00:00.000",
"description": "Report",
"row_id": 1726857,
"text": "NPN 0700-1900\n\n1 Alt. in Resp. Function\n\nRESP: Remains in room air, LS clear/=, mild SC retractions.\nNo spells or desats thus far. Problem resolved at this time.\n\nFEN: Tolerating working up on enteral feeds well, no spits,\nminimal aspirates. Abdomen soft/flat, good bs, girth stable.\nD10 infusing via PIV. Plan to repeat bili in AM.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Currently kangaroo'in with\nDad, tolerating well thus far.\n\nPARENTS: Both parents in throughout shift, updated by this\nRN, asking appropriate questions. Parents becoming more\nindependent with cares.\n\nREVISIONS TO PATHWAY:\n\n 1 Alt. in Resp. Function; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-14 00:00:00.000",
"description": "Report",
"row_id": 1726858,
"text": "NICU Nursing Note 1900-0700\n\nFluid and Nutrition\nInfant's wt. 1655gms (-70). Total fluids 100cc/k/day; feeds\nvia NGT @75cc/k/day Q4hrs over 30 min. Infant tol.feeds\nwell; no spits or aspirates. Abd. soft, no loops, B.S.(+).\nAbd. girth stable. Blood sugar 67. Infant's PIV infusing\nwithout incident via (R) hand @ 25cc/k/day. See flowsheet.\nVoiding q.s., stooling meconium.\n\nDevelopment\nInfant awake and alert with care periods, and sleeps quietly\nbetween cares. MAE, AFOF. Temp. stable; infant nested in\nsheepskin in heated isolette on servo mode.\nInfant brings hands to face and sucks on pacifier.\n\nParenting\nNo contact with infant's parents thus far this shift.\n\nInfant had a bili level drawn; results pending.\nPKU done.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-17 00:00:00.000",
"description": "Report",
"row_id": 1726874,
"text": "Addendum:Infant with noted pustule on anterior portion of LL leg. be r/t ID tag against skin therefore removed.Will cont. to evaluate.No drainage or swelling appears slightly red.NNP aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-30 00:00:00.000",
"description": "Report",
"row_id": 1726932,
"text": "Attending Note\nPhysical Exam\nGen active well appearing in no distress\nlungs clear bilaterally\nCV reuglar rate and rhythm no murmur\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused brisk cap refill\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-30 00:00:00.000",
"description": "Report",
"row_id": 1726933,
"text": "Attending Note\nDay of life 19 PMA 36\nin room air RR 30-40\nday no spells\nHR 150-160 BP 80/36 mean 54\nweight 2035 up 25 grams on min 130 cc/kg/day of BM or 24 took in 139 cc/kg/day\nin open crib stable temp\n\nImp-stable making progress\nwill continue to monitor for spells\nwill consider transfer to if bed available\nwill have a lactation consult\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-30 00:00:00.000",
"description": "Report",
"row_id": 1726934,
"text": "PCA note 0700-1900\n\n\n1. FEN: TF min 130cc/kg BM or 24. At 0800 bottled 55cc\nBM. At 1200 feed breastfed for 10-15 min and bottled 30 cc\n 24. Tolerating feeds well; abdomen benign, positive\nbowel sounds and one small spit. Voiding and had one lg.\nheme negative stool thus far this shift. P: Continue to\nsupport nutritional needs.\n\n2. G/D: Temps stable and swaddled in crib. Alert and active\nwith cares. Settles well in between cares. MAE well. AFSF.\nAGA. P: Continue to support developmental needs.\n\n3. Parenting: Both in for 0800 cares. Independent\nwith cares. Loving and involved . Asked appropriate\nquestions. Dad left for work at approximately 0900 Mom\nstayed for afternoon cares. were updated on infant's\ncondition at bedside by RN. P: Continue to support and\nupdate .\n\n4. Respiratory: Infant remains on RA. RR 30-50's. LS\nclear/=. No retractions. No spells or apnea episodes thus\nfar this shift. P: Continue to monitor respiratory status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-30 00:00:00.000",
"description": "Report",
"row_id": 1726935,
"text": "NPN 0700-1900\n Ihave read and agree w/ the assessment and plan for #1 as noted by PCA- . Day of brady count.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-31 00:00:00.000",
"description": "Report",
"row_id": 1726936,
"text": "NPN 7p-7a\n\n\n#2 FEN: Infant weight 2060 grams with a gain of 25 grams. TF\nmin 130 cc/kg of BM or 24 (45 cc q4h). Infant bottling\n60 cc q4h. Took 129 cc/kg/24 hr plus breast feeding amounts.\nOne small spit. Abdomen pink and soft with active bowel\nsounds and no loops. Voiding and heme negative stool. On\niron. A: Infant well coordinated with bottling, taking\nadequate volume, and gaining weight. P: Continue with\ncurrent plan.\n\n#3 Dev: Infant swaddled in an open crib, temp stable. Alert\nand active during cares and sleeps well in between. Wakes\nfor all care times. Quiet alert after feedings. A:\nAppropriate for gestational age. P: Continue to support\ndevelopmental needs.\n\n#4 : No contact so far this shift.\n\n#7: As/Bs: No spells so far this shift. Now day count.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-31 00:00:00.000",
"description": "Report",
"row_id": 1726937,
"text": "Attending Note\nPhysical Exam\nGen well appearing no distress\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused brisk cap refill\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-17 00:00:00.000",
"description": "Report",
"row_id": 1726875,
"text": "Neonatology Attending\nDOL 6 / PMA 34-1/7 weeks\n\nIn room air with no distress. One bradycardia yesterday, none overnight.\n\nNo murmur. BP77/52 (58).\n\nWt 1695 (+15) on TFI 150 cc/kg/day BM20. Alternating PO/PG. Abd benign. Voiding and stooling normally.\n\nOff phototherapy with rebound bilirubin decreased to 7.2.\n\nTemp stable in weaning isolette.\n\nA&P\n33-2/7 week GA with feeding and respiratory immaturity, resolved hyperbilirubinemia\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Advance caloric density\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-17 00:00:00.000",
"description": "Report",
"row_id": 1726876,
"text": "Rehab/OT\n\nReviewed worksheet for activities birth through one. Discussed back to sleep, and cobedding. AAP is inconsistent on recommendations on this subject. Mom referred to her pediatrician to discuss further.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-17 00:00:00.000",
"description": "Report",
"row_id": 1726877,
"text": "NPN 0700-1900\n\n5 Hyperbili\n6 A/B's\n\nFEN: Calories increased today. Tolerating full enteral feeds\nwell, no spits or aspirates. Offered bottle at first cares,\ninfant tolerated well and bottled with good coordination.\nAbdomen soft/round, good bs, girth stable, V&S.\n\nG/D: Temp stable swaddled in weaning air isolette. A&A\nw/cares, sleeps well in between. Sucks on pacifier for\ncomfort.\n\nPARENTS: Both parents in for first cares. Updated by this\nRN, asking appropriate questions. Mom staying throughout day\n- becoming very independent with cares.\n\nBILI: Remains off phototherapy, rebound WNL. Problem\nresolved at this time.\n\nA/B's: No spells or desats thus far this shift (0/24').\nProblem resolved at this time.\n\nREVISIONS TO PATHWAY:\n\n 5 Hyperbili; resolved\n 6 A/B's; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-18 00:00:00.000",
"description": "Report",
"row_id": 1726878,
"text": "NPN 1900-0700\n\n\nF/N: Weight=1725g (+30gms). BW=1775g. TF 150cc/kg/day SSC22\n=44cc Q4hrs. Tolerating PG feeds over 45 minutes. Alt po/pg.\nBottled 34cc at 2400 and was eager/well coordinated using\nown playtex bottle system w/slow flow nipple. Remainder by\nNGT. Abdomen exam benign. AG stable. Voiding well; stooled\nheme(-). P: Continue to monitor and support F/N.\n\nDEV: Maintaining stable temps swaddled in weaning Air mode\nisolette, minimal heat settings. A&A w/her cares and sleeps\nwell between. Brings hands to face/mouth to comfort self and\nloves to suck vigorously on pacifier. AFSF. MAEW. AGA. P:\nCOntinue to promote Dev and monitor for Dev milestones.\n\nParenting: Dad called x1 this shift and updated via phone by\nthis RN. Dad asking appropriate questions. Parents plan to\nbe here in the morning. Loving/vested first time parents. P:\nContinue to update, educate and support.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-18 00:00:00.000",
"description": "Report",
"row_id": 1726879,
"text": "Neonatology Attending\nDOL 7 / PMA 34-2/7 weeks\n\nIn room air with no distress and no cardiorespiratopry events in 24 hours.\n\nNo murmur. BP 66/55 (57). Well-perfused.\n\nWt 1725 (+30) on TFI 150 cc/kg/day BM/SC22, tolerating well. Alternating PO/PG. Abd benign. Voiding and stooling (heme negative).\n\nTEmp stable in off isolette.\n\nA&P\n33-2/7 week GA with feeding immaturity\n-COntinue to monitor for apnea and await maturation of oral feeding skills\n-Advance caloric density to 24 kcal/oz and start iron\n-Awaiting bed in \n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-16 00:00:00.000",
"description": "Report",
"row_id": 1726870,
"text": "NPN \n\n\n\n #2. TF adv to 150cc/k this am BM/SC 20(44cc pg'd over\n40min). Mom bottled @1200. She was eager and coordinated.\nShe took 26cc. PG'd remainder. Abd benign. 1 spit. Min asp.\nV+no stool thus far today. A: Tol current feeding plan. P:\nCont to encourage po feeds. Lac consult needed. Will set up.\nIncrease cals tommorrow.\n\n #3. Temp stable swaddled in sheepskin boundaries in weaning\nair isolette. A+A w/cares. Much easier settled now that she\nis swaddled. Loves pacifier. A: AGA P: Cont to support G+D.\n\n #4. Parents in @1000 today. Dad went to work Mom stayed for\ncares and learn to bottle infants. Fam meeting planned for\n1530. Dad plans to attend. Updated at the beside on infant's\nprogress by this RN. Parents interested in transfer to\n. Would like to visit unit first. A: Involved vested\nparents. P: Cont support, update and educate.\n\n #5. Infant conts to be sl jaundiced. Lights off this am.\nRebound to drawn tommorrow am. A: REsolving bili P: Follow\nlevels.\n\n #6. Infant had 1 A/B this am QSR. Remains in RA. RR 30-50.\nSating >98%. A: AOP P: Cont to monitor for and document\nA/B's.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-16 00:00:00.000",
"description": "Report",
"row_id": 1726871,
"text": "6 A/B's\n\nREVISIONS TO PATHWAY:\n\n 6 A/B's; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-16 00:00:00.000",
"description": "Report",
"row_id": 1726872,
"text": "NP NOTE\nPE: small well apearing preterm infant neslted in isolette.\nPink well perfused in RA, mldly jaundiced.\nAFOF sutures approximated, eyes clear, ng in place, MMMP\nChest is clear, equal bs, comfortabel\nCV: RRR, no murmur, pulses+2=\nAbd: soft with active bs\nGU: normal external female\nEXt: , \nneuro: active and reposnosive, symmetric tone and reflexes.\n\n\nFmaily meeting held today with NUrse , parents and myself.\nReviewed perinatal events, anticipated hospital course and criteria for dischareg. Parents will visit SCN and hope that infants will be able to be transfered there. Motivated first time parents eager to assume care of infants, asking appropiate questions,seeking resources for additional help at home. Will continue to keep infomed and involved in care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-17 00:00:00.000",
"description": "Report",
"row_id": 1726873,
"text": "Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant on TF 150cc's/kg/day.To rec.Special Care\n20/BM20 44 cc's q 4 hrs. alt. po/pg feeds over 40 min.Infant\nbottling 29-34 cc's with Playtex Nurser.Appears\ncoordinated.Weight=1.695 up 15 grams.Abd. soft with pos\nbs,no loops or spits,minimal aspirates.Girth 21.5-22.Voiding\nand stooling.A:Adequate Weight Gain.P:Cont. to assess\ntolerance of feeds and monitor weight gain.\n\nDEV:AF soft and flat.Alert and active with cares.Sleeping\nwell b/t.At times irritable with cares,calms with\ncontainment and pacifier.MAE.Infant presently swaddled with\nnested boundaries.Temp. maintained in air controlled\nisolette.A:Appropriate for GA.P:Cont. to support growth and\ndev.\n\nParenting:Parents invested and loving.A/P:Cont. to\nupdate,support,and educate.Possible d/c to \nHospital,awaiting bed availability.\n\nBili:Infant appears jaundice but well perfused.Rebound bili\ndrawn results pnd'ing.\n\nResp:Infant remains in RA saturating 96-100%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's or\ndesats thus far.A:Stable P:Cont. to assess resp. status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-02 00:00:00.000",
"description": "Report",
"row_id": 1726948,
"text": "Neo Attending\nDay 22 now 36.3 wk\nra, clear = bs, rr 30-50s, no spells x 5 day.\n130-150s, 8/46, 62\nwt up 55 gm to 2170 gm\n24 bm or . I>130 cc/kg/day + BF.\nuop and stool wnl.\nFe\nTemp stable, alert.\n involved.\nPassed hearing , car seat,\nHad Hep B vaccination. Dr. Ped, appt on Monday .\n\nAssess: Infant is ready for discharge.\nDischarge home.\nPt evaluated and discussed with team.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-02 00:00:00.000",
"description": "Report",
"row_id": 1726949,
"text": "NURSING DISCHARGE\nInfant in RA --color pink, BS clear and equal. Warm and well perfused.\nNo murmur. Infant BF and bottle feeding --24 BM or 24. prepared formula in RN's presence to take home a supply of fortified Similac. Mom BF independently. Infant tol feeds well. Mod spit x1.\nAbd exam benign, no loops, no distention. Voiding and stooling-Gneg.\nReviewed discharge teaching. Private pedi appt scheduled for Monday.\nInfant d/c to home secured in carseat at 2:45 pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-15 00:00:00.000",
"description": "Report",
"row_id": 1726864,
"text": "Neonatology NP Note\nPE\nnested in isolette under phototherapy\nAFOF, sutures approximated\nminimal subcostal retractions in room air,lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nmarkedly jaundiced\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-15 00:00:00.000",
"description": "Report",
"row_id": 1726865,
"text": "Neonatology Attending\nDOL 4 / PMA 33-6/7 weeks\n\nIn room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 72/42 (53).\n\nBilirubin to 8.4/0.2 under single phototherapy.\n\nWt 1690 (+35) on TFI 120 cc/kg/day BM20, tolerating well. D-stick 78. Abd benign. Voiding and stooling normally.\n\nTemp stable\n\nA&P\n33-2/7 week GA with hyperbilirubinemia\n-Advance TFI to 140 cc/kg/day\n-Continue phototherapy and repeat bilirubin in 24 hours\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-15 00:00:00.000",
"description": "Report",
"row_id": 1726866,
"text": "NPN \n\n\n\n #2. TF increased to 120cc/k/d this am BM/SC 20 (36cc pg'd\nover 40min). Abd benign. Soft w/active BS. Min asp. AG\nstable. No loops. V+no stool yet today. A: Tol current\nfeeding plan P: Adv 15cc/k as tol.\n\n #3. Temp stable nested in sheepskin boundaries in air mode\nisolette. A+A w/cares. Settles w/pacifier and sleeps\nbetween. Did kangaroo care w/mom x60min. Tol well. A: AGA P:\ncont to support dev needs.\n\n #4. Mom in for all cares. Independent w/diaper and temp.\nUpdated on infant's progress at the bedside. Asking approp\nquestions. Anxious about A/B's. A: Involved, loving parents.\nP: Cont support, keep updated and educate.\n\n #5. Infant conts to be jaundiced. Remains under single\nphoto therapy. Eye in place. No stool yet today.\nRepeat bili 8.4/0.2. A: Hyperbili improved. P: D/C light\nwed. Rebound thurs am.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-16 00:00:00.000",
"description": "Report",
"row_id": 1726867,
"text": "Nursing Progress Note\n\n\n2. Feedings BM/SC 20 cals at 135ml/kg/d tolerated well\nbottle/gavage. Awake and vigouously rooting for feedings,\nbottled two feedings taking 20-31ml with good suck/swallow\ncoordination. No spits or aspirates, abdomen benign.\nVoiding qs, no stools this shift. Continue to offer bottles\nor breast when mom here when infant shows readiness to feed.\nAdvance feedings to 150ml/kg/d at next feeding.\n3. In air isolette with stable temp. Swaddled in blanket\nand sheepskin nest. Wakes for feeds. Doing well. Support.\n4. Mom . be in for family meeting today.\nConsidering transfer to .\n5. Phototherapy d/c'd at 0400. Color is jaundiced. Bili\ndrawn this AM, pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-16 00:00:00.000",
"description": "Report",
"row_id": 1726868,
"text": "Neonatology Attending\nDOL 5 / PMA 34 weeks\n\nIn room air with no distress. One bradycardia in 24 hours.\n\nNo murmur. BP 60/47 (51).\n\nOff phototherapy this morning.\n\nWt 1680 (-10) on TFI 150 cc/kg/day BMSC20, tolerating well. Abd benign. Voiding and stooling normally. Bottling partial volumes with remainder by gavage.\n\nTemp stable in weaning isolette.\n\nA&P\n33-2/7 week GA with feeding and respiratory immaturity, resolving hyperbilirubinemia\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Repeat bilirubin in 24 hours\n-Advance caloric density tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-16 00:00:00.000",
"description": "Report",
"row_id": 1726869,
"text": "SOCIAL WORK\nMet mother of these triplets today. Will follow while in NICU, plan to attend family meeting today. Mother related that there are extended family who have triplets and twins so feels support within family constellation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726945,
"text": "NPN 0700-1900\n\n\nFEN: Infant feeding on ad lib demand schedule with TF min\n130cc/kg/day BM/Similac 24. Needs 46cc Q4hrs. Infant took\n55cc at 0700 and 75cc at 1100 today. She is eager and well\ncoordinated w/her playtex bottle. Abdomen exam is benign.\nVoiding/stooling qs. Iron and Desitin. 2 small spits. P:\nContinue to monitor and support FEN status.\n\nDEV/Discharge: Maintaining stable temps swaddled in OAC. A&A\nw/her cares and sleeps well bwtn. Brings hands to face to\ncomfort self and loves to suck on pacifier. AFSF. MAEW. AGA.\nPassed hearing screen this shift. Needs to have Car Seat\ntest this evening. Has received her Hep B vaccine. Mom to\nmake Pedi appt today, left message, awaiting response. Med\n with Iron to be reinforced for second time today.\n , case mgr, working on setting up VNA services\nto home in , MA. Mom made 24 similac\nrecipe at bedside today with this RN. All other elements of\ndischarge planning/teaching are in place for possible d/c\ntomorrow . P: Continue to monitor for dev milestones.\nContinue with discharge planning/teaching.\n\n: Mom here at bedside for entire shift. Updated at\nbedside throughout day. Mom asking lots of appropriate\nquestions, preparing to take this home tomorrow.\nMom able to care for and feed infants independently. P:\nContinue to update and support NICU family.\n\nA's and B's: No spells thus far this shift. Infant is now\nDay for brady countdown. P: Continue to monitor.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726946,
"text": "Case Management Note\nReceived call back from () and there is NO MCH availability for area for next week. Mom is aware and prepared for no VNA. She states she has a friend who is a MCH nurse and will have her stop over. Mom is working on setting up Pedi appts for triplets. All aware of no VNA. I will follow up next week to see if anything has changed w/ availablity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-02 00:00:00.000",
"description": "Report",
"row_id": 1726947,
"text": "NPN 7p-7a\n\n\nFEN - Wt 2170g up 55g. TF min 130cc/kg/d of BM/ 24 .\nYesterday infant took 121cc/kg plus BFx1. Infant tolerating\nfeeds well with no spits thus far. Abd is soft, round, with\n+BS and no visible loops. V&S. Infant bottles well.\nContinue to monitor and support nutritional status.\n\nDEV - Temps remain stable swaddled in an OAC. A&A with\ncares and settles well in between. Wakes for all feeds.\nBrings hands to face and sucks on pacifier for comfort.\nInfant to have CST tonight. Continue to support\ndevelopmental growth.\n\nPAR - Mom called x1, updated by RN. Continue to support.\nContinue to prepare for D/C.\n\nA/Bs - No spells noted thus far. Day 5 of 5. Continue to\nmonitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-19 00:00:00.000",
"description": "Report",
"row_id": 1726885,
"text": "Neonatology SNNP note\nPE:\n\nNEURO: Infant swaddle in open crib, AFOS, sutures sl overlap, MAE x4,\n\nCARDIAC: Color pink, no audible murmur, RRR, pulses palp = x4, cap refill < 3 secs.\n\nRESP: Infant in R/A, breath sounds = clear with mild subcostal retractions, RR 30-50's.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam, stooling.\n\nGU: voiding in diapers, normal female genitalia\n\n SNNP\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-20 00:00:00.000",
"description": "Report",
"row_id": 1726886,
"text": "NPN:\n\nRESP: Sats 97-100% in RA. RR=40-50s with SC retraction. BBS =/clear. No A&Bs thus far tonight; none over past 24 h.\n\nCV: No murmur. HR=140-160s. BP=72/41 (52). Color pink w/good perfusion.\n\nFEN: Wt=1790g (+ 25g). TF=150cc/kg/d; 45cc BM/SC-24 q 4 h via PO/PG. Alternate bottle/gavage. Bottled slowly w/good coordination x 1 for 33cc. Small spit x 1; minimal residuals. Abd benign. Voiding qs; green stool. FeS04.\n\nG&D: CGA=34 wk. Temp stable in crib. Not waking for fdgs. Active and alert w/cares. Perianal area sl reddened -> Desitin applied w/each diaper change. Swaddled and resting well.\n\nSOCIAL: Mother called x 1 for update. She plans to be here for 0800 feeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-20 00:00:00.000",
"description": "Report",
"row_id": 1726887,
"text": "Neonatology Attending Note\nDay 9, PMA 34 4\n\nRA. RR40-50s. Baseline mild sc rtxns. No murmur. HR 130-150s. BP 72/41, 52.\n\nWt 1790, up 25. TF 150 BM24/SC24. PO/PG. Tol well exc for mild spits. Improved with longer pg infusion. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nGrowing preterm infant with immature feeding skills. Cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-20 00:00:00.000",
"description": "Report",
"row_id": 1726888,
"text": "Nursing PRogress Note\n\n\n#2 O: TF 150cc/k/d BM24/SSC24; alt po/pg feeds. fair latch\non for mom this morning, sl. better w/bottle this afternoon.\ntol pg well over 75mins w/tiny spits at end. abd benign, vdg\nand stooling . Ferinsol as ordered. A: learning to eat P:\npresent care.\n#3 O: see above re: feeds, temp stable swaddled in open\ncrib. alert w/cares, pacifier for pg feeds and to settle. A:\nAGA P: present care.\n#4 O: here for first 2 cares. independent, loving\nw/babies. updated. P: present care. transfer to \nHospital when beds available.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-20 00:00:00.000",
"description": "Report",
"row_id": 1726889,
"text": "NNP Physical Exam\nAsleep. AFOF with good tone. Breath sounds clear and equal on room air with slight retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with active BS, no masses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-21 00:00:00.000",
"description": "Report",
"row_id": 1726890,
"text": "Nursing NICU Note\n\n\n2. F/N. O/Tf remain at 150cc/k/d of BM24/SC sim24 PO/pngt.\nPlease refer to flowsheet for examinations of pt from this\nshift. Voiding. Stooling. No spits noted thus far. A/Appears\nto be tolerating present feeding regimen. P/cont. to monitor\nfor s/s of feeding intolerance.\n\n3. Dev. O/Temp stable in crib. Occasionally wakes for feeds.\nAwake and alert at care times and sleeping well in between.\n on pacifier. A/Alt. in g/d. P/Cont.\nto support pt's growth and dev. needs.\n\n4. . O/MOther called and wad updated on pt's status\nand plan of care. A/ are known to be involved in pt's\ncare. P/cont. to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-14 00:00:00.000",
"description": "Report",
"row_id": 1726862,
"text": "Nursing Progress Note\n\n5 Hyperbili\n\n#2- O/A: TF goal increased to 120/kilo. Enteral feeds\nincreased this shift to 90/kilo of BM/SC 20cal- 27cc q4h\ngavaged over 30 min. IVF dc'd d/t PIV puffy in appearance,\nteam aware. Abdomen benign, no spits or aspirates, AG\n20.5-21cm. Voiding with each diaper and passing trace to\nlarge mec. stools. P: Cont. to increase enteral feeds by\n15/kilo at 8 + , monitor tolerance and wt. ,\n check d/s with next feed.\n\n#3- O/A: Nested in servo isolette with stable temps. Alert\nand active with cares, irritable at times with cares and in\nbetween. Brings hands to face and sucks on pacifier.\nKangarooed x 1hr and tolerated well. Fontanels soft and\nflat, MAEW. P: Cont. to support developmental needs of\ninfant.\n\n#4- O/A: Mom up for all cares thus far, independent with\ndiaper change and temp taking. Asking approriate questions,\nupdated at bedside by this RN. Mom kangarooed with infant x1\nhr. Dad up briefly with relatives, updated at bedside as\nwell by this RN. P: Cont. to support and educate family,\nschedule family mtg.\n\n#5- O/A: Infant under single light phototherapy with eye\nshield in place at all times for a bili this am of 10.4/0.2.\nInfant ruddy-jaundiced appearing. P: Check bili in am.\n\n\nREVISIONS TO PATHWAY:\n\n 5 Hyperbili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-07-15 00:00:00.000",
"description": "Report",
"row_id": 1726863,
"text": "Nursing Progress Note\n\n\n2. Feedings advanced to 105ml/kg/d at this shift.\nTolerated all feeds of BM/SC20 well by gavage without spits\nor aspirates. Infant rooting and sucking vigorously on\npacifier: offered mom's mild from bottle taking 10ml quickly\nwith good suck/swallow coordination. Mom up at , infant\nput to breast (awake and crying) and latched on and sucked\nbriefly. Abdman o=soft with good bowel sounds, stable\ngirth. One mec stool, voiding qs. To advance to full\nvolume at 120ml/kg/s at 0800 today.\n3. Alert and active, sucking on pacifier. Slept well\nbetween feeds. Rooting. Nested on sheepskin. AGA.\nSupport G&D.\n4. Parents up at to bring up milk but stayed and\nnursed as she was crying and not consoling easily.\nVery happy to nurse baby, had not put babies to breast\nbefore. Loving parents. Allow parents to put infants to\nbreast once/shift or more if infants behavior warrants it.\nSupport and teach.\n5. Under single spotlight phototherapy. Bili drawn at\n0400, pending. Check results of bili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-01 00:00:00.000",
"description": "Report",
"row_id": 1726942,
"text": "NNP On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: alert infant in open crib\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nCHest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nABD; soft; no masses; + bowel sounds; cord healed\nExt: moivng all\nNeuro: alert; + suck; + grasps; rooting\n"
}
] |
|
20,977 | 100,538 | The patient was taken to the Operating Room for a coronary artery bypass graft times three, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to posterior descending coronary artery, and saphenous vein graft to obtuse marginal. Postoperatively, the patient did well. Chest tube was extubated promptly in the Intensive Care Unit. Chest tube was taken out on postop day number one. The patient was subsequently transferred to the floor on postop day number one. Upon arriving on the floor the patient was able to work with physical therapy to ambulate. Upon discharge the patient was able to ambulate approximately 300 feet with assistance. The patient will be discharged to rehab facility on . | toradol started for comfort & resp. ALL IS WELL A THIS TIME. I IMAGINE WE WILL WEAN THE FIO2 AS TOLERATED. Hemodynamics stable. Pt delined without problem. remains fully lined with good co/ci. care. compliance.see flow sheet. Also on Toradol. RESP CARE NOTE: PT RECEIVED INTUBATED, OET IS SECURE AND PATENT. pt. improved hemodynamics after volume,levo & epi weaned off. PT HAS BILATERAL BREATH SOUNDS. Transfer noteNeurologically pt is intact, but sleepy at times. a paced->sr/st after waking. extubated w/o incident.sleepy & needs encouragement to perform resp. h.o aware of hct this am no rx at this time. PT IS ON VENTILATION, CURRNT SETTINGS ARE: SIMV 700X12, PEEP 5, PSV 5, AND 100%. Lung CTA Bilatterally but diminished. U/O qs. stable remains off all gtts. Toradol and MS04 for pain with effect. GENERAL VENTILATOR MANAGEMENT WILL BE GIVEN T/O THE SHIFT AS WELL AS SUCTIONING WHEN NEEDED. A paced rhythmBorderline low voltage in frontal leadsQT long for rateDiffuse ST-T abnormalitiesConsistent with ischemiaSince last ECG, atrial pacing noted; T wave changes more pronounced inpercordial leads, but less pronounced laterally plan to deline, advance activity, transfer to 6. turns well in bed. Doppler pulses in feet. Rt femoral sheath dc'd at 9030 by PA. No hematoma or bleeding noted. medicated for pain with IV ms04 during the night with good effect. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2176-11-05 00:00:00.000",
"description": "Report",
"row_id": 1537658,
"text": "RESP CARE NOTE: PT RECEIVED INTUBATED, OET IS SECURE AND PATENT. PT IS ON VENTILATION, CURRNT SETTINGS ARE: SIMV 700X12, PEEP 5, PSV 5, AND 100%. I IMAGINE WE WILL WEAN THE FIO2 AS TOLERATED. PT HAS BILATERAL BREATH SOUNDS. GENERAL VENTILATOR MANAGEMENT WILL BE GIVEN T/O THE SHIFT AS WELL AS SUCTIONING WHEN NEEDED. ALL IS WELL A THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-05 00:00:00.000",
"description": "Report",
"row_id": 1537659,
"text": "improved hemodynamics after volume,levo & epi weaned off. a paced->sr/st after waking. extubated w/o incident.sleepy & needs encouragement to perform resp. care. toradol started for comfort & resp. compliance.see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-06 00:00:00.000",
"description": "Report",
"row_id": 1537660,
"text": "pt. stable remains off all gtts. medicated for pain with IV ms04 during the night with good effect. Also on Toradol. turns well in bed. h.o aware of hct this am no rx at this time. remains fully lined with good co/ci. plan to deline, advance activity, transfer to 6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-06 00:00:00.000",
"description": "Report",
"row_id": 1537661,
"text": "Transfer note\nNeurologically pt is intact, but sleepy at times. Hemodynamics stable. Lung CTA Bilatterally but diminished. U/O qs. Hypoactive bowel sounds, tolerating po ice chips. Pt delined without problem. Rt femoral sheath dc'd at 9030 by PA. No hematoma or bleeding noted. Doppler pulses in feet. Toradol and MS04 for pain with effect.\n"
},
{
"category": "ECG",
"chartdate": "2176-11-05 00:00:00.000",
"description": "Report",
"row_id": 309611,
"text": "A paced rhythm\nBorderline low voltage in frontal leads\nQT long for rate\nDiffuse ST-T abnormalities\nConsistent with ischemia\nSince last ECG, atrial pacing noted; T wave changes more pronounced in\npercordial leads, but less pronounced laterally\n\n"
}
] |
26,766 | 191,216 | She was admitted to cardiac surgery. She was seen by cardiology and was taken to the cath lab where she underwent pericardial drain for 610 ml of bloody fluid. Repeat echocardiogram the following day showed no effusion and her pericardial drain was discontinued. She was transferred to the floor on post-procedure day 1. Repeat echocardiogram on showed small pericardial effusions and she was ready for discharge home. | Mild tomoderate (+) aortic regurgitation is seen. care pericardial drg per protocol. No PS.Physiologic PR.PERICARDIUM: Small pericardial effusion. Indeterminate PA systolicpressure.PERICARDIUM: Moderate to large pericardial effusion. The effusion appearsloculated, subtending the right atrial free wall. RV diastolic collapse, c/w impaired fillling/tamponadephysiology.Conclusions:The left atrium is normal in size. The aortic arch is mildlydilated. There are noechocardiographic signs of tamponade.Compared with the findings of the prior study (images reviewed) of , the pericardial effusion has been drained; cardiac tamponade is nolonger evident. No RVdiastolic collapse.Conclusions:The left atrium is moderately dilated. There is a small pericardial effusion. Mildly dilated ascending aorta. Mild mitralannular calcification. Trivial mitralregurgitation is seen. Normaltricuspid valve supporting structures. Noechocardiographic signs of tamponade. Noechocardiographic signs of tamponade. The mitral valve appears structurally normal withtrivial mitral regurgitation. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No atheroma in ascending aorta.Mildly dilated aortic arch. No right ventricular diastolic collapse is seen.IMPRESSION: small pericardial effusion that overlies the right atrium andright ventricular free wall. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No right atrial diastolic collapse isseen. There is asmall pericardial effusion. Theeffusion appears circumferential. There is right ventricular diastolic collapse,consistent with impaired fillling/tamponade physiology.IMPRESSION: moderate-to-large circumferential pericardial effusion; cardiactamponade Normalmitral valve supporting structures. Normal LV inflow pattern for age.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There are noechocardiographic signs of tamponade. The effusion appears loculated. Effusion is loculated. Effusion is loculated. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. There is sustained right atrial collapse,consistent with low filling pressures or cardiac tamponade. The ascending aorta is mildly dilated. Focal calcifications inaortic root. Mild thickening of mitral valve chordae. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. TamponadeHeight: (in) 64Weight (lb): 138BSA (m2): 1.67 m2BP (mm Hg): 130/90HR (bpm): 76Status: InpatientDate/Time: at 16:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). TamponadeHeight: (in) 64Weight (lb): 138BSA (m2): 1.67 m2BP (mm Hg): 106/54Status: InpatientDate/Time: at 15:14Test: Portable TTE (Focused views)Doppler: Limited Doppler and no color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Small pericardial effusion. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Normal aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 64Weight (lb): 138BSA (m2): 1.67 m2BP (mm Hg): 108/62HR (bpm): 70Status: InpatientDate/Time: at 11:03Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Right ventricular chamber size and free wall motionare normal. Atelectasis left base. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No RA diastolic collapse. Cardiac outline does appear somewhat more globular and this is confirmed on the lateral film. NSR, no vea. denies cp/sob. Effusion circumferential.Sustained RA diastolic collapse, c/w low filling pressures or early tamponade. Cardiac size is somewhat enlarged but does not have a pericardial effusion contour. No echo evidence of tamponade.Compared with the prior study (images reviewed) of , the effusion isslightly smaller. VS perflow sheet. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%) There is noventricular septal defect. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation. Focal calcifications in aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). skin w/d. There is a moderate to large sized pericardial effusion. There is leftatrial diastolic collapse. The pulmonary artery systolic pressure could not bedetermined. No significant respiratory variation inmitral/tricuspid valve flows.Conclusions:Left ventricular wall thickness, cavity size and regional/global systolicfunction are normal (LVEF >55%) Right ventricular chamber size and free wallmotion are normal. No AS. No AS. Calcified tipsof papillary muscles. There are focal calcifications in the aortic arch. IMPRESSION: A catheter in place. belly soft. No resting LVOT gradient. 3+pp, no edema.Ls cta, RA sat >94%. monitor cardiac. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%) Rightventricular chamber size and free wall motion are normal. No MVP. There is no mitral valve prolapse. There is no mitral valve prolapse. map>60, pericardial drg site cdi-bag to gravity-serosang drg-care per protocol. No TS. Admitted for pericardial drg.Recieve patient from Cath lab via bed, s/p pericardial tap 510cc removed and pericardial drain sutured to chest, drainage bag to gravity.Pt a+ox3, pleasant, no deficit. CHEST This film was taken in the PA as opposed to the comparison film which was taken AP. collapse. Cardiomegaly. No MS. The tip of the catheter, which runs from below up upwards presumably in the pericardial space lies in the region of the ascending aorta. Atelectasis at the left base is present. IMPRESSION: Change in shape of heart with a somewhat globular appearance which may represent a recurrence of the effusion. No failure is present, atelectasis is seen at both bases. control pain. support 11:42 AM CHEST (PA & LAT) Clip # Reason: evaluate for ? effusion FINAL REPORT CLINICAL HISTORY: Patient with pericardial window, evaluate for effusion. | 7 | [
{
"category": "Radiology",
"chartdate": "2182-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1010737,
"text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pericardial effusion drainage by catheter\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with\n REASON FOR THIS EXAMINATION:\n pericardial effusion drainage by catheter\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post drainage of pericardial effusion by catheter.\n\n CHEST: There are no previous chest x-rays available for comparison.\n\n Cardiac size is somewhat enlarged but does not have a pericardial effusion\n contour. Atelectasis at the left base is present. The tip of the catheter,\n which runs from below up upwards presumably in the pericardial space lies in\n the region of the ascending aorta.\n\n IMPRESSION: A catheter in place. Cardiomegaly. Atelectasis left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1010841,
"text": " 11:42 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for ? effusion\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p pericardial window\n REASON FOR THIS EXAMINATION:\n evaluate for ? effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Patient with pericardial window, evaluate for effusion.\n\n CHEST\n\n This film was taken in the PA as opposed to the comparison film which was\n taken AP. Cardiac outline does appear somewhat more globular and this is\n confirmed on the lateral film. Return of the pericardial effusion is\n therefore a possibility and cardiac ultrasound is recommended.\n\n No failure is present, atelectasis is seen at both bases.\n\n IMPRESSION: Change in shape of heart with a somewhat globular appearance\n which may represent a recurrence of the effusion.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-13 00:00:00.000",
"description": "Report",
"row_id": 1612811,
"text": "Shift Cover:2300-0700\nNeuro:Alert/oriented x3,MAE,PERRL.Answers all questions appropriately and follows commands.\nCV:NSR 80''s,no vea.Map>60->80,cuff BP 108-129/67-79.Palpable DP/PT pulses.Pneuboots on LE biltaerally\nResp:RR 9-20 unlabored,lungs CTA biaterally,O2 sat>94 on RA.\nGU/GI:patient voided post procedure.She vomited 100ml taking percocet tabs on empty stomach tx IV Zofran-> relieved c/o nausea/vomiting.Abdomen soft,nontender,nondistended and positive bowel sounds.Tolerating clear liquids well.\nPain:Pain at pericardial drain site managed well with 2 percocet tabs.\nSkin/wound:Pericardial drain is patent and to gravity drainage bag-> moderate amounts serosanquious drainage with small thready clots.Dsd dressing is clean/dry/intact,care of pericardial drain per protocal.\nID:Afebrile.\nEndo:FS tx per protocal\nPlan:Monitor for cardiac tamponade. Pericardial drainage x24 hours,repeat echo in am and Monday if effusion resolved ?d/c drain.Advance diet as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-13 00:00:00.000",
"description": "Report",
"row_id": 1612810,
"text": "Pt w/ pmh chest trauma in ->CT scan showed pericardial effusion->have serial echos/repeat CT scan show increase pericardial effusion. Admitted for pericardial drg.\nRecieve patient from Cath lab via bed, s/p pericardial tap 510cc removed and pericardial drain sutured to chest, drainage bag to gravity.\nPt a+ox3, pleasant, no deficit. conversing. NSR, no vea. VS perflow sheet. map>60, pericardial drg site cdi-bag to gravity-serosang drg-care per protocol. skin w/d. 3+pp, no edema.\nLs cta, RA sat >94%. denies cp/sob. belly soft. tol cl liquid.\ngave morphine sulfate x1 dose for pain at pericardial drg site ->started po percocet. spouse at bedside->infor and support given.\n\na/p: eval by dr at bedside. care pericardial drg per protocol. monitor cardiac. control pain. support\n"
},
{
"category": "Echo",
"chartdate": "2182-04-15 00:00:00.000",
"description": "Report",
"row_id": 85187,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 64\nWeight (lb): 138\nBSA (m2): 1.67 m2\nBP (mm Hg): 108/62\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:03\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. Effusion is loculated. No\nechocardiographic signs of tamponade. No RA diastolic collapse. No RV\ndiastolic collapse.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no mitral valve prolapse. There is a\nsmall pericardial effusion. The effusion appears loculated. There are no\nechocardiographic signs of tamponade. No right atrial diastolic collapse is\nseen. No right ventricular diastolic collapse is seen.\n\nIMPRESSION: small pericardial effusion that overlies the right atrium and\nright ventricular free wall. No echo evidence of tamponade.\n\nCompared with the prior study (images reviewed) of , the effusion is\nslightly smaller.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-04-13 00:00:00.000",
"description": "Report",
"row_id": 85188,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tamponade\nHeight: (in) 64\nWeight (lb): 138\nBSA (m2): 1.67 m2\nBP (mm Hg): 106/54\nStatus: Inpatient\nDate/Time: at 15:14\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small pericardial effusion. Effusion is loculated. No\nechocardiographic signs of tamponade. No significant respiratory variation in\nmitral/tricuspid valve flows.\n\nConclusions:\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%) Right ventricular chamber size and free wall\nmotion are normal. There is a small pericardial effusion. The effusion appears\nloculated, subtending the right atrial free wall. There are no\nechocardiographic signs of tamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the pericardial effusion has been drained; cardiac tamponade is no\nlonger evident.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2182-04-12 00:00:00.000",
"description": "Report",
"row_id": 85189,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tamponade\nHeight: (in) 64\nWeight (lb): 138\nBSA (m2): 1.67 m2\nBP (mm Hg): 130/90\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 16:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. No atheroma in ascending aorta.\nMildly dilated aortic arch. Focal calcifications in aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Indeterminate PA systolic\npressure.\n\nPERICARDIUM: Moderate to large pericardial effusion. Effusion circumferential.\nSustained RA diastolic collapse, c/w low filling pressures or early tamponade.\n collapse. RV diastolic collapse, c/w impaired fillling/tamponade\nphysiology.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. The ascending aorta is mildly dilated. The aortic arch is mildly\ndilated. There are focal calcifications in the aortic arch. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Mild to\nmoderate (+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Trivial mitral\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined. There is a moderate to large sized pericardial effusion. The\neffusion appears circumferential. There is sustained right atrial collapse,\nconsistent with low filling pressures or cardiac tamponade. There is left\natrial diastolic collapse. There is right ventricular diastolic collapse,\nconsistent with impaired fillling/tamponade physiology.\n\nIMPRESSION: moderate-to-large circumferential pericardial effusion; cardiac\ntamponade\n\n\n"
}
] |
27,632 | 183,440 | 1. Respiratory: was noted to have several episodes of cyanosis with oxygen desaturations to 60%. A chest x-ray was within normal limits. In between his episodes of desaturation, he was in room air with oxygen saturations greater than 95%.He remained in hospital for 5 days free of any episodes. 2. Cardiovascular: Due to the unknown etiology of the cyanotic episodes, had an initial basic cardiac evaluation. A chest x-ray showed normal heart size and pulmonary blood flow. EKG was notable for a QRS axis of 160 degrees with normal intervals. He had four limb blood pressures that were within normal limits. On exam, he had no murmur and had 2+ femoral pulses. Baseline heart rates of 100 to 150 beats per minute with a blood pressure of 78/41, mean pressure of 55 mm of mercury. 3. Fluids, electrolytes, nutrition: Baby breast fed well and was continued on breast feeding ad lib. Supplemental IV fluid was started and discontinued on day of life 4. Serum electrolytes on admission to the neonatal intensive care unit had a sodium of 140 mEq per liter, potassium 3.4 mEq per liter, chloride 104 mEq per liter, total carbon dioxide of 23. He has been feeding well at breast and bottle with a current wt at 3975 grams. 4. Infectious disease: Due to the unknown etiology of the cyanotic episodes, was evaluated for sepsis upon admission to the neonatal intensive care unit. A white blood cell count was 13,300 with an unremarkable differential. A blood culture was obtained. A lumbar puncture was done, showing 17 red blood cells, 6 white blood cells, normal glucose and protein and a negative gram stain. Intravenous ampicillin and gentamicin were started after the cultures were obtained. Blood culture remained no growth at 48 hours and the antibiotics were discontinued on . 5. Hematology: Hematocrit on admission to the neonatal intensive care unit was 56.3%. 6. Gastrointestinal: Serum bilirubin on day of life 2 was 2.9 mg per dl/0.3 mg per dl direct. He never developed any significant clinical jaundice. 7. Neurology: Except for the cyanotic episodes, maintained a normal neurological exam. 8. Sensory: Audiology: Hearing screening not yet been performed. Recommended prior to discharge. 9. Hepatitis B immunization given on . 10. Circumcision done on . | Abd benign, V/S, stooling. 1 desat to 53requiring BBO2 (pt had been sucking pacifier vigorously).Stable. EKG done this shift, temp99.4-98.9 on warmer, temp decreased.AP:stable, continue tomonitor closely.REVISIONS TO PATHWAY: 1 RESP; added Start date: 2 FEN; added Start date: 3 Infant with Potential Sepsis; added Start date: Baby remains on TF 60cc/kg/d D10W via piv. See discharge summary.F/U appt with pedi made.VNA to come day post discharge. Breath soundsclear and equal, No GFR. Admission NoteOb-Delivering Ob-Pedi-- Covering Pedi- Dr. Abd soft, active bs, voiding, stooling(transitional). Will obtain a CXR on admissionCV-pre and post ductal sat are okay as are the 4 extremity BP. Infant is a&a withcares. Abd benign, noloops, +BS. P: Spellsresolving, no resp distress.2. P: Contto support growth & nutrition.G&D: Temps stable, swaddled in OAC. P: check bld cx. LS clear/equal, no increased WOB. BP stable. Continue tomonitor respiratory status.#2 FEN: TF min 100cc/kg/day BM/SIM20. A:stable in rm air, no spells P: monitor#2 cont with IVF D10W with NaCl and KCl inf well until 06:30when needed restart for inf. tomonitor po intake. VNA scheduled for Sat, pedi appt on Mon. P: Cont tomonitor for A's & B's.FEN: Wt 3975g (up 165g). Circumcised and site pink and swollon mildly. Infant noted to have further desats to 60's/80's when not sucking on pacifier. in this AM, d/c planning/teaching complete. Updated at bedside by RN. NPNOTeI have examined the , i agree with above note by PCA. Some resolution of desaturation episodes noted. A:Gaining weight, Po feeding adequate amts. There is normal abdominal ascites. lytespending. BSC and equal on RA with no increased resp effort. A:Stable resp status. tomonitor. #3 Sepsis: pt remains on IV ampi/gent.Blood culture ngtd. No spells so farthis shift.P:Cont to monitor for A/B's#2FENO:Cont on BM/Sim20, taking 110-120cc's per feed. #2 FEN: ad lib demand BF/BM20. remains in for antibiotics. cont meds. Cardiac evaluation normal. Infant voiding, stooling (heme neg). Nose suctioned and patent. He was noted to have dusky spell to 60 while sucking on pacifier/BBO2 given. Dr. aware. LS cl/=. Voiding and stooling heme neg. baby remains in RA with O2 sats >95%. Seeflowsheet. Abdomen soft and round, active bowelsounds. SaO2 97-100. P: Monitor, feedas demanded.4. Testes descended. O: TF at 100cc/k/d min intake, PO ad lib as demanded.Taking 120-130cc of EBM Q2-3 hr. Pt. abd benign, soft, +BS, no loopsor distention. AP:stable, continue to offer BF as tolerated, lytespending, continue to monitor closely.3. Nursing Progress Note#1 Resp: RA, 20-40, lungs clear/equal. AGA. O: BS are cl= to bases, no GFR. H.L. continue on antibiotics. to support/update. Small void this shift withstool. Cont. Cont. Cont. Cont. NICU NPN1. Neonatology AttendingDay 3Remains in RA. Wakingevery 2-3hrs for feeds. Ruling out on antibiotics. Temp stable in OAC, swaddled. Otherwise will keep NPO on IVFID-will plan to obtain LP. Neonatology NNP on-call procedure noteProcedure Lumbar puncture indications r/o meningitis, infant with dusky episodes.Time out observed. 0000-0700 PCA NOTEG&D: Temps stable, swaddled in OAC. 0000-0700 PCA NOTEG&D: Temps stable, swaddled in OAC. for Mon/Tues at /BUR with Dr .VNA set upHome in am if no bradys or desats. Continueto support nutrition needs.Parenting: in early this shift. pt remains in RA, breathing 30-60's, lung sounds cl/=, O2Sats remain stable at 93-100%, no g/f/r noted, pt appearscomfortable in respiratory effort, cont to monitor pt'srespiratory status & intervene if necessary2. NPN: Mom in today and was updated on infant's status at bedside. Baby was treated with supplemental O2 with episodes.RR - in RA, RR 30-40s, no retractions noted.O2 sats - 95-100% in RA.CVS - HR - 110-140sBPs - 4 ext wnl BP 67/36 48Wt. P: Cont to monitor resp status, D2/5 for spellcountdown.#2 FEN: Infant ad lib breast and bottlefeeding BM20, min100cc/kg. Voiding and stooling normally.Tmemp stable in open crib.A&PFull term infant with intermittent (infrequent) cyanosis. P: Cont to monitor FENstatus.#3 ID: Temp stable, infant is acting appropriately. Discharge PlanningVNA referral called to (T:, F:). /NEON DOL 7 CGA 41 RA, RR30-60 HR 130-160 no episodes of A/B ,Wt 3810 down 10 , took 178 cc/kgSpoke with mom, she will make pedi appt. Abd benign, V/S, stooling. Abd benign, V/S, stooling. Ad-lib demand, waking q2.5-3hrs.Bottled 95, 120, and 130cc. PCA Progress Note 2300-700RESP: Resting in RA. P: Continue to monitor for desats,spells, and increased work of breathing.#2 FEN: TF's remain 60 cc/kg/day, BM 20, ad lib demand.Infant has bottled 65-90 cc thus far plus breastfeeding.Total intake in 24 hours= 92 cc/kg plus breastfeeding.Abdomen is soft, active bowel sounds. Well-perfused.Remains on amp/gent.Wt 3650 on min TFI 60 ml/kg/day with intake 92 ml/kg/day in addition to breastfeeding over the past 24 hours. Infant is a&a with have examined infant and agree with above note & flowsheet documentation by PCA.es. Infant is a&a with have examined infant and agree with above note & flowsheet documentation by PCA.es. 3705gm birthweightBaby doing small amounts of breastfeeding.No urine output in NICU.DS 70On 60ml/kg/d of D10W.ID - cc - wbc 13,300 diff 58P 28L Hct 56%LP doneCSF 6 wbc 17rbcsAssessment/plan:Term infant with intermittent episodes of desaturation.Will complete cardiac work-up as well as continue close monitoring.Antibiotics to continue.Will continue with breastfeeding only. NPN Days3 Infant with Potential Sepsis4 Alt in Parenting#1 Resp: RA, 30-40's, c/=. Updated on infant's condition and plan of care by this RN. Updated on infant's condition and plan of care by this RN. TF remains a min100=BM/Sim20= 64cc. Abxsd/c'd for bld cx NTD. Day on a spell countdown.Continue to monitor respiratory status.FEN: Current weight 3810g (-10g). Mom given 1cc syringes for Fe administration. pt remains in RA, breathing 20-50's, lung sounds cl/=, O2Sats 97-100%, pt has had no desats so far this shift, nog/f/r noted, pt appears comfortable in respiratory effort,cont to monitor pt's respiratory effort & intervene ifnecessary2. The corrected number is now in the chart. A: Toleratingfeeds well. NPN Days#1 Resp: RA, 30-50's, c/=, no WOB. | 35 | [
{
"category": "Radiology",
"chartdate": "2122-06-20 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 965554,
"text": " 6:37 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: cardiac size and shape\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with dusky episodes\n REASON FOR THIS EXAMINATION:\n cardiac size and shape\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP VIEW OF THE CHEST\n\n Clinical history of dusky episode.\n\n There are 12 pairs of ossified ribs. Other bones look normal. Cardiac size\n is normal for age. Vascular pattern in the lungs is likewise normal. Aortic\n arch is likely left sided. Tracheal air shadow is poorly delineated on this\n single film. There is normal abdominal ascites.\n\n Single AP view is normal although tracheal air shadow is not well delineated.\n If the child has further problems, then AP with lateral film would be\n reasonable. There are no plain film findings of congenital heart disease\n (sensitivity of plain films for all types of heart diseases is approximately\n 75%).\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-20 00:00:00.000",
"description": "Report",
"row_id": 2044245,
"text": "Nursing note\n\n1 RESP\n2 FEN\n3 Infant with Potential Sepsis\n\n1. baby remains in RA with O2 sats >95%. Breath sounds\nclear and equal, No GFR. No spells or desats noted.\nHyperoxia test done. AP:stable in room air without spells\nthis shift.\n2. Baby remains on TF 60cc/kg/d D10W via piv. Baby also\nbreastfeeding every 3-4 hours. Small void this shift with\nstool. Dr. aware. Weight 3475 grams. lytes\npending. AP:stable, continue to offer BF as tolerated, lytes\npending, continue to monitor closely.\n3. continue on antibiotics. EKG done this shift, temp\n99.4-98.9 on warmer, temp decreased.AP:stable, continue to\nmonitor closely.\n\nREVISIONS TO PATHWAY:\n\n 1 RESP; added\n Start date: \n 2 FEN; added\n Start date: \n 3 Infant with Potential Sepsis; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-20 00:00:00.000",
"description": "Report",
"row_id": 2044246,
"text": "Respiratory Care\nPerformed hyperoxia test as part of cardiac workup...arterial blood gas stick was unsucessful. Pt. reached 319, attending/NNPs notified.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-21 00:00:00.000",
"description": "Report",
"row_id": 2044247,
"text": "NNP Physical Exam\nAwake and alert in open crib. AFOF. Vigerously sucking on pacifier. BSC and equal on RA with no increased resp effort. No audible murmur, well perfused wiht normal pulses. ABD soft and rounded with active BS, no masses. Circumcised and site pink and swollon mildly. Testes descended.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-21 00:00:00.000",
"description": "Report",
"row_id": 2044248,
"text": "NPN 7p-7a\n\n\n#1 has remained in rm air tonight with no desats,\ncolor pink, LS clear and equal, no GFR. SaO2 97-100. A:\nstable in rm air, no spells P: monitor\n#2 cont with IVF D10W with NaCl and KCl inf well until 06:30\nwhen needed restart for inf. abd benign, soft, +BS, no loops\nor distention. vdg qs, no stool. weight unchanged. to breast\nfeed with mom x's 3, difficult to get to latch but once on\nsucks well for 20-30 min. bottled twice for 70 and 45cc. A:\nfeeding well P: DC IVF, cont po as able.\n#3 infant with no S/S sepsis, antibiotics cont as ordered.\nA: stable on meds. P: check bld cx. cont meds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-21 00:00:00.000",
"description": "Report",
"row_id": 2044249,
"text": "Neonatology Attending\n\nDay 3\n\nRemains in RA. RR 30-40s. Had desaturation while sucking on pacifier to 50's this morning. BP mean 60. Cardiac evaluation normal. On ampicillin and gentamicin. Blood culture no growth. Weight 3605g. All po feeds now. Lytes yesterday 140/3.4/104/23 Ca 9.1. Stable temperature in open crib.\n\nDoing well overall. Some resolution of desaturation episodes noted. Etiology unclear. Ruling out on antibiotics. Feeding well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-21 00:00:00.000",
"description": "Report",
"row_id": 2044250,
"text": "Nursing Progress Note\n\n\n#1 Resp: RA, 20-40, lungs clear/equal. 1 desat to 53\nrequiring BBO2 (pt had been sucking pacifier vigorously).\nStable. Cont. to monitor. #2 FEN: ad lib demand BF/BM20. See\nflowsheet. Abd soft, active bs, voiding, stooling\n(transitional). H.L. remains in for antibiotics. Cont. to\nmonitor po intake. #3 Sepsis: pt remains on IV ampi/gent.\nBlood culture ngtd. No overt s/s sepsis. Stable. Cont. to\nmonitor. Parents: both in for several hours, mom put baby to\nbreast, asking appropriate questions. Will return later\nthis evening to visit. Cont. to support/update. See\nflowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044264,
"text": "PCA Progress Note \n\n\n#1 RESP: Infant in room air breathing 40-50s with O2 sats\n>96%. LS clear/equal, no increased WOB. No spells so far\nthis shift. Breathing comfortably in room air. Continue to\nmonitor respiratory status.\n\n#2 FEN: TF min 100cc/kg/day BM/SIM20. Ad lib demand infant\nbreast feeding as well as taking 100cc with feeds.\nCoordinated with both bottle and breast. Abd benign, no\nloops, +BS. Voiding and stooling heme neg. No spits.\nTolerating feeds. Continue to follow nutritional plan.\n\n#4 SOC: Mom and dad in throughout afternoon for cares.\nIndependent with son. Updated at bedside by RN. Mom saw\nlactation as well. Loving family. Continue to update and\nsupport.\n\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044265,
"text": "Lactation Consult\nMet w/ mom at 12pm to assist w/ infant latch and assess milk supply. Mom is pumping 8X per 24 hrs yielding 500-700cc per 24hrs. However infant has had to receive formula when breast milk has run out. Encouraged mom to continue pumping frequently and put to breast as often as possible when she visits.\nInfant placed cross cradle using a nursing support pillow. Infant attempting to latch but was unsuccessful and becoming more frustrated. Infant latched w/ a nipple shield and nursed off and on X 40 mins. did have strong frequent sucks, audible swallows and milk in shield. He then slept X 30 mins and woke again. Encouraged mom to try and nurse during the day as often as possible and have staff bottle the at night.\nReviewed w/ mom how to follow infant cues for hunger and fullness. Also reviewed voids and stools per day. Mom plans to use an LC at for support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-25 00:00:00.000",
"description": "Report",
"row_id": 2044269,
"text": "#1Resp\nO:Infant remains in RA breathing 40-60, sats >95%. Lung\nsounds clear and equal, no retractions. No spells so far\nthis shift.\nP:Cont to monitor for A/B's\n\n#2FEN\nO:Cont on BM/Sim20, taking 110-120cc's per feed. Waking\nevery 2-3hrs for feeds. Abdomen soft and round, active bowel\nsounds. Infant voiding, stooling (heme neg). No loops, one\nsmall spit. Cont on iron and multi vit.\nP:Cont so support nutritional needs.\n\n#4Parents\nO:Mom and dad in at 0730. Mom not feeling well, felt\nfeverish. Was told by RN to go see her doctor. Dad came back\naround 1200. Both very loving and caring, asking appropriate\nquestions.\nP:Cont to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-25 00:00:00.000",
"description": "Report",
"row_id": 2044270,
"text": "NPNOTe\nI have examined the , i agree with above note by PCA. visited,mom was seen in triage in , has mastities, on antibiotics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-25 00:00:00.000",
"description": "Report",
"row_id": 2044271,
"text": "NICU NPN\n\n1. O: BS are cl= to bases, no GFR. No spells or desats. A:\nStable resp status. Day of brady countdown. P: Spells\nresolving, no resp distress.\n\n2. O: TF at 100cc/k/d min intake, PO ad lib as demanded.\nTaking 120-130cc of EBM Q2-3 hr. No spits, abd is soft,\nfull, voiding and stooling. Weight up 165g to 3975g. A:\nGaining weight, Po feeding adequate amts. P: Monitor, feed\nas demanded.\n\n4. O: Dad in to visit with grnadmother. Independent and\ninvolved with cares and feeds.A: Loving, involved, invested\nparent.Excited about pot DC tomorrow. Mom sick with\nmastitis. P: Support and keep informed. Will be in at 0900.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-26 00:00:00.000",
"description": "Report",
"row_id": 2044272,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA, maintaining O2 sats >94%. RR\n40s-60s. LS cl/=. No A's or B's thus far. P: Cont to\nmonitor for A's & B's.\n\nFEN: Wt 3975g (up 165g). Infant is adlib feeding with TF\nmin 100cc/kg/day of BM20/Sim20 = >66cc q4hrs. Infant waking\nq1.5-3hrs over night. Well coordinated. Took 40cc, 90cc,\n120cc, & 15cc thus far. Abd exam benign; no spits. Voiding\n& stooling heme negative. On iron & multivitamins. P: Cont\nto support growth & nutrition.\n\nG&D: Temps stable, swaddled in OAC. Infant is a&a with\ncares. Waking for feeds. Sucks pacifier to comfort self.\nAFSF. AGA. P: Cont to support dev needs.\n\nSOCIAL: No contact with family. Will be in at 0900 for\nd/c. P: Cont to update, support & prepare family for d/c.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-26 00:00:00.000",
"description": "Report",
"row_id": 2044273,
"text": "/NEON DOL 8 CGA 41 \nRA, no cyanotic episodes\nFeeding well\nHome today. See discharge summary.\nF/U appt with pedi made.\nVNA to come day post discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-26 00:00:00.000",
"description": "Report",
"row_id": 2044274,
"text": "Discharge Note\n Infant in RA, 20-40's, c/=, no spells for 5 days. Ad lib feeding BM20/Sim20, taking > min required volumes without diff, good weight gain. Abd benign, V/S, stooling. Cont on MVI and iron. Temp stable in OAC, swaddled. Alert and active with cares, wakes for feeds. in this AM, d/c planning/teaching complete. asking appropriate questions, excited to take infant home. VNA scheduled for Sat, pedi appt on Mon. See flowsheet for further details, infant d/c to home at 10:30 this AM without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-20 00:00:00.000",
"description": "Report",
"row_id": 2044241,
"text": "Admission Note\nOb-\nDelivering Ob-\nPedi-- \nCovering Pedi- Dr. \n\nAsked by Dr. to see baby boy because of dusky episodes. He is the 2 day old 3705 grams product of a term (EDC ) gestation born to a 33 yo G1 P0 mom with PNS blood type A positive, antibody negative, RPR NR, Rubella Immune, Hep B negative, GBS negative mother. Pregnancy was uncomplicated as was labor. He was born by NSVD with Apgar scores of 9 (1 min) 9(5 min).\n\nHe was in the NBN when he was noted to have 3 episodes of duskiness. He was referred to the NICU for further management by Dr. .\n\nExam-infant active and well appearing in no distress who intermittent will have desaturations to the 60's one episode requiring BBO2\nweight 3705 grams HC 34.5 cm length 19.5 in\nTemp 98 HR 166 RR 42\nRL BP 75/40 mean 53 RA 95/48 mean 67 LL 84/53 mean 64 LA 89/44 mean 61 preductal sat 96 postductal sat 100% D stick 71\nHEENT normocephalic atraumatic ant font open flat palate intact red reflex present bilaterally nares patent bilaterally\nskin pink intact no jaundice\nneck supple\nlungs clear bilaterally\nCV regular rate and rhythm no murmur femoral pulses 2+ bilaterally\nAbd soft with active bowel sounds\nGU normal circumcised male external genetalia\nAnus patent\nSpine midline\nhips stable\nClavicles intact\nExt warm well perfused brisk cap refill\nNeuro good tone DTR knees 2+ bilaterally moved all extremities equally\n\nIMP-infant at term with several episodes of duskiness of unclear etiology. This could be sepsis/meningitis. This could be a cardiac in nature or pulmonary hypertension. It is less likely to be an immature breathing pattern.\n\nRESP-will provide oxygen as needed. Will obtain a CXR on admission\nCV-pre and post ductal sat are okay as are the 4 extremity BP. Will consider a EKG and further cardiac evaluation\nFEN-will allow to breast feed while stable. Otherwise will keep NPO on IVF\nID-will plan to obtain LP. Will draw cbc and blood culture. Will begin amp/gent for min of 48 hours\nNEURO-will consider a seizure evaluation if other etiologies are negative\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-20 00:00:00.000",
"description": "Report",
"row_id": 2044242,
"text": "Nursing Admission Note\nBaby is 2 day old term infant admitted to NICU from regular nursery for dusky spells.Infant arrived in NICU pink/well perfused with admission sat of 100%. He was noted to have dusky spell to 60 while sucking on pacifier/BBO2 given. RR 30-50. Lungs clear. No labored respirations noted. HR 150-160. No murmur heard. BP stable. CBC and blood culture sent. Hep lock placed for antibiotics. Infant noted to have further desats to 60's/80's when not sucking on pacifier. Nose suctioned and patent. NNP to obtain consent from parents for LP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-20 00:00:00.000",
"description": "Report",
"row_id": 2044243,
"text": "Neonatology NNP on-call procedure note\nProcedure Lumbar puncture indications r/o meningitis, infant with dusky episodes.\n\nTime out observed. Infant positioned for procedure with left side down, sucrose pacifier given prior to procedure. Infant's lower back prepped with betadine and sterile drapes applied, 1% lidocaine 0.1ml given intradermally at LP (L-3 L-4) site prior to procedure. #22 gauge spinal needle inserted to L-3 L-4 with sl blood tinge clear fluid return on 1st attempt. 3 1ml specimem sent to lab for usual studies. 4th 1ml specimem to lab to hold for additional studies in warranted. Infant tolerated procedure well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-20 00:00:00.000",
"description": "Report",
"row_id": 2044244,
"text": "Neonatology Attending Progress Note\nNow day of life 2 for this term infant with episodes of desaturation.\nBaby's respiratory status - no apnea noted, 5 desaturation episodes noted in total. Baby was treated with supplemental O2 with episodes.\nRR - in RA, RR 30-40s, no retractions noted.\nO2 sats - 95-100% in RA.\nCVS - HR - 110-140s\nBPs - 4 ext wnl BP 67/36 48\n\nWt. 3705gm birthweight\nBaby doing small amounts of breastfeeding.\nNo urine output in NICU.\nDS 70\nOn 60ml/kg/d of D10W.\n\nID - cc - wbc 13,300 diff 58P 28L Hct 56%\nLP done\nCSF 6 wbc 17rbcs\n\nAssessment/plan:\nTerm infant with intermittent episodes of desaturation.\nWill complete cardiac work-up as well as continue close monitoring.\nAntibiotics to continue.\nWill continue with breastfeeding only.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044266,
"text": "Discharge Planning\n\nVNA referral called to (T:, F:). Visit scheduled for Saturday, . Visiting nurse will call family morning of visit to arrange time. Mom aware of and in agreement with plan.\n\n RN\n Nurse Case Manager\nB:\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-25 00:00:00.000",
"description": "Report",
"row_id": 2044267,
"text": "PCA Progress Note 2300-700\n\n\nRESP: Resting in RA. RR: 30-60's. O2sat: 95-100%. LS cl/=.\nNo spells noted this shift. Day on a spell countdown.\nContinue to monitor respiratory status.\n\nFEN: Current weight 3810g (-10g). TF remains a min100=\nBM/Sim20= 64cc. q4h. Ad-lib demand, waking q2.5-3hrs.\nBottled 95, 120, and 130cc. + BF thus far. Abd benign, soft.\n+BS. Voiding and stooling heme -. No spits noted. Continue\nto support nutrition needs.\n\nParenting: in early this shift. Continue to update\nand support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-25 00:00:00.000",
"description": "Report",
"row_id": 2044268,
"text": "/NEON DOL 7 CGA 41 \nRA, RR30-60 HR 130-160 no episodes of A/B ,\nWt 3810 down 10 , took 178 cc/kg\nSpoke with mom, she will make pedi appt. for Mon/Tues at /BUR with Dr .\nVNA set up\nHome in am if no bradys or desats.\u0013\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044259,
"text": "0000-0700 PCA NOTE\n\n\n1. pt remains in RA, breathing 30-60's, lung sounds cl/=, O2\nSats remain stable at 93-100%, no g/f/r noted, pt appears\ncomfortable in respiratory effort, cont to monitor pt's\nrespiratory status & intervene if necessary\n\n2. wt 3820 - up 145, pt continues on ad-lib/demand feeding\nschedule waking q2.5-3.5hrs for feeds, pt continues on TF\nmin100cc/k of BM20, pt is very eager & coordinated with\nbottle using yellow nipple, pt has bottled 110 & 145cc at\ncares this shift, medium spit x1, burps well, abdomen is\nsoft & round with active bowel sounds, pt is\nvoiding/stooling, heme - stools, cont to monitor & support\npt's weight gain & intake\n\n4. No contact with so far this shift, cont to update\n& support as needed\n\n***SEE FLOWSHEET FOR FURTHER DETAILS***\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044260,
"text": "0000-0700 PCA NOTE\nG&D: Temps stable, swaddled in OAC. Infant is a&a with have examined infant and agree with above note & flowsheet documentation by PCA.es. Settles well in between. Sucks pacifier to comfort self. AFSF. AGA. P: Cont to support dev needs.\n\nMom & Dad in at with visitors. BF 15min. Updated on infant's condition and plan of care by this RN. Mom scheduled for LC apt later today. Loving family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044261,
"text": "0000-0700 PCA NOTE\nG&D: Temps stable, swaddled in OAC. Infant is a&a with have examined infant and agree with above note & flowsheet documentation by PCA.es. Settles well in between. Sucks pacifier to comfort self. AFSF. AGA. P: Cont to support dev needs.\n\nMom & Dad in at with visitors. BF 15min. Updated on infant's condition and plan of care by this RN. Mom scheduled for LC apt later today. Loving family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044262,
"text": "/NEON DOL 6 CGA 41 \nRA, no desats/brady since . RR 30-40, HR 110-150\nWt 3820 up 145 checked twice, took in 186 cc/kg BM20\nOn Vits and iron.\nCalled and left message yesterday, recalled number today and was told not correct. Will have nurses enquire current phone number when mom comes in this eve.\nPlan: Fri discharge with F/U within 5 days at /BUR, Dr..\nVNA day post discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-24 00:00:00.000",
"description": "Report",
"row_id": 2044263,
"text": "NPN: Mom in today and was updated on infant's status at bedside. Was asked to confirm home phone number that is present in chart, because Dr. has been trying to reach family without success. Mom was shown the chart and stated it was indeed wrong. The corrected number is now in the chart. The home phone # is: (.\nFurther discharge teaching was reviewed. Was informed that probable discharge may occur on (in 2 days), and she should make appointment for Pedi on Monday (VNA will visit on ). Mom given 1cc syringes for Fe administration. Mom also had lactation consult with , RN,LC., and plans to be here tomorrow most of day in order to promote BF'ing. Will cntinue to support/teach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-23 00:00:00.000",
"description": "Report",
"row_id": 2044255,
"text": "1900-0700 PCA NOTE\n\n\n1. pt remains in RA, breathing 20-50's, lung sounds cl/=, O2\nSats 97-100%, pt has had no desats so far this shift, no\ng/f/r noted, pt appears comfortable in respiratory effort,\ncont to monitor pt's respiratory effort & intervene if\nnecessary\n\n2. wt 3675 - up 25, pt continues on ad-lib/demand feeding\nschedule with TF min 60cc/k, pt's 24 hr TF was 134cc/k +\nBFx2, pt wakes for feeds every 2-4 hours, pt has bottled 60\n& 125cc at cares so far this shift in addition to\nbreastfeeding >1 hour, pt is bottling BM20/Sim20 using\nyellow nipple & is very eager & coordinated, pt burps well &\nhas had one small spit so far this shift, pt was put to\nbreast at ~ & remained there until ~2115 - pt was very\nirritable & would latch & suck intermittently while at\nbreast - pt's suck was strong & eager using nipple shield,\npt is voiding/stooling well, heme - stools, abdomen is soft\n& round with active bowel sounds, circumcision site is c/d/i\nwith no active bleeding, vaseline & gauze applied at each\ncare, cont to monitor & support pt's weight gain & intake,\ncont to support pt & MOB with breastfeeding efforts\n\n3. pt remains off antibiotics, pt shows no s/s of sepsis so\nfar, cont to monitor pt for sepsis & intervene if necessary\n\n***SEE FLOWSHEET FOR FURTHER DETAILS***\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-23 00:00:00.000",
"description": "Report",
"row_id": 2044256,
"text": "Nursing Note 1900-0700\n\n\nI have examined this infant & agree with above note by PCA\n .\n\nSpoke with parents at the bedside. Family is loving &\nappropirate with infant. Mother is asking questions r/t\nbreastfeeding. Lactation consult scheduled for tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-23 00:00:00.000",
"description": "Report",
"row_id": 2044257,
"text": "/NEON DOL 5 GA 40 \nRA, no episodes of cyanosis since am, RR 30-40, HR 110-160\nEKG,Chest film neg\nWt 3675 up 25 on adlib breast/bottle taking 134 cc/kg plus breast\nOn Vits and Fe.\nS/P sepsis R/O\nCalled and left message for mother.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-23 00:00:00.000",
"description": "Report",
"row_id": 2044258,
"text": "NPN Days\n\n3 Infant with Potential Sepsis\n4 Alt in Parenting\n\n#1 Resp: RA, 30-40's, c/=. No desats or spells so far this\nshift. P: Cont to monitor resp status, D2/5 for spell\ncountdown.\n#2 FEN: Infant ad lib breast and bottlefeeding BM20, min\n100cc/kg. Infant is taking > min required, waking every 2 to\n3 hours, taking 55-70cc per feed plus breastfeeding well\nwith nippleshield. Abd benign, V/S, stooling. Cont on MVI\nand iron. P: Cont to monitor FEN status.\n#4 Parents: Parents in this afternoon, mom held and\nbreast/bottlefed infant. Parents asking appropriate\nquestions, mom has appt with lactation consultant tomorrow.\nP: Cont to encourage parental calls and visits.\nSee flowsheet for further details.\n\nREVISIONS TO PATHWAY:\n\n 3 Infant with Potential Sepsis; resolved\n 4 Alt in Parenting; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-22 00:00:00.000",
"description": "Report",
"row_id": 2044251,
"text": "PCA 7pm-7am\n\n\n#1 RESP: Infant remains in room air. No desats thus far, no\nspells thus far. RR 20's-40's. Lung sounds clear and equal,\nno retractions noted. Infant is pink, well perfused. A:\nStable in room air. P: Continue to monitor for desats,\nspells, and increased work of breathing.\n\n#2 FEN: TF's remain 60 cc/kg/day, BM 20, ad lib demand.\nInfant has bottled 65-90 cc thus far plus breastfeeding.\nTotal intake in 24 hours= 92 cc/kg plus breastfeeding.\nAbdomen is soft, active bowel sounds. No spits thus far.\nInfant is voiding and stooling; heme negative. A: Tolerating\nfeeds well. P: Continue to monitor for feeding intolerance.\n\n#3 Sepsis: Infant shows no signs or symptoms of sepsis.\nContinue to monitor.\n\nSee flowsheet for further details.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-22 00:00:00.000",
"description": "Report",
"row_id": 2044252,
"text": "Neonatology Attending\nDOL 4\n\n remains in room air with one desaturation (53%), and no apneas/bradycardias.\n\nNo murmur. BP 78/41 (55). Well-perfused.\n\nRemains on amp/gent.\n\nWt 3650 on min TFI 60 ml/kg/day with intake 92 ml/kg/day in addition to breastfeeding over the past 24 hours. Abd benign. Voiding and stooling normally.\n\nTmemp stable in open crib.\n\nA&P\nFull term infant with intermittent (infrequent) cyanosis. Sepsis excluded. Hyperoxia test, EKG and CXR within normal limits.\n-Continue cardiorespiratory monitoring for now\n-Will start iron and multivitamins\n-COntinue antibiotics for 48 hours pending culture result\n-Consider echocardiogram unless events completely resolve\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-22 00:00:00.000",
"description": "Report",
"row_id": 2044253,
"text": "NNP PHysical Exam\nPE: pink, AFOF, breath sounds clear/equal, easy WOb, no murmur, well perfused, abd soft, + bowel sounds, circ healing, active, good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-06-22 00:00:00.000",
"description": "Report",
"row_id": 2044254,
"text": "NPN Days\n\n\n#1 Resp: RA, 30-50's, c/=, no WOB. No desats or spells so\nfar this shift. P: Cont to monitor resp status, need 5 days\nw/out a spell, will f/u with cards re: echo if infant has\nanother episode.\n#2 FEN: Infant ad lib feeding, waking about every 3-4 hours\nfor feeds. Breastfed well with mom, 80-100cc per\nfeed BM20. Abd benign, V/S, stooling. P: Cont to monitor FEN\nstatus.\n#3 ID: Temp stable, infant is acting appropriately. Abxs\nd/c'd for bld cx NTD. P: Resolved issue.\nSee flowsheet for further details.\n\n\n"
}
] |
68,457 | 109,940 | Brief Course: 69 yo F diastolic heart failure with pulmonary hypertension, CAD with CABG, morbid obesity, CKD, who was admitted for TKR, s/p TKR on , transferred to the floor given on CKD and volume overload, then transferred to for altered mental status. She underwent dialysis and mental status improved and transferred to the floors. A tunneled line was placed and transplant surgery was consulted for possible AV graft after discharge. Pt was discharged to rehab. | Trivial mitral regurgitation is seen. The mitral valve leaflets are mildlythickened. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Criteria for inferior wallmyocardial infarction are less prominent. Mild [1+] TR. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Since the previous tracing inferior T waves areimproved. MildPA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Non-specific ST-T wave changes inaddition to the secondary repolarization changes raising consideration ofischemia, etc. There is mild pulmonary artery systolic hypertension.There is no pericardial effusion.IMPRESSION: Normal global and regional biventricular systolic function.Elevated LVEDP and mild pulmonary hypertension.Compared with the prior study (images reviewed) of , the findingsare similar. The tricuspid valve leafletsare mildly thickened. Sinus rhythm. Sinus rhythm. Heart rate is minimally faster with QTc interval not as long.Clinical correlation is suggested. Compared to the previous tracing of axis is moreleftward. Complete right bundle-branch block withleft axis deviation and possible left anterior fascicular block. Noresting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Diffuse ST segment depression and T wave inversions.Compared to the previous tracing of the rate has slowed. Sinus bradycardia. Baseline artifact. Baseline artifact. Right bundle-branch block. Possibleprior inferior wall myocardial infarction. The axis is probablymore rightward than claculated, more on the order of more positivethan plus 90 degrees. Since theprevious tracing of the axis is not changed. Right ventricular chamber size and free wall motion are normal.The diameters of aorta at the sinus, ascending and arch levels are normal. No AS. PATIENT/TEST INFORMATION:Indication: Evaluate EF/diastolic dysfunction; now with fluid overload and ARF not responding to diuresis.Height: (in) 65Weight (lb): 256BSA (m2): 2.20 m2BP (mm Hg): 153/60HR (bpm): 76Status: InpatientDate/Time: at 09:47Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). Completeright bundle-branch block is no longer seen. TissueDoppler imaging suggests an increased left ventricular filling pressure(PCWP>18mmHg). Clinical correlation is suggested. Clinical correlation is suggested. Repolarization abnormalities,however, are more prominent. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%). TDI E/e' >15, suggesting PCWP>18mmHg. | 4 | [
{
"category": "Echo",
"chartdate": "2131-11-15 00:00:00.000",
"description": "Report",
"row_id": 101696,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate EF/diastolic dysfunction; now with fluid overload and ARF not responding to diuresis.\nHeight: (in) 65\nWeight (lb): 256\nBSA (m2): 2.20 m2\nBP (mm Hg): 153/60\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 09:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets\nare mildly thickened. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nElevated LVEDP and mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , the findings\nare similar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-11-13 00:00:00.000",
"description": "Report",
"row_id": 298768,
"text": "Baseline artifact. Sinus rhythm. Right bundle-branch block. Since the\nprevious tracing of the axis is not changed. The axis is probably\nmore rightward than claculated, more on the order of more positive\nthan plus 90 degrees. Since the previous tracing inferior T waves are\nimproved. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-11-27 00:00:00.000",
"description": "Report",
"row_id": 298766,
"text": "Sinus bradycardia. Diffuse ST segment depression and T wave inversions.\nCompared to the previous tracing of the rate has slowed. Complete\nright bundle-branch block is no longer seen. Criteria for inferior wall\nmyocardial infarction are less prominent. Repolarization abnormalities,\nhowever, are more prominent. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-11-20 00:00:00.000",
"description": "Report",
"row_id": 298767,
"text": "Baseline artifact. Sinus rhythm. Complete right bundle-branch block with\nleft axis deviation and possible left anterior fascicular block. Possible\nprior inferior wall myocardial infarction. Non-specific ST-T wave changes in\naddition to the secondary repolarization changes raising consideration of\nischemia, etc. Compared to the previous tracing of axis is more\nleftward. Heart rate is minimally faster with QTc interval not as long.\nClinical correlation is suggested.\n\n"
}
] |
20,604 | 156,216 | The patient was admitted to the Trauma Service. He was made NPO and fluid resuscitated. Neurosurgical consultation was obtained. The patient was prophylactically treated with Dilantin for seizure prophylaxis and frequent neurologic checks were ordered. The patient was admitted to the Surgical Intensive Care Unit initially. An ophthalmology consultation was also obtained for the orbital wall fractures and it was advised that the patient follow-up as an outpatient in the Eye Clinic in four to six weeks after discharge. Repeat head CT on hospital day number two showed a stable scan with no interval change. The patient did well through his hospital course and by hospital day number four the patient's pain was well tolerated and he was ambulating and tolerating a regular diet. | IMPRESSION: Stable appearance of hemorrhagic right frontal contusion, without new areas of hemorrhage identified. TECHNIQUE: Non-contrast head CT. TECHNIQUE: Non-contrast head CT. TECHNIQUE: Axial head CT without contrast. Clear TLS and possibly c-spine. FINDINGS: The alignment of the cervical spine is within normal limits. Per films C-spine clear. There is partial opacification of the right maxillary sinus, ethmoid air cells, and sphenoid sinus. PELVIS, SINGLE AP VIEW: There is overlying trauma-board artifact. SC Heparin to start in am.ID: Afebrile.GI: abd soft, non distended. IMPRESSION: Unremarkable radiographs of the thoracic spine. extension to orbit REASON FOR THIS EXAMINATION: facial fx No contraindications for IV contrast FINAL REPORT (REVISED) INDICATION: Status post fall, evaluate for facial fractures. IMPRESSION: No change in the appearance of the intraparenchymal frontal hemorrhage. Also noted is partial opacification of the right maxillary sinus, ethmoid air cells, and sphenoid sinus. FINDINGS: There is normal vertebral body height and alignment throughout the thoracic and lumbar spines. The area at the junction between the inferior pubic ramus and left acetabulum is incompletely evaluated. There is no abnormal prevertebral soft-tissue swelling. TRAUMA SERIES CHEST, SINGLE AP VIEW: The heart is not enlarged. The cardiomediastional silhouette is within normal limits for technique. FINDINGS: There has been no interval change in the appearance of the hemorrhagic right frontal contusion. Rule out fracture. There is slight irregularity along the right L3 transverse process. Mag repleted.SKIN: Right middle finger swollen and ecchymotic. RR 12-18 with no respiratory distress noted.HEME: Pneumoboots intact. FINDINGS: There has been no interval change in the appearance of the right intraparenchymal hemorrhage. Again seen is a hemorrhagic contusion within the right frontal lobe. No overt fracture seen. Please see the dedicated head CT report. Right hand films completed, pending. TECHNIQUE: Contiguous axial images were obtained through the cervical spine without intravenous contrast. The visualized bony pelvis is normal. TECHNIQUE: Contiguous axial images were obtained through the facial bones without intravenous contrast. FINDINGS: There is a depressed fracture of the superior wall of the right orbit, which appears to be in two pieces. The previously identified fracture of the right superior orbital wall is not well evaluated on this study. Probable soft tissue swelling, correlate clinically. There is no impingement of the spinal canal. Cervical collar intact. Logroll precautions maintained.CV: HR NSR 70-80's with no ectopy. The disk spaces are preserved. Fluid/mucosal thickening in right maxillary sinus and moderate mucosal thickening in the ethmoid sinuses. IMPRESSION: 1) Large right frontal hemorrhagic contusion. The osseous structures are intact. Fluid in sphenoid sinus. LS: clear throughout. IMPRESSION: No evidence of fracture or subluxation. No new areas of hemorrhage or mass effect are identified. No new areas of hemorrhage or mass effect are identified. A fracture is considered less likely. FINDINGS: There is a large hemorrhagic contusion within the anterior right frontal lobe. Subtle lucency in this area is of indeterminate significance. There is no shift of normally midline structures or hydrocephalus. FINAL REPORT *ABNORMAL! The superior oblique muscle is just inferior to the medial aspect of the fracture. This may represent a fracture, though detail is slightly obscured by overlying bowel gas. There is no shift of normal midline structures or hydrocephalus. Irregularity of the L3 right transverse process may represent a malformation. No other fractures are identified. No fractures are identified within the thoracic spine. IMPRESSION: No evidence for fracture or other abnormality. Moves all four extremities without difficutly. Given hospital contact number. No fractures are identified. Also with mid-thoracic back pain. Urgent neurosurgical and ophthalmologic consultation is recommended. Coronal and sagittal reformations were performed. Coronal and sagittal reformations were performed. Allowing for this, no obvious displaced fracture and no pubic symphysis or SI diastasis is identified. Maintain SBP <140. IMPRESSION: Blow-in fracture of the right orbital roof. The osseous structures about the chest are grossly unremarkable. NOTE: Film dated presented now for official interpretation. FINAL REPORT INDICATION: S/P fall with pain. Provide for pt comfort. Carpal alignment is unremarkable. SBP 120-130's, goal <140. No other areas of hemorrhage are identified within the brain or within the extraaxial spaces. TWO VIEWS OF THE THORACIC AND TWO VIEWS OF THE LUMBAR SPINE. Needs clinical exam. 2) Fracture of the right superior orbital wall, better seen on the facial bone CT. The index and long finger of both hands demonstrate soft tissue swelling most prominent about the proximal interphalangeal joint. There is a large, comminuted fracture of the right superior orbital wall, better demonstrated on the dedicated facial bone CT. Recieved Dilantin loading dose, standing dose to start in am. No CHF, focal infiltrate, effusion, or supine film evidence of pneumothorax detected. This was discussed with Dr. at the time of interpretation. TLS pending. Please correlate with clinical exam. The joint spaces are maintained. Taken to hospital where CT scan showed intraparenchymal bleed, hairline nondisplaced fx, and right frontal bone and orbital fx. VIEWS BILAT Clip # Reason: Fx ? No brain tissue is seen herniating into the orbit at this time, but MRI would be much more definitive in this regard. INDICATION: Status post fall, evaluate for hemorrhage. There is a small amount of mass effect upon the adjacent structures. NPO. Sleepy, but arouses to verbal stimuli. 8:28 AM CT HEAD W/O CONTRAST Clip # Reason: Eval for extension of bleed, mass effect Admitting Diagnosis: INTRACRANIAL BLEED MEDICAL CONDITION: 44 year old man s/p fall, + intracranial bleed REASON FOR THIS EXAMINATION: Eval for extension of bleed, mass effect No contraindications for IV contrast FINAL REPORT INDICATION: Fall, evaluate area of intracranial hemorrhage. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2121-11-21 00:00:00.000",
"description": "Report",
"row_id": 1532899,
"text": "07-1500 NPN:\n\nsee carevue for details\n\nNEURO: patient alert and oriented X3, moves all extremities with equal strength, pupils were 3-4mm and briskly reactive but were dilated by opthomology for an exam (dilation will last 4-6 hours).\n\nCV: BP 130-140s/70-80s, HR 70s, NSR\n\nRESP: LSCTA, 02 sat 99-100% on RA, NARD\n\nGI/GU: denies n/v, abd s/nt/nd, +bs, foley with clear yellow urine out.\n\nSOCIAL: wife into visit today, updated on plan.\n\nPLAN: transfer to floor late today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-11-21 00:00:00.000",
"description": "Report",
"row_id": 1532898,
"text": "NPN TSICU Admission note\n44 YO M fell down 12 stairs early morning of with positive LOC. Pt had been drinking throughout night (in celebration of world series). Taken to hospital where CT scan showed intraparenchymal bleed, hairline nondisplaced fx, and right frontal bone and orbital fx. Transfered to for further treatment.\n\nPMH includes pt currently on HTCZ at home.\nWife states pt drinks 3-4 nights/week, and consumes 6-12 beers each times he drinks.\n\nNEURO: Neuro exams Q1/hr overnoc. Sleepy, but arouses to verbal stimuli. A&OX3, able to verbally communicate. Moves all four extremities without difficutly. Pupils 3mm, reactive to light. Recieved Dilantin loading dose, standing dose to start in am. Anxious at times, trying to sit up in bed, restless----ativan given with moderate results. Pt complains of aching back pain, Morphine given with positive results. Per films C-spine clear. Needs clinical exam. Cervical collar intact. TLS pending. Logroll precautions maintained.\n\n\nCV: HR NSR 70-80's with no ectopy. SBP 120-130's, goal <140. Strong pedal pulses. NS@100cc/hr.\n\nRESP: RA SATS 96-99%. LS: clear throughout. RR 12-18 with no respiratory distress noted.\n\nHEME: Pneumoboots intact. SC Heparin to start in am.\n\nID: Afebrile.\n\nGI: abd soft, non distended. NPO. Positive BS.\n\nGU: foley draining clear yellow urine with adequate UO. Banana bag started. Mag repleted.\n\nSKIN: Right middle finger swollen and ecchymotic. Right hand films completed, pending. Right eye ecchymotic and swollen.\n\nSOCIAL: wife in for visit initially. Given hospital contact number. visit tomorrow am.\n\nPLAN: Repeat head CT this am. Clear TLS and possibly c-spine. Maintain SBP <140. Provide for pt comfort. ??Possible transfer to floor.\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 843371,
"text": " 3:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL +SDH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p fall, + sdh\n REASON FOR THIS EXAMINATION:\n +sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 4:00 PM\n Large right frontal hemorrhagic contusion.\n Fluid/mucosal thickening in right maxillary sinus and moderate mucosal\n thickening in the ethmoid sinuses. Fluid in sphenoid sinus.\n No overt fracture seen.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Status post fall, evaluate for hemorrhage.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a large hemorrhagic contusion within the anterior right\n frontal lobe. There is a small amount of mass effect upon the adjacent\n structures. No other areas of hemorrhage are identified within the brain or\n within the extraaxial spaces. There is no hydrocephalus. There is a large,\n comminuted fracture of the right superior orbital wall, better demonstrated on\n the dedicated facial bone CT. There is partial opacification of the right\n maxillary sinus, ethmoid air cells, and sphenoid sinus.\n\n IMPRESSION:\n\n 1) Large right frontal hemorrhagic contusion.\n\n 2) Fracture of the right superior orbital wall, better seen on the facial bone\n CT. These findings were relayed immediately to Dr. , in the ER, by\n telephone.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-20 00:00:00.000",
"description": "LUMBO-SACRAL SPINE (AP & LAT)",
"row_id": 843377,
"text": " 3:49 PM\n LUMBO-SACRAL SPINE (AP & LAT); T-SPINE Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with fall\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old post-fall with known intracranial hemorrhage. Also\n with mid-thoracic back pain.\n\n TWO VIEWS OF THE THORACIC AND TWO VIEWS OF THE LUMBAR SPINE.\n\n FINDINGS:\n\n There is normal vertebral body height and alignment throughout the thoracic\n and lumbar spines. The disk spaces are preserved. No fractures are\n identified within the thoracic spine. There is slight irregularity along the\n right L3 transverse process. This may represent a fracture, though detail is\n slightly obscured by overlying bowel gas. The visualized bony pelvis is\n normal.\n\n IMPRESSION:\n\n Unremarkable radiographs of the thoracic spine. Irregularity of the L3 right\n transverse process may represent a malformation. A fracture is considered\n less likely. Please correlate with clinical exam. This was discussed with Dr.\n at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 843422,
"text": " 8:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for extension of bleed, mass effect\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p fall, + intracranial bleed\n REASON FOR THIS EXAMINATION:\n Eval for extension of bleed, mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall, evaluate area of intracranial hemorrhage.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: .\n\n FINDINGS: There has been no interval change in the appearance of the\n hemorrhagic right frontal contusion. No new areas of hemorrhage or mass\n effect are identified. There is no shift of normally midline structures or\n hydrocephalus. The previously identified fracture of the right superior\n orbital wall is not well evaluated on this study.\n\n IMPRESSION: Stable appearance of hemorrhagic right frontal contusion, without\n new areas of hemorrhage identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 843524,
"text": " 12:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change in bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p fall, + intraparenchymal bleed, eval for interval change\n REASON FOR THIS EXAMINATION:\n interval change in bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall with intraparenchymal bleed. Evaluate for interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Axial head CT without contrast.\n\n FINDINGS: There has been no interval change in the appearance of the right\n intraparenchymal hemorrhage. No new areas of hemorrhage or mass effect are\n identified. There is no shift of normal midline structures or hydrocephalus.\n\n IMPRESSION: No change in the appearance of the intraparenchymal frontal\n hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-20 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 843370,
"text": " 3:15 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: 44 YEAR OLD MAN S/P 12 FT FALL, + SUBDURAL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status-post 12 foot fall, and subdural.\n\n TRAUMA SERIES\n\n CHEST, SINGLE AP VIEW: The heart is not enlarged. The cardiomediastional\n silhouette is within normal limits for technique. No CHF, focal infiltrate,\n effusion, or supine film evidence of pneumothorax detected. The osseous\n structures about the chest are grossly unremarkable.\n\n PELVIS, SINGLE AP VIEW: There is overlying trauma-board artifact. Allowing\n for this, no obvious displaced fracture and no pubic symphysis or SI diastasis\n is identified. The area at the junction between the inferior pubic ramus and\n left acetabulum is incompletely evaluated. Subtle lucency in this area is of\n indeterminate significance.\n\n NOTE: Film dated presented now for official interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-20 00:00:00.000",
"description": "B HAND, AP & LAT. VIEWS BILAT",
"row_id": 843402,
"text": " 9:39 PM\n HAND, AP & LAT. VIEWS BILAT Clip # \n Reason: Fx ?\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p fall, swelling B 2nd and 3rd finger\n REASON FOR THIS EXAMINATION:\n Fx ?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall with pain.\n\n 2 VIEWS OF EACH HAND are submitted. The osseous structures are intact. The\n joint spaces are maintained. Carpal alignment is unremarkable. The index and\n long finger of both hands demonstrate soft tissue swelling most prominent\n about the proximal interphalangeal joint.\n\n IMPRESSION:\n\n No evidence of fracture or subluxation.\n\n Probable soft tissue swelling, correlate clinically.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-20 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 843372,
"text": " 3:23 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: S/P FALL, +SDH, R/O FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p fall, + sdh, + skull fx ? extension to orbit\n\n REASON FOR THIS EXAMINATION:\n facial fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Status post fall, evaluate for facial fractures.\n\n TECHNIQUE: Contiguous axial images were obtained through the facial bones\n without intravenous contrast. Coronal and sagittal reformations were\n performed.\n\n FINDINGS: There is a depressed fracture of the superior wall of the right\n orbit, which appears to be in two pieces. The superior oblique muscle is just\n inferior to the medial aspect of the fracture. No brain tissue is seen\n herniating into the orbit at this time, but MRI would be much more definitive\n in this regard. No other fractures are identified. Again seen is a hemorrhagic\n contusion within the right frontal lobe. Please see the dedicated head CT\n report. Also noted is partial opacification of the right maxillary sinus,\n ethmoid air cells, and sphenoid sinus.\n\n IMPRESSION: Blow-in fracture of the right orbital roof. Urgent neurosurgical\n and ophthalmologic consultation is recommended. These findings were relayed by\n telephone to Dr. immediately after completion of the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-11-20 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 843373,
"text": " 3:23 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: S/P FALL, +SDH, R/O FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man s/p fall, + sdh\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, neck pain. Rule out fracture.\n\n TECHNIQUE: Contiguous axial images were obtained through the cervical spine\n without intravenous contrast. Coronal and sagittal reformations were\n performed.\n\n FINDINGS: The alignment of the cervical spine is within normal limits. No\n fractures are identified. There is no abnormal prevertebral soft-tissue\n swelling. There is no impingement of the spinal canal.\n\n IMPRESSION: No evidence for fracture or other abnormality.\n\n"
}
] |
4,840 | 126,635 | Respiratory: Maximum ventilatory settings on admission were SIMV of 20, PIP 20; PEEP 5 and 21 percent FI02. Infant received a total of two doses of surfactant. Ventilatory settings were weaned and the infant was extubated to C-PAP on day of life two. Caffeine citrate was also started on day of life two. On day 25, the infant was noted to have profound apnea and bradycardia, requiring reintubation. Maximum ventilatory settings at that time were a SIMV of 30, PIP 24, PEEP of 6 requiring 25 to 30 percent FI02. Infant self-extubated on day of life 34 to C-Pap and remained on C-Pap until day of life 46 and was transitioned to nasal cannula, 75 cc to 125 cc. The infant remains on nasal cannula, requiring 50 to 75 cc of flow. She received a trial of Lasix for three days from day of life 55 to 57. On , Diuril was started and she is currently on 40 mg per kg per day of Diuril. Caffeine citrate was discontinued on . The last apnea nad bradycardia was on . She also received Vitamin A for the prevention of chronic lung disease for a total of 12 doses intramuscularly. | Placed back on prong CPAP. Placed back on prong CPAP. Sxn'd as per flowsheet. BBSclear/=, IC/SC retractions. Resp. Oncaffeine. P/Cont. P/Cont. P/Cont. A/REquires CPAP. to supply and wean FiO2 as ptneeds/tolerates.3. Stable on CPAP cont to follow. Min residuals. Swaddledwithin boundaries. Maintaining temp. Updateprovided. inResp. Stable on CPAP.3. Placed back on prong CPAP. TF 160 cc/k/day NPO. to supply and wean FiO2 as ptneeds/tolerates.3. Respiratory CarePt currrently on +7cm H2O prong CPAP. Hct 30.3. Resp. P/Cont. P/Cont. P/Cont. P/Cont. On diuril/kcl. LS C/=, mild-mod IC/SCR. Swaddledwithin boundaries. to support andeducate . Blood cx NGTD.Transitioned to CPAP well thus far. DUV now infusing D10PN, D/S 61. BS clear after sxn. LS clear/=, naressuctioned q4hrs for moderate amt cloudy secretions. PICC D/C'd today.DEV: Temps stable in servo control isolette, nested withsheepskin. A/Sepsis eval. Nospits, min asp. D10W with hep & KacetatePB in DUV. RR30s-70s, mild SC/IC retractions present. A: Stable on CPAP. Respiratory CarePt cont on NP CPAP. P:Support.#10 O: Remains on vanco & gent. RR 30s-60s, mild SC/IC retractionspresent. On ampi and gent asordered.A/P: COn to follow#7Bili:O: 24 hr bili 3.1/0.3. Nl S1S2, grade murmur audible. Vanco dose inc after peaklevel drawn. Vanco levels due thisevening. O/BLd cultures neg to date. BS clear after sxn. Resp. P/Cont. P/Cont. P/Cont. P/Cont. P/Cont. BS clear after suctioning. RequiresCPAP. Plan tocontinue CPAP, monitor resp. Wt. Temp.stable. Passed heme positive awareand was in to examine pt at that care time. A/ Stable on CPAP. O/Team aware of dstick results from noc shift andthis am. A/Advanced caloriestoday. Stable temp in servo isolette. ONETOUCH AT 0500226, NNP AWARE. P/Cont. P/Cont. P/Cont. P/Cont. P/Cont. P/Cont. temps stablein off isolette. Resp. Resp. Resp. BS COURSE TO CLEAR. IC/SubC retractions. Guaiac neg. PICC line heplocked in situ.A; Asymptomatic. Caffiene conts. Min asps. Stable on CPAP cont to follow. Respiratory CarePt currently on prong CPAP. I/C S/C rtxs. TEmp stable. Fio2 .24-.27. bs clear, rr 40-60. Mild baseline IC/SCR noted.LS clr/=. Spoke w/this RN. A/A for cares.Uses pacifier with support around CPAP. A: Stable on prong CPAP. LS C/=, mildSCR. Min benign asps. MAE, FOS & Full - last HUS ,results normal.5. Remains oncaffeine. On caffeine.Murmur persists. Respiratory CarePt currently on prong CPAP. Fio2 .25-.30. bs clear, rr 40-60. Nl S1S2, grade murmur appreciated. S/C I/C rtxs. 4.2cc asp, partiallydigested, refed. Stable on CPAP cont follow. 21, bs clear, rr 40-60, sx for scant amt. Respiratory CarePt conton prong CPAP. BBS CLEAR, RR 30-60'S.3. LSC/=, mild SCR. RR 30's-60's with mild IC/SCR. BP 74/42 (48).Wt 1545 (unchanged) on TFI 150 cc/kg/day SC32PM, tolerating well by gavage. swaddled in off isolette.Temp. cxr done. P: ContinueCPAP, wean O2 as tolerated.#3FEN. Suctionedw/every cares. A: Stable FiO2 on CPAP. Respiratory Carept cont on prong CPAP. LS C/=, mild SCR. Remains oncaffeine. LS C/=, IC/SCR. Presently on settings 22/6, f 24, Fio2 .25. bs coarse, rr 20's-40. Ampi and Gent given . A/ Stable on CPAP. PICC hl'd. On vanco andgent. Respiratory CarePt cont on NP CPAP. LSCL=, SCR noted. Temps stable inservo isolette. UAC recal. Dopapiggybacked into secondary UVC. MildIC/SC retractions. UO 3cc/k/hfor 24h. Suctioning NPT & nare PRN. PNS: AB+, Ab-, +, RPRNR, RI, GBS?. A/Stableon CPAP. Updated bythis RN. Reintubated for ^desats. Fio2 .21, bs clear, rr 30-70. sx for sm amt. X2 A/B so far this shift. A/ in G&D. NGT vented afterfeeds. Infant cont onthese settings thus far. BBS clear/=. BLSc/=, mild sc/ic retractions. Occassionalloops. Current feeds + supps meeting recs for kcals/pro/vits and mins. P/Cont. P/Cont. P/Cont. P/Cont. P/Cont. P/Cont. P/Cont. Resp. Resp. Resp. A/Appears to be tolerating presentfeeding regimen. Contson vite and fe. d/tPrematurity P:Cont. to support andeducate . Cont to supportdevelopmental milestones.Sepsis: Oxacillian complete. Active/alert w/ cares; settles well b/t withfirm boundaries. to assess resp. ID from TCH over today forconsult. Stable on CPAP. A: Stableresp. P/Cont. P/Cont. P/Cont. Resp. Oncaffeine. P: Continueto moniter. recievedlasix. Currently pt. Wt. to suppy and wean FiO2 as ptneeds/tolerates.3. pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. A: nwe murmur today, with stable B/Ps. O/Pt. O: Pt. Updates given. status on CPAP. Respirat6ory Care NotePt. Respirat6ory Care NotePt. Respirat6ory Care NotePt. Respirat6ory Care NotePt. I then sx'd lrg. I then sx'd lrg. I then sx'd lrg. LS C/=, IC/SCR.FEN: Remains NPO, D10 w/2,1,Hep infusing via central picc inright leg. BBSclear/=, mild SC/IC retractions. continues to have occ. Suctioned w/every cares. Updated by thisnurse. A: Stableon N/C. Will be intomorrow. Cont oncaffeine and diuril. CXR obtained. A/ in G&D. to support andeducate . Remains on Vit E, iron, & prune juice.Started KCl this shift.G/D: Temp stable swaddled in OAC. Remains on oxacillin. Weaning on . Respiratory CarePt cont on prong CPAP. Stable temp in servo isolette. Stable temp in servo isolette. Mild SC/IC retrx noted. sxn for smallamount clear secretions. Stable CV status P: Monitorand document. Nl S1S2, grade murmur audible. Wgt: 1.410 ^55g A: Stable, tolerating feeds andgaining weight. A: Stable P: Monitor. was sx'd for a lrg. Vit E and FeS04. Respiratory CarePt cont on prong CPAP. 2.0cc max asperatepartially digested. P- Cont to assess for Respneeds.#3-O/A- TF=150cc/kg/d of BM/SCsim30w/ProMod via NGT. BS cl. NGplacement verifed and residuals assessed ac. Continues onCaffeine. BP 56/40, 46.Bili < 1.0.Wt 565, up 25. LScoarse/equal, mild-mod IC/SC retractions. Monitor and support resp status.FENInfant on Tf 150 cc/k/d SC32PM gavaged/1'. G&DALERT WITH CARE. Montior weight and exam.G/DInfant in off isolette. Stable on CPAP cont to follow. RR 40-60's, BBS coarse ->clear with sxn. Active, alert in an isolette, AFOf, sutures opposed, good tone, IUGR. G&D=O/Temp stable swaddled in off isolette. Stable temp in isolette. Gavagestol well. Updated by thisnurse. Cont oncaffeine. P/Cont to support andeducate . Remains on Oxacillin. Mod subcostal retractions. )A/Stable in NCO2. A/ in G&D. A/ in G&D. UAC noted. A/Stablein NCO2. Abd benign. Abd benign. A/Tolerating current regime. TF at 130 cc/k/d being tolerated via gavage. Diuresed well afterlasix. Cong off CPAP.ntinue to support and update. Cong off CPAP.ntinue to support and update. Abdomensoft/round, good bs, V&S.G/D: Temp stable swaddled in OAC. Calms well aftercares w/containment. V&S (heme negative).G/D: Temp stable swaddled in OAC. Since the prior examination, the ascending venous vascular catheter on the right has been withdrawn as has been the nasogastric tubes. The remainder of the ventricles appear normal. There has been interval placement of a right groin central venous line. Murmur.Status: InpatientDate/Time: at 18:12Test: Portable TTE (Congenital, complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Conclusions:Pediatric study. | 434 | [
{
"category": "Nursing/other",
"chartdate": "2103-05-11 00:00:00.000",
"description": "Report",
"row_id": 1744334,
"text": "NPN\n\n\n#1 Resp: infant continues on NP CPAP=6 FiO2=21%. Sats\n95-100% with RR 30-60s. no spells so far this shift. BBS\nclear/=, IC/SC retractions. on caffeine. Sxn oral/NP tube\nQ4h for thick cloudy white and blood tinged secretions. cont\nto closely monitor.\n\n#3 FEN: infant TF 150cc/kg/d. Enteral feeds restarted\n@50cc/kg/d BR20 NG Q4h with plans to advance 20cc/kg every\nother feeding to goal of 90cc/kg/d. IV fluid D10+NaK via\nPICC line, plan to restart PN/IL tonight. tolerating feeds\nwell, abd full, soft, girth=19cm. voiding, stool X2 heme\nnegative. cont to closely monitor.\n\n#4 G&D: infant remains nested in servo isolette. lethargic\nand less active than normal. weak cry during diaper change.\ntemps stable. cont to closely monitor.\n\n#8 Sepsis: infant continues on vanco and gent through PICC\nline. cultures remain pending. plan to get LP this afternoon\nafter consent obtained. infant temps stable, remains\nlethargic. cont to closely monitor.\n\n#9 CV: infant pink, good pulses. no murmur heard upon\nauscultation. HR 130-150's. cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-11 00:00:00.000",
"description": "Report",
"row_id": 1744335,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21%. Pt's respiratory rate 30's to 60's, pt on caffine. Plan is to follow pt on CPAP, wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-11 00:00:00.000",
"description": "Report",
"row_id": 1744336,
"text": "Neonatology- Progress Note\n\nPE: Remains in her isolette, nested on CPAP, bbs sl cse=, rrr s1s 2no murmur,abd soft, nontender, V&S, afso, active with care, picc and gavage in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744337,
"text": "Nursing Progress Note 1900-0700\n\n\nResp:NP-ET CPAP-6,FIO2 21%.RR 30-50's with IC/SC\nretractions.LS remain clear and equal b/l.Sxn'd large amt.\nof old blood via ET and moderate yellow in nares.Infant with\nno spells thus far.Cont's on Caffiene as ordered.A:Alt. in\nResp. d/t Prematurity P:Cont.to assess resp.status.\n\nF/E/N:Infant cont's on TF 150cc's/kg/day.Enteral feeds adv.\nat 0100 to 90cc's/kg/day receiving 9cc's of BM20 gavaged\nover 20 min.IVPN D12 AT 60cc's/kg/day infusing at 1.3cc's/hr\nalong with Lipids at 0.3cc's/hr in PIC.PIC site in R leg\nsite intact no s/sx's of infiltrate.Abd. soft,pos bs,no\nloops or spits,aspirates 2.0-2.4cc's.Re-fed \n.Girth= 18-20.Urine output=3.2cc's/hr,stooling\nseedy stool.Weight=0.630kg up 15 grams.A:Alt. in F/E/N d/t\nPrematurity P:Cont. to assess tolerance of feeds.\n\nG/D:AFOS.Infant alert and active with cares.Remains in Servo\nisolette,temp. maintained.Infant presently in flex. position\nbringing hands to face and mouth intermitently sucking on\npacifier.A:AGA P:Cont. to support growth and dev.\n\nID:Infant cont's on IV Vanco and Gent as ordered.No s/sx's\nof sepsis noted.Blood cx's no growth thus far.A:Stable\nP:Cont. to assess for s/sx's of Sepsis.\n\nParents:Mom called x 2 asking appropriate questions.Very\n and invested.A/P:Cont. to update support,update,and\neducate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744338,
"text": "Respiratory Care\nBaby continues on prong CPAP 6, 21-23%. BS clear. NPT replaced- tube plugged. Sxn'd as per flowsheet. 2.5 NPT placed in naris without incident. RR 30's-50's with mild IC/SCR. On caffeine, abx. No spells noted. Will cont to follow closely, wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-04 00:00:00.000",
"description": "Report",
"row_id": 1744501,
"text": "NPN 7p-7a\n\n\n#1 Remains on NPCPAP @ 7cm. Fio2 27-28%. BBS slightly coarse\nto clear. Mild IC/SC retractions present. + cough. Duoderm\napplied to nasal bridge d/t irritated and reddened-without\nany evidence of breakdown. Suctioned for small clear/white\nsecretions via oral route and small old blood via . On\ncaffeine. No spells thus far in shift-does occasionally have\nsome sat drifts to the 70-80 range which SR. A: comfortable\non CPAP P: follow resp status\n\n#3 Tf's 150cc/k. Receiving 25cc of SC32+PM q 4hrs on a pump\nover 1hr. No spits or residuals. Abdominal exam\nunremarkable. Voiding and stooling-heme neg. Weight ^ 20g.\nA: tolerating feeds, gaining weight P: Follow weight and\ntolerance to feeds\n\n#4 Temps stable in low air isolette. Sweet disposition.\nAlert and active with handling. Sleeps peacefully. Swaddled\nwithin boundaries. A:AGA P: support developmental needs, 1st\neye exam today\n\n#5 Mom in with family. Participated in sister's care. Update\nprovided. LP consent signed. A: informed P:Cont to inform\n\n#10 Temps stable. On oxacillin-day 11. Blood cx NGTD.\nAwaiting 2nd LP A: r/o sepsis P: Cont Abx as ordered, follow\nlabs, repeat LP\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-04 00:00:00.000",
"description": "Report",
"row_id": 1744502,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 7 FIO2 27-28%. Suctioned for sm amt of old blood. Breath sounds coarse/clear. Duoderm applied to . Occasional drifts on the sat monitor. Baby is on caffeine RR 40-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-04 00:00:00.000",
"description": "Report",
"row_id": 1744503,
"text": "Attending Note\nDay of life 35 CGA 33 0/7\nCPAP 7 FiO2 27-30% RR 40-50 on caffeine no spells last CBG 7.31/55\nHR 140-160 hct 34 77/57 mean 62\nweight 1035 up 20 on SSC 32 with promod\nvoiding and stooling\non vit E and iron\n\neye exam this am\n\nImp-stable currently\nwill continue on CPAP\nwill not have LP done\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-17 00:00:00.000",
"description": "Report",
"row_id": 1744584,
"text": "Neonatology- Physical Exam\n\nInfant remains in an open crib, currently on NC. Active, alert, AFOF, sutures opposed, good tone. BBS clear and equal with fair air entry, moderate retractions. Gr murmur, pulses +2, /pink, RRR. Abdomen soft, round, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n\nCXR 7 ribs, areas c/w atelectasis noted\nIncreased desats requiring increased NC flow.\nWill place on CPAP.\nCBC, diff, blood culture sent.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-17 00:00:00.000",
"description": "Report",
"row_id": 1744585,
"text": "Respiratory Care Note\nThis former 28 wga infant was taken off CPAP on . Placed back on +6 prong CPAP today for increased WOB, increased desats requiring increased O2 flow. CXR 7 ribs expanded, c/w atelectasis. FiO2 on CPAP 33%. BS clear. Will follow and support as necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744586,
"text": "NPN NOCS\n\n\n1. Remains on prong CPAP of 6. FiO2 mainly 29-30%. LS clear.\nNo spells. On caffeine. RR 30-50's. Stable on CPAP.\n\n3. Wt up 25gms. TF at 150cc/kg SSC32 with PM. Gavaged over\n60min. Adomen benign. Small spit x1. Min residuals. Voiding,\nno stool.\n\n4. Alert and active with cares. Temp stable in open crib.\nCobedding with sibling. Continues with small amt yellow eye\ndrainage to left eye, e-mycin as ordered. Eye exam for\ntoday. AGA.\n\n5. Mother called and updated. Asking appropriate questions.\nWill be in for 0400 cares. Involved parent.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744587,
"text": "respiratory Care Note\nPt. continues on 6cmH2O of nasal prong CPAP and 29-41%. BS clear. On Caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744591,
"text": "Respiratory Care Note\nPt continues on prong CPAP +6, .28-.32FiO2. BBS ess clear. Comfortable RR 50s-70s. NARD. Continues on caffeine w/no documented spells noted. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744592,
"text": "NPN\n\n\n1.Received On CPAP 6, 28%. Remains on same with FiO2 weaned\nas low as 25% at times. Sats 93-100%. Well perfused, pink.\nBBS cl+=, no murmur audible at this time. VSS as charted on\nflow sheet.\nCont to monitor closely. Cont on CPAP as ordered.\n3. TF 150cc/kg/day. Tol volume, min spits, min asp. All PG.\nAbd soft but full. A/G stable at 25cm. Voiding qs. No stool\nthis shift.\nCont current feeding plan. Offer po when off CPAP.\n4. Cobedding with twin sister. Maintaining temp. Sucks well\non pacifier. Eye exam today. See consult note for results.\n5. Dad called and updated on status. Will not be in this\neve.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744593,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 5 FiO2 24-29%. RR 30-60's breath sounds are clear. Baby is on caffeine. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744594,
"text": "NPN:\n\nRESP: prong CPAP 6cm, 25% 02. RR=40-50s with SC retraction. BBS =/clear. No A&Bs thus afr tonight; none over past 24 h. Remains on Caffeine.\n\nCV: Soft murmur. HR=150-170. BP=57/24 (36). Color pink /good perfusion.\n\nFEN: Wt=1545g (+ 55g). TF=150cc/kg/d. Tolerating 39cc SC-32 w/promod q 4 h via NG over 1 h. No spits; minimal redsiduals. Abd full, soft, active bs, no loops. Voiding qs; no stool since ysterday. FeS04, Vit E.\n\nG&D: CGA=35 wk. Temp stable in crib. Active and alert w/cares. Swaddled, nested and resting well.\n\nEYE DRAINAGE: Small amt yellow drainage , rt eye. Erythromycin Ophth, day .\n\nSOCIAL: No contact w/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744424,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt remains on NP CPAP of 6, primarily in 21-29%\nthis shift thus far. Remains on caffeine. No A/B noted thus\nfar this shift. Periodic breathing occasionally noted with\nbrief desaturations noted as low as 80% (requiring increase\nin FiO2). A/REquires CPAP. P/Cont. to monitor for evidence\nof resp distress. Cont. to supply and wean FiO2 as pt\nneeds/tolerates.\n\n3. F/N. O/TF remain at 150cc/k/d of simsc32pm pngt over 1\nhour. PLease refer to flowsheet for examinations of pt from\nthis shift. Voiding (see u/o). Trace amt of stool passed\nthis shift. Rectal area noted to be swollen ( \nand Attending MD, notified). NGT vented in\nbetween feeds. A/Appears to be tolerating present feeding\nregime. P/Cont. to monitor for s/s of feeding intolerance.\n\n4. G/D. O/Temp remains stable on servo control, nested in an\nisolette. Awake and alert at care times. Intermittently\nsucking on pacifier. Kangaroo'd with mother this afternoon.\nA/Alt. in G/D. P/Cont. to support pt's growth and dev.\nneeds.\n\n5. . O/Mother called this am and was in to visit this\nafternoon. Mother updated on pt's status and plan of care.\nMother assisted with afternoon cares and kangaroo'd with pt.\nA/ are known to be actively involved in pt's care.\nP/Cont. to support and educate .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744425,
"text": "Respiratory Care Note\nPt had a severe brady/desat that required pulling NP tube by RN. Tube was plugged. Large amount thick bloody secretions suctioned from nares. Placed back on prong CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744426,
"text": "Respiratory Care Note\nPt had a severe brady/desat that required pulling NP tube by RN. Tube was plugged. Large amount thick bloody secretions suctioned from nares. Placed back on prong CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744427,
"text": "Respiratory Care Note\nPt changed to +6 NP CPAP from prong CPAP due to pressure on nose and redness. 3.0 tube placed w/o difficulty. BS clear. Suctioned for large amount thick yellow secretions. RR 30-40's. On caffeine and Vitamin A. No bradys noted this shift as of this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744428,
"text": "Respiratory Care Note\nPt had a severe brady/desat that required pulling NP tube by RN. Tube was plugged. Large amount thick bloody secretions suctioned from nares. Placed back on prong CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744493,
"text": "NPNOte\nAddendum: Infant in a air mode Isolette swaddled with blanket, rechecked temp later 99.1, aware.Infant alert,active, large amount et and oral secretions suctioned, BBs coarse ,Iv heplock on lt leg without any redness,flushed easily.Antibiotics given as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744588,
"text": "Neonatology NP Exam Note\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small infant nesteled in open crib, on prong CPAP.\nAFOF, sutures split. Eyes bright, ng in place, MMMP\nChest is clear, fair exchange, Comfortable resp pattern\nCV: RRR, no murmur, pulses+2=\nAbd: full, soft, active bs\nGU: normal external female genitalia\nEXTl MAE, WWP\nNeuro: active abd responsive, symmetric tone, reflexes,\nSkin: clear, hypo-pigmented area on back, likely area where bandaid had been placed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744589,
"text": "Neonatology Attending\n\nDay 49 CGA 35 0/7 weeks\n\nRemains on CPAP after going on yesterday for atelectasis and recurrent desaturation episodes. On CPAP at 6 with fio2 0.25-0.3. No apnea since going back on. Soft, intermittent murmur. HR 150-160s. Hct 30.3. BP mean 39. WBC in normal range yesterday. Platelet count 136k yesterday. Weight 1490 gms (+25). SC32 with Promod via feeding tube. Benign abdomen. Stable girth on CPAP. Passing heme negative stool. Active and alert. Swaddled in open crib.\n\nImproved respiratory status on CPAP. Will continue to monitor closely. Gaining weight well. Eye exam today. Family in earlier this morning. They are up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 1744667,
"text": "Nursing NICU NOte\n\n\n1. Resp. O/Pt remains on NC FiO2 100% with a 50-100cc/min\nflow. Please refer to flowsheet. A/Resp status remains\nstable on NC FiO2. P/Cont. to monitor for evidence of resp\ndistress. Cont. to supply and wean FiO2 as pt\nneeds/tolerates.\n\n3. F/N. O/TF remain at 150cc/k/d of SC 32PM PO/PNGT.\nPlease refer to flowsheet for examinations of pt from this\nshift. Voiding. Passed a large stool. A/Appears to be\ntolerating present feeding regimen. P/Cont. to monitor for\ns/s of feeding intolerance.\n\n4. G/D. O/Temp stable swaddled in an open crib. Awake and\n with cares and sleeping well in between. Held. A/\nin G/D. P/Cont. to support pt's growth and dev. needs.\n\n5. . O/MOther called this shift. Mother updated on\npt's status and plan of care. MOther stated that she would\nbe in this morning. Mother stated that she would like\ninfant's picture to be take prior to transfer. A/ are\nknown to be involved in pt's care. P/Cont. to support and\neducate .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 1744668,
"text": "Neonatology Attending Note\nDay 63\nCGA 37 1\n\nNC 50-100cc, 100%. RR40-60s. Mild rtxns. On diuril/kcl. Off caffeine. +soft murmur. HR 130-160s.\n\nHct 30.7, r 6.0.\n\nWt 1870, down 15gms. TF 130 cc SC32 w promod. PG>PO. Tol well. Nl voiding and stooling.\n140/4.4/96/37\n\nEyes - immature zone 3. Repeat for 3 weeks - due .\n\nIn open crib.\n\nA/P:\n-- resolving lung dz, wean O2 as tol, cont diuril and KCL. Given diuretic induced hypochloremic alkalosis will inc K supps (3.2 meq per kg per day)\n-- F&G - no change to nutritional plan\n-- plan to transfer to today per request\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744279,
"text": "Nursing Progress Note\n\n\nCV: No murmur. HR's 130-140's. MAP's 42 and greater. See\nflow sheet for vital signs and assessment. Problem\nresolved, will cont to monitor for s/s PDA.\n\nFEN: TF increased to 160cc/kg/d in response to Na 146.\nytes 146/5.6/117/19. D-stick 97. Voiding 6.3cc/kg/hr past\n8hrs, passed mec stools. Abd soft with active bowel sounds.\nAbd exam full with soft loops until passing stool, then soft\nand AG down 2.0cm. NGT left OTA. 3.0cc max bilious\nasperate discarded and shown to team. See also flow sheet.\n Plan for lytes in the am.\n\nParents: Plan for family meeting tomorrow at 2pm. Parents\nupdated throughout day at bedside.\n\nBili: Level 1.6/0.5. Cont off photo, plan for bili in the\nam.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-04 00:00:00.000",
"description": "Report",
"row_id": 1744280,
"text": "Respiratory Care\nbaby remains on cpap 5 21%.RR 30-70.BS clear throughout.No spells documented thus far this shift.On caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-04 00:00:00.000",
"description": "Report",
"row_id": 1744281,
"text": "NPN\n\n\nNPN#1 O= remains on Prong CPAP of 5cm in 21% FIO2 all shift,\nsats>95%, no desats/no bradys overnight, cont on caffeine as\nordered, RR 30's-60's, LS clear & equal bilat with mild\nIC/SCR, A= stable on CPAP in 21% P= cont to monitor for AOP,\ncont plan of care\n\nNPN#2 O= no murmer heard on exam, HR 140's-160's, pink &\nwell perfused, pulses equal &strong, nobounding, MAP 42-46\nA= no murmer P= cont tp monitor closely for S&S of PDA\n\nNPN#3 O= WT 532 down 53gms, remains NPO, TF at 160cc/kg/d of\nTPND11.5 & lipids at 140cc/kg/d via DUVC and now D5%W at\n20cc/kg/d piggybacked into DUV for ^'ing DS's over shift DS=\n151 to 196 at 0530..D5%added, AG 17-17.5, abd exam soft +\nactive BS, no loops, uo= 4.8cc/kg/hr, no stool, lytes 138/\n5.3/ 111/ 17 asp=0 , A=increasing DS's P= cont to monitor DS\nclosely..adjusting fluids as ordered, strict I & O's\n\nNPN#4 O= received in heated isolette on seervo with air temp\n37-38degrees..moved infant to double walled isolette on\nservo with temp 98.6-98.7 with air temp 34-35.0..AF soft &\nflat, active & alert with good tone for GA, MAE, sl\nirrotable at times but settles with containment/ pacifer,\nnested in sheepskin with gel pad/ bumper in place A=\nsl irritable but settles P= cont to assess & support dev\nneeds\n\nNPN#5 O= mom up for 2100 cares..assited with diaper change &\ntemp taking, updated at bedside..later called..mom to be\nd/c'd today after family meeting at 1400 A= involved &\n mom P= cont to teach/ update & support\n\nNPN#7 O= remains off phototherapy with rebound bili of 1.4/\n.4/ 1.0 9 1.6 yesterday) A= hyperbili resolved P= cont to\nfollow\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-04 00:00:00.000",
"description": "Report",
"row_id": 1744282,
"text": "Neonatology Attending Note\nDay 4\n\nCPAP pr 5, RA. RR30-70s. No A&Bs. On caffeine. No murmur. HR 140-160s. BP 56/34, 42. Pink, well perfused.\n\nReb bili 1.4/0.4.\n\nWt 532, no change. TF 160 cc/k/day NPO. DL UVC PN11/IL at 140 + 20 piggyback D5 for inc d/s.\nu/o 4.8\nNo stool\n138/5.3/111/17\n\nIn servo isolette.\n\nA/P:\n-- maintain cpap\n-- monitor aop on caffeine\n-- follow bili again w lytes in a couple of days\n-- initiate enteral feedings\n-- HUS today\n-- family meeting today\n-- rec'g vitamin A\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-17 00:00:00.000",
"description": "Report",
"row_id": 1744370,
"text": "Respiratory Care\nBaby remains on cpap 6 21%.Sx nptube for mod-lg cldy secs.BS clear throughout.1 spell documented,on caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744494,
"text": "NPN 7p-7a\n\n\n#1 Received infant intubated on settings 24/6 x 22. Infant\nself extubated ~ . Placed on prong CPAP 6cm. CBG ~ 0130:\nph 7.24 PCO2 63. CPAP ^ 7cm . BBS coarse but\nwell aerated. Mild-mod IC/SCR. FIo2 requirements 35-39%.\nSuctioned for mod-lg amts clr/old bloody secretions via\n and orally. Has had 2 significant drifts in sats to\nthe 60-70 range which have resolved with ease with small ^\nin O2 and as well has had 1 spell thus far in shift. A:\nstable for moment on CPAP P: Follow closely\n\n#3 TF's 150cc/k. Receiving 25cc of SC32+PM q 4hrs on a pump\nover 1hr. Weight ^ 42g. Abdomen is full and OG tube is\nvented. No spits or residuals. Voiding and passing green\nstool-heme neg. A: tolerating feeds P: follow tolerance\n\n#4 Temps 98.5-98.6x consistently overnoc in low air\n isolette. Pleasantly alert and calm overnoc. Swaddled\nwithin boundaries. A: temps wnl P:Support developmental\nneeds\n\n#5 Mom phoned for an update x 1 thus far overnoc.\n\n#10 Temps stable. On d of oxacillin Rx. Blood cx NGTD.\nTransitioned to CPAP well thus far. Active when disturbed.\nA: Abx coming to close P:F/u with TM re: plan\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744495,
"text": "RESPIRATORY CARE NOTE\nBaby #2 received intubated on settings 24/5 rate 22 FiO2 31%. At hrs baby self extubated and was placed on Prong CPAP 6 FIO2 32-39%. Cap gas PO2 32 CO2 63 PH 7.24 28 -2. CPAP increased to 7. Suctioned for mod amt of old blood tinge secretions. Breath sounds are coarse. A few drifts on the sat monitor, resolved with increased Fio2. Baby looks comfortable on CPAP. Will cont to monitor for any increased work of breathing and the need for reintubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744496,
"text": "Neonatology\nOn CPAp in approx 30% Fio2. Comfortable apeparing.\nCBG in good range. No murmur. CV stable. COmfortable apeparing.\n\nHct 34 yesterday.\n\nRemains on oxacillin Repeat BC sent last night. CBC shows 6 bands. Skin w/o leisons except for breakdown about nasal bridge. Skeleton normal. Will consider widening abx coverage if continued temp instability.\n\nWt 1015 up 40. Tolerating feeds at 150 cc/k/d of 32 cal.Abdomen benign.\n\nTemp stable except for single temp to 101.2 yetserday. Will contiunue abx for at least another day, while awaiting cx result from last night. Will discuss LP with .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744497,
"text": "Respiratory Care\nPt currrently on +7cm H2O prong CPAP. Fio2 .30-.46, bs coarse, rr 50-70 with mild retractions. On caffeine. No spells noted. cbg this am 7.31/55. Plan to support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 1744669,
"text": "1. remains on 50-100cc nasal cannula O2, RR 40-60,\nsc retractions, BS clear, mild nasal congestion, on diuril\nand KCL-dose increased today , am lytes:140/4.4/96/37 A:\naltered respiratory related to prematurity P: continue to\nwean/supply O2 to maintain sats.\n3. TFR 130cc/k/d SC32 with promod 41cc q4h, took all po this\nam, next feeding pg, abd soft, sl full, no loops, active\nbowel sounds, voiding and passsing stool, on vitamin e,\nferinsol and prune juice P: continue present care.\n4. temp stable swaddled in open crib, active with cares,\nlearning to po, eyes immature zone3-f/u wk of , repeat\nPKU sent this am, passed hearing screen A: AGA P; 60 day\nimmunizations to coordinate with twin sister, continue to\nsupport growth and development.\n5. Mom called x3 so far this am, obtained telephone consent\nfor transfer to Hospital A: planning for transfer\nto ~1500.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 1744670,
"text": "Neonatology- Progress Note\n\nPE: remains in her open crib, in nasal cannula O2, bbs cl=, upper nasal secretions audible, rrr soft systolyc murmur, abd soft, nontender, full +bs, V&S, afso, soft umbilical hernia, active with care, gavage tube in place\n\nSee attending note for plan\n\nTo Hospital today\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-03 00:00:00.000",
"description": "Report",
"row_id": 1744671,
"text": "Baby ready for transfer to hospital via ambulance accompanied by RN on cardio-resp and sat monitors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744262,
"text": "Respiratory Care\nPt extubated and placed on +6cm prong CPAP. FIO2 .21, bs clear, rr 30-50. Started on caffeine. No spells. Plan to support as needed. Will follow-up with blood gas.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744271,
"text": "NPN 0700-1900\n\n6 I&D\n\nRESP: Received infant on prong CPAP 6, 21% - no changes\nmade. LS C/=, mild-mod IC/SCR. On caffeine, no spells this\nshift.\n\nCV: Weaned off of Dopamine @ 1515, blood pressures remain\nstable. No murmur, pink/well perfused.\n\nFEN: NPO, 0.5NS+0.5UHep, PND10w/Hep, & IL infusing via UAC &\nDLUVC. Abdomen soft/round, good bs, girth stable. Voiding,\nno stool this shift. Lytes to be checked w/1st evening\ncares.\n\nPARENTS: Both parents in for all cares. Updated at bedside\nby this RN, asking appropriate questions. Plan to visit for\nall cares at this time.\n\nSEPSIS: Finished 48' R/O of Amp & Gent @ 1900. BC remain\nnegative. Antibiotics D/C'd. Problem resolved.\n\nBILI: Remains under single phototherapy, eye shields in\nplace. Plan to recheck bili w/next cares.\n\nREVISIONS TO PATHWAY:\n\n 6 I&D; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744272,
"text": "Neonatology-NNP Procedure Note\nUsing sterile technique, UAC removed without incident\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744273,
"text": "Respirtory Care\nBaby remains on cpap 6 21%.BS clear throughout.Rr 40-80.abg 7.29/40/84/20/-6 with no changes at this time.On caffeine,no spells documented thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744274,
"text": "Nursing progress note\n\n\n#1 O: Remains on 6cm prong CPAP, 21% O2. Breath sounds equal\n& clear with mild IC/SC retractions. Remains on caffeine. No\nA's, B's, or desats. A: Stable on CPAP. P: Cont to assess.\n#2 O: No murmur heard. BP means 42-48. Pink & well perfused.\nA: Stable. P: Cont to assess.\n#3 O: Wgt up 60 gms. NPO. Presently receiving 150cc/k/d. UAC\nremoved by NNP, after lytes drawn. D10W with hep & Kacetate\nPB in DUV. DUV infusing well. DS 64-78. UOP 2.5cc/k/h. Abd\nwas sl distended & NGT inserted & 10cc air evacuated. Abd\nsoft with active bowel sounds & transient loops X's 1. A:\nReceiving fluids as ordered. P: Cont to assess.\n#4 Remains on warmer, nested in sheepskin With heat shield.\nTemp stable. Irritable with cares. Sucks on pacifier. A:\nEasily stressed. P: Cluster cares.\n#5 O: Parents visited several times. Mom changed baby's\ndiaper. A: Involved parents. P: Support.\n#7 O: Single phototherapy d/c'd at 1AM. A: Resolving\nhyperbili. P: Cont to assess.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744275,
"text": "Neonatology Attending\nDay 3\n\nPrCPAP6, 21%. RR30-40s. On caffeine. ABG 7.29/40/84/-6. No A&Bs. No murmur. HR 130-140s. Off dopamine. 53/46, 48.\n\nBili 1.7/0.5 --> photot turned off this am.\n\nWt up 65 to 585. TF 150 cc/k/day. PN/IL 100, IVFs at 50. NPO.\n147/3.4/120/15 (since inc TF and removed NaCl in UAC).\nVoiding 2.5. Passed mec.\n\nOn radiant warmer.\n\nA/P:\n-- Maintain CPAP\n-- Minimal A&B on caffeine\n-- Rebound bili in am\n-- TF to stay at 150 - PN/IL w/ max acetate, inc K, min Na, NPO till acidosis improved\n-- HUS Friday\n-- Check lytes in afternoon, and in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744276,
"text": "Rehab/OT\n\nCare plan posted at the bedside. Reviewed with parents. Recommended dark blankets to cover isolettes. OT to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744277,
"text": "Nursing Progress Note\n\n\nResp: Infant cont on prong CPAP 6cm, FIO2 21%. Breath\nsounds clear and equal. RR mostly 40-60's with very mild\ninter/subcostal retractions. No bradys, cont on Caffeine.\nPlan to cont to monitor resp status closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-03 00:00:00.000",
"description": "Report",
"row_id": 1744278,
"text": "Respiratory Care\nPt recieved on nasal prong CPAP +6cm's with the fio2 21%. Pt's respiratory rates 30's to 60's, on caffine with clear B/S. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-17 00:00:00.000",
"description": "Report",
"row_id": 1744371,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS ON NPCPAP OF 6 IN 21% FIO2 ALL NIGHT. BS CL&= WITH MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING. SX'D FOR MOD-LG SECRETIONS Q4HRS, TUBE PATENT AT PRESENT. REMAINS ON CAFFEINE WITH ONE SPELL NOTED THIS SHIFT. HR 130-140'S WITH STABLE BP. COLOR PINK AND WELL PERFUSED.\n\nFEN: WEIGHT UP 7GMS TO 680GMS. REMAINS ON 150CC/KG/D OF BM/SC24CAL. ABD SOFT, FULL AND PINK WITH +BS AND STABLE GIRTH. NO EMESIS OR SIGNIFICANT RESIDUALS NOTED. VOIDING 2CC/KG/HR TONIGHT, NO STOOL.\n\nID: REMAINS ON VANCO & GENT AS ORDERED. TEMP STABLE IN SERVO CONTROLLED ISOLETTE.\n\nDEV: ACTIVE AND ALERT WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES. IRRITABLE AT TIMES BUT CONSOLABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-17 00:00:00.000",
"description": "Report",
"row_id": 1744372,
"text": "Attending Note\nDay of life 17 CAG 30 3/7\nCPAP 6 FiO2 21% RR 30-50 on caffeine\none spell overnight\nHR 130-150 60/36 MAP 40\nweigh 680 up 7 on 150 cc/kg/day 24 cal/oz pg over 1 hour\nvoiding and stool yesterday\non vit E and iron\n\nImp-stable currently\ndoing well has completed abx\nwill advance to 26 cal/oz\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-17 00:00:00.000",
"description": "Report",
"row_id": 1744373,
"text": "Neonatology NP exam Note\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small infant in isolette, on NP CPAP, comfortable.\nAFOF, sutures approximated, eyes clear, nares patent, MMMP\nChest is clear, good air exchange\nCV: RRR, no murmur, pulse+2=\nAbd: soft, prtruberant,m active bs, NTND\nGU: immature female genitlia\nEXTL , < WWP\nNeuro: quiet, responsive, appropruiate tone for GA, symmtric reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-17 00:00:00.000",
"description": "Report",
"row_id": 1744374,
"text": "0700- NPN\n\n\nRESP: Remains on NP CPAP-6, fi02 21%. LS clear/=, nares\nsuctioned q4hrs for moderate amt cloudy secretions. RR\n30s-70s, mild SC/IC retractions present. No bradys,\noccasional quick desats. Continues on Caffeine.\n\nFEN: TF 150cc/kg/d SC26/BM26, pg'd q4hrs over 40min. No\nspits, min asp. Abdomen soft, full, no loops, active BS.\nVoiding and stooling. On vitE and Fe. PICC D/C'd today.\n\nDEV: Temps stable in servo control isolette, nested with\nsheepskin. MAE, fontanels soft and flat. Alert and irritable\nwith cares, sleeping between cares. Brings hands to face,\nsucks on pacifier for comfort. AGA.\n\nPARENTING: Mom visiting this afternoon, updated by RN.\nAppropriate and .\n\nSEPSIS: 7 day course of Gentamicin and Vancomycin completed\ntoday. Antibiotics D/C'd. No evidence of sepsis at this\ntime.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-17 00:00:00.000",
"description": "Report",
"row_id": 1744375,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21%. Pt suctioned for a mod amt of thick cloudy secretions. NP-tube placed, 2.5 at 5cm's, tolerated well. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-18 00:00:00.000",
"description": "Report",
"row_id": 1744376,
"text": "Respiratory Care\nBaby remains on cpap 6 21%.Sx nptube for mod-lg cldy secs.RR 40-70's.BS clear throughout.On caffeine no spells.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744454,
"text": "Respiratory Care\nBaby received on 24/6, R 28. 02 this shift 21-32% with higer increases required for interventions. BS clear after sxn. Sxn for sm-lg amts cldy/ white secretions as per flowsheet. ABG in 37% 02: 7.35/55/71/32/2; rate decreased to 24. RR 24-30's. On caffeine, abx. One A&B with a spit recorded as of this writing. Will cont to wean vent as tol, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-17 00:00:00.000",
"description": "Report",
"row_id": 1744582,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt remains on NC primaily 100cc/min-175cc/min\nflow, 100%. Occasional brief drifts in O2 saturations noted\nin to the mid-high 80%s. Pt noted to have a few\ndesaturations as low as 68%, requiring BBO2 and one apneic\nspell. , notified. Mod retractions noted.\nIntermittent nasal flaring noted. notified\nof increased WOB. RT notified of increased WOB. CBC/diff and\nbld cx sent. A/increased WOB noted and reported to team.\nP/Cont. to monitor closely for need of additional resp\nsupport.\n\n3. F/N. O/TF remain at 150cc/k/d of SCsim32PM PNGT over 1\nhour. Please refer to flowsheet for examinations of pt from\nthis shift. Voiding/stooling. A/Appears to be tolerating\npresent feeding regimen. P/Cont. to monitor for s/s of\nfeeding intolerance.\n\n4. G/D. O/Weaned from isolette to crib. Pt now cobedding\nwith sibling in lg crib. Temp has remained stable thus far.\nDrowsy at care times and appears less active from \n notified and in to examine. Pt did open eyes and\ndemonstrated a brief period of quiet alertness once left\nundisturbed, prior to being fed. A/. in growth and dev.\nDecrease in vigor and alertness noted and reported to .\nP/Cont. to monitor closely.\n\n6. Sepsis. O/CBC/diff and blood culture drawn and sent.\nPlase refer to results. A/Sepsis eval. P/Cont. to monitor\nfor s/s of sepsis.\n\n5. . O/mother in this afternoon. Mother updated on\npt's status and plan of care. Mother participated in cares\nby changing pt's diaper and checking pt's temp. A/\nare known to be actively inovled in pt's caqre. P/Cont. to\nsupport and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-17 00:00:00.000",
"description": "Report",
"row_id": 1744583,
"text": "Neonatology Attending\n\nDOL 48 CGA 34 6/7 weeks\n\nContinues on NCO2 with increasing requirement. Today in 100-200 ml. Frequent sat drifts requiring O2 adjustment. 1 A/B today. On caffeine. R 60s-70s.\n\nSoft intermittent murmur. BP 59/30 mean 38\n\nOn 150 ml/kg/d SC 32 with promod pg. Voiding. Stooling. Wt 1465 grams (up 55).\n\nSepsis eval done secondary to increased drifting and decreased activity. CBC benign with hct 30.3, wbc 9.9 25P/0B/63L, plt 136. BC sent. No antibiotics.\n\nTemp stable in crib cobedding with sister.\n\nL eye drainage being treated with erythromycin\n\n visiting and up to date.\n\nA: Off CPAP x 2 days with some drifting in sats and increased O2 requirement. No evidence of infection. Tolerating feeds. Conjunctivitis being treated.\n\nP: Monitor\n Check CXR for lung inflation\n If atelectasis, increasing spells or desats and/or need for >250 ml NCO2, will need to restart CPAP\n Follow cultures\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-02 00:00:00.000",
"description": "Report",
"row_id": 1744662,
"text": "NPN 1900-0700\n\n\nRESP: NC 100% 50cc. LS C/=, mild SCR. On caffeine, no spells\nor drifts.\n\nFEN: Tolerating feeds well. Mom offered bottle to infant at\nfirst cares - took her full volume! Abdomen\nsoft/round, good bs, V&S. On Vit E, Iron, KCl, and prune\njuice.\n\nG/D: Temp stable swaddled in OAC, wakes for some feeds,\nsleeps well in between. Plan to transfer to when\nready.\n\n: Mom visited X1 w/sibling. Updated at bedside by\nthis RN, reviewed discharge teaching, asking appropriate\nquestions. Plans to call in AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744263,
"text": "NPN Addendum:\nInfant placed on CPAP 6 at 1400, 21% w/o change in status. Blood gas,\nCBC w/diff, lytes and bili pending. Dopamine now at 10mcg/k/min and maintaining BPm's, is pink and active. DUV now infusing D10PN, D/S 61. Dad in again this evening to visit and was updated at the bedside. Is currently resting comfortably in no apparent distress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744264,
"text": "NEonatology-NNP PRogress Note\n\nPE: is currently on an open warmer, on CPAP, bbsd sl cse=, rrr s1s2 no murmur,abd soft, full, dluvc, uac in place, afs, sutures approximated, nested active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744265,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 21%. RR 40-60's breath sounds are clear. Baby is on caffeine. Stable on CPAP cont to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744266,
"text": "NPN\n\n\n#1Resp:\no: remains on nasal prong CPAP 6 in RA with sats in 96-100\nrange. RR 40-70, mild IC/SC retractions. lungs cl=. no\nspells. desats when prongs fall out. On caffeine.\nA: Pot for spells\nP; Cont to monitor\n\n#2CV:\no: On Dopamine drip mixed 60mcg/50cc piggybacked into\nsecondary port UVC. Infant weaned to 5 mcg at present. Brief\nperiods of low maps in 29 range to high MAPs in 45 range.\nSee flowsheet for details. HR 140's, no murmur, ruddy/pink\nwell perfused.\nA: BP fluctuations but attempting to wean slowly.\nP: Cont to wean as tol.\n\n#3FEN:\no: NPO WT 520(-90 gms) 24 hr lytes 150/3.6/120/22 Increased\nTF 120cc/k/d, Double lumen UVC infusing PN D10 / and\nsecondary port changed to D10 with hep and dopamine. UVC\ninfusing 1/2 NS with 1/2 u hep /cc at 1cc/hr. One touch 95,\nvoiding 4.4 cc/k/h. no stools. tent placed over infant to\ndecrease insensible water loss.\nA: Adequate diuresis\nP: Cont to monitor FEN\n\n#4G@D:\nO: High temps on warmer. probe readjusted. Warmer shut off\nseveral times. Nsted in sheepskin. opens eyes. irritable and\nactive., .\nA/P: Cont to monitiior\n\n#6 I/D:\nO: repeat CBC and diff WBC 5.6 HCT 40. On ampi and gent as\nordered.\nA/P: COn to follow\n\n#7Bili:\nO: 24 hr bili 3.1/0.3. Began single lamp\nA/P: Cont to follow bili\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744267,
"text": "7 alt in Bilirubin\n\nREVISIONS TO PATHWAY:\n\n 7 alt in Bilirubin; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744268,
"text": "Neonatology Attending Note\nDaily note in bedside chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744269,
"text": "Respiratory Care\nPt cont on CPAP. Fio2 .21-.23, bs clear, rr 40-60. sx for sm amt. On caffeine. No spells noted. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-02 00:00:00.000",
"description": "Report",
"row_id": 1744270,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains on CPAP. Active, alert, AFOF, IUGR, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, RRR, precordium not active. Abdomen soft, non-distended with active bowel sounds, no HSM. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744363,
"text": "NPN 1900-0700\n\n\nRESP: Remains in NP CPAP 6 21%. LS C/=, IC/SCR. Suctioned x1\nthus far. On Vitamin A & caffeine, no spells thus far\n(').\n\nFEN: Tolerating full enteral feeds and increased calories\nwell, no spits or aspirates. Abdomen soft/round, no loops,\ngood bs, girth stable. V&S.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Soothes well w/hand\ncontainment and pacifier.\n\n: Mom in at change of shift, updated by this RN,\nasking appropriate questions. Independent w/cares, plans to\nkangaroo on day shift.\n\nSEPSIS: Day of Vanco & Gent. BC remain negative.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744364,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on NP CPAP 6 FiO2 21-24%. Suctioned NP tube for mod amt of cloudy secretions. Breath sounds are clear. Baby is on caffeine. RR 30-50's stable on CPAP con to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744365,
"text": "Case Management Note\n Baby has been followed on-site by Harvrad Pilgrim insurance. For d'c planning, please contact at for prior authorizations. I wil cont to assist in any d'c plans w/team/family input.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744366,
"text": "Attending Note\nDay of life 16 CGA 30 2/7\nCPAP 6 FiO2 21 % on caffeiene three spells in 24 hours\ngetting vit A\nHR 140-160 52/33 mean 39\nday of vanco and gent\nweight 673 down 4 on 150 cc/kg/day 22 cal oz BM or SSC\nno spits voiding and stooling\n\nImp-doing well currently\nwill increase to 24 cal/oz\nwill begin iron and vit E\nwill continue vanco and gent\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744367,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. Breath sounds clear and equal. Nl S1s2, no audible murmur. Pink and well perfused. Abd softly distended with active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744368,
"text": "Respiratory Care\nPt cont on NP CPAP. Fio2 .21-.23, bs clear, rr 30-50, sx for mod amt. On caffeine, 1 spell noted. Plan to support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-16 00:00:00.000",
"description": "Report",
"row_id": 1744369,
"text": "0700- NPN\n\n\nRESP: Remains on NP CPAP-6, fi02 21-23% (increased to 28%\nduring kangaroo'ing). RR 30s-60s, mild SC/IC retractions\npresent. LS clear/=, suctioned q4hrs for moderate amt thick\ncloudy secretions via NP tube (tube may need to be changed\nlater this shift). Brady with desat x2 at this time,\ncontinues on Caffeine.\n\nFEN: TF 150cc/kg/d BM24/SA24 (increased from 22 calories),\npg'd q4hrs over 40min, TW. No spits, min asp. Abdomen soft,\nvery full ( aware), no loops, active BS. Voiding, trace\nyellow stool x1. Plan to start vitE and Fe later today.\n\nDEV: Temps stable in servo control isolette, nested with\nsheepskin. MAE, fontanels soft and flat. Alert and active\nwith cares, sleeping between cares. Sucks on pacifier for\ncomfort. AGA.\n\nPARENTING: have been visiting since noon today,\nupdated by RN. Mom assisted with cares and kangaroo'd this\ninfant for about an hour while Dad held the twin. \nare appropriate and invested.\n\nI/D: Day 6 out of a planned 7 day course of antibiotics,\ntreating with Vancomycin and Gentamicin for presumed sepsis.\nNo evidence of sepsis at this time (VS stable per\nflowsheet).\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744455,
"text": "NURSING PROGRESS NOTE\n\n\n#1 O: REMAINS ORALLY INTUBATED 24/6. ABG drawn & rate to\n20 after gas. O2 21-30%. Breath sounds equal & clear after\nsuction for mod-lg wh secretions from ETT & mod-lg blood\ntinged secretions from OP. Remains on caffeine. Baby had 1\n with desat with spit, requiring mild stim, inc O2 &\nsuction. A: Stable on vent. P: Cont to assess.\n#3 O: Wgt down 21 gms. Total fluids remain 150cc/k/d. Baby\nis receiving 32 cal SSC w/PM. Feeds given pg, q4h over 1 hr.\nAbd soft with active bowel sounds & no loops. Baby had 2\nguaiac positive stools. aware. Minimal aspirate & mod\nspit X's 1. A: Abd exam unchanged. Guaiac positive stools\nprobably d/t bloody oral & nasal secrtions from suctioning.\nP: Assess for signs of feeding intolerance.\n#5 O: Mom phoned for update. A: Involved . P:\nSupport.\n#10 O: Remains on vanco & gent. Vanco dose inc after peak\nlevel drawn. Peak gent level to be drawn after next dose.\nBlood cultures neg to date. A: Sepsis suspect. P:\nAntibiotics as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744456,
"text": "Nursing progress note\n\n\n#4 O: Temp elevated X's 1 d/t probe placement. Alert with\ncares. Nested in sheepskin. A: More active this shift. P:\nCont to assess.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744457,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. Breath sounds clear and equal with fine crackles in bases. Nl S1S2, grade murmur audible. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744458,
"text": "Attending Note\nDay of life 28 CGA 32 0/7\nintubated 24/6 rate 24 FiO2 21-27% RR up to 30's on caffeine\nABG 7.35/55/71/32\nHR 150-170 72/45 mean 53\n857 down 21 of 150 SSC 32 with promod pg over 1 hour\none spit overnight no asp\nUO 3.4 cc/kg/hr\n twice both heme positive\non vit A, vit E, and iron\non vanco/gent day \nNa 136 K 4.8 Cl 100 CO2 25\nin servo isolette\n\nImp-making progress\nwill wean vent as tolerated\nwill continue current calories\nwill not have LP at this time because her decompensation was most likely due to her respiratory status\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-09 00:00:00.000",
"description": "Report",
"row_id": 1744535,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on prong CPAP 5 in 24-33% overnight.\nRR 50's-60's. Breath sounds are clear and equal. Mild IC/SC\nretractions noted. No bradycardias noted thus far. Infant\ncontinues with occaisional QSR O2 sat drifts. Remains on\ncaffeine. A: Stable on CPAP. P: Continue to monitor resp\nstatus.\n\n#3. O: Infant remains on TF's of 150cc/k/dd of SC32PM. No\nspits. Minimal aspirates. AG stable. Abd soft and round with\nactive bowel sounds. No loops. Voiding qs. Small green stool\nx1, neg heme. Wgt is up 45gms tonight to 1175gms. A:\nTolerating feeds. P: Continue to monitor feeding tolerance.\n\n#4. O: Infant remains in off isolette with stable temp. She\nis alert and active with cares. MAEW. Sucking on pacifier\nintermittently. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n#5. O: Mom and friend in this evening. Mom took temp and\nchanged diaper. Asking appropriate questions. A: Involved\nfamily. P: Continue to inform and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-02 00:00:00.000",
"description": "Report",
"row_id": 1744663,
"text": "Neonatology Attending Note\nDay 63\nCGA 37\n\nNC 50cc, 100%. RR40-60s. On diuril/KCL. Cl and = BS. Mild rtxns. On caffeine. +murmur. HR 140-150s.\n\nWt up 35 to 1885. TF 130 cc/k/day SC32. PO 2 xday/PG. Tol well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\n-- given advancing GA, resolving will d/c caffeine\n-- wean O2 as tol\n-- eye exam next week\n-- monitor lytes while on diuril and KCL\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-02 00:00:00.000",
"description": "Report",
"row_id": 1744664,
"text": "Neonatology- Progress Note\n\nPE: remains in her open crihb, nested, in nasal cannual O2, bbs cl=, intermittent tachypnea, rrr soft systolyc murmur, abd soft, nontender, V&S, afs, sutures approximated, active with care, gavage tube in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-02 00:00:00.000",
"description": "Report",
"row_id": 1744665,
"text": "#5 \ns/o: Mom called x3- updated. Discussed plans to possibly\ntransfer infant to Hospital tomorrow. Mom visited\nthe facility today. Mom aware she will need to sign consent\nfor transfer when she visits tonight. A: Invested mom\nP: updated. Plan for transfer to Hospital\ntomorrow in order for infant to be closer to home.\n#4 G&D\ns/o: Drowsy for cares x2- yet tone good. with noon\ntime care- and po fed well--steadily with coordinated\nsucking. Initial sucks assoc with desat-- yet infant self\nregulated and no further distress with that feeding. Temp\nstable in open crib. A: CGA 37 wks-- beginning to po feed\nP: cont dev supportive care. F/u eye exam next week.\n#1 RESP\ns/o: Rec'd in 50cc flow of 100% FiO2. color . RR 40-60\nwith very mild ic/sc retractions. BS CTA. Some clear\ndrainage from eyes and some nasal stuffiness noted. Attempt\nto gently bulb sx yielded no secretions. Remains on diuril,\nKCl A: Remains flow dependent to maintain sats in 90s.\nDiuretics continue. P: Cont to mtr wob, sats, adjust flow to\nmaintain sats>90. check crit and retic with AM .\n#3 FEN\ns/o: FR at 130cc/k/d of SC 32 with promod. PO feeding -\notherwise- pg fed. TOl well without emesis and min asp. Abd\nfull-+flatus, some stool (G-). Remains on daily prune juice.\nA; full abd -bears cont close mtring. Cal dense feeds to\npromote growth. P: Mtr abd, report changes, Lytes to be\ndrawn in AM along with hct and retic.\nDaily wt.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-02 00:00:00.000",
"description": "Report",
"row_id": 1744666,
"text": "Addendum--\nIncrease in flow to 100cc with bottling- gradual wean and presently on 75cc flow to maintain sats.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-15 00:00:00.000",
"description": "Report",
"row_id": 1744358,
"text": "NPN 1900-0700\n\n\nRESP: Remains on NP CPAP 6, 21%, LS coarse-->clear after\nsuctioning. On caffeine, no spells thus far. NP tube changed\nby RT after suctioning large amounts of thick secretions.\n\nFEN: Tolerating full feeds well, no spits, minimal\naspirates. Abdomen soft/round, good bs, girth stable, V&S.\nHep locked central PICC remains intact in right leg.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Soothes well w/hand\ncontainment and pacifier.\n\n: Mom called x1 thus far, updated by this RN, asking\nlots of appropriate questions. Plans to visit on day shift.\n\nSEPSIS: Day of Vanco & Gent. BC remains negative. LP\nresults negative. Will continue to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-15 00:00:00.000",
"description": "Report",
"row_id": 1744359,
"text": "Attending Note\nDay of life 15 CGA 30 1/7\nCPAP 6 FiO2 21% RR 40-50\non caffeine had one spell in 24 hour\non vitamin A\nintermittent murmur HR 130-150 67/43 mean 50\nweight 677 up 12 on 150 cc/kg/day on 150 cc/kg/day of BM 20\ntolerating feeds well\nvoiding and passed trace stool\nin isolette\nday \n\nImp-making good progres\nwill check vanco levels today\nwill advance to 22 cal/oz\nwill complete antibiotic course\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-15 00:00:00.000",
"description": "Report",
"row_id": 1744360,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt remains on NP CPAP of 6, FIO2 primarily 21%\n(Occainally increasing FiO2 briefly during care times to\napprox 30%). See flowsheet for spells noted this shift.\nRemains on caffeine. A/Occasional spells noted. Requires\nCPAP. P/Cont. to monitor for A/B and intervene as pt needs.\nCont. to monitor for increase in WOB.\n\n3. F/N. O/Tf remain at 150cc/k/d of BM22/PE22 pngt over\n30min. Please refer to flowsheet for examinations of pt from\nthis shift. Voiding. Passed heme positive aware\nand was in to examine pt at that care time. A/Advancing diet\ngradually. P/Cont. to monitor for evidence of feeding\nintolerance.\n\n4. G/D. O/Pt remains on servo control in an isolette. Temp\nslightly elevated this afternoon- see flowsheet. Pt awake\nand briefly alert with cares. Sleeping well in between.\nA/Alt. in g/d. P/Cont. to support pt's growth and dev.\nneeds.\n\n5. . O/Mother called this am. Mother updated on pt's\nstatus and plan of care. MOther stated that she would be in\nat 4:30pm today. A/ are actively involved in pt's\ncare. P/Cont. to support and educate .\n\n8. Sepsis. O/BLd cultures neg to date. Remains on Gent and\nVanco via intact PICC. P/Cont. to monitor for s/s of sepsis.\nCont. with current treatment plan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-15 00:00:00.000",
"description": "Report",
"row_id": 1744361,
"text": "Neonatology NP Exam NOte\nPlease refer to attending note for details of evaluation and plan.\n\nPE: small infant nesteled in isolett on CPAP\nAFOF sutures open, eyes clear, nares intact, MMMP\nChest with fair air exchange, comfortable resp pattern\nCV: RRR, no murmur, nl S1, split S2, pulses+2=\nAbd: soft, protruberant, active bs\nGU: immature\nEXT: MAE, lean, WWP\nNeuro: active and responsive with exam. Stress intolerant. Consoles with boundaries.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-15 00:00:00.000",
"description": "Report",
"row_id": 1744362,
"text": "Resp care\nPt remains supported on 6cm/h2o of NPCPAP, 21%\nRR- 30-50's w/ mild retractions\nB/S clear, Sx small amount of cloudy secretions\nBaby receiving caffeine, 1 spell documented thus far\nrequiring moderate stimulation, & increased Fio2\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744446,
"text": "Respiratory Care\nBaby continues on 24/6, R30, with 02 22-36% this shift. BS clear after sxn. Sxn as per flowsheet for mod-lg amts white sec. RR 30-38. No bradys recorded, but occ sat drifts/desats noted. Infant usually requires increased 02 for handling. On caffeine, abx. CBG pending. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744447,
"text": "Neonatology Attending\n\nDay 27 CGA 31 6/7 weeks\n\nRemains on simv 24/6, x30, 0.22-0.36. CBG 7.23/61/37, 7.27/57. On caffeine. Had one bradycardia episode over last 24 hours. BP mean 49. On vancomycin and gentamicin. Weight 878 gms (+33). TF at 150 cc/kg/d. On SC 32 with Promod. Mild intermittent spits. Benign abdomen. Urine output 2.4 cc/kg/hr. Stable temperature on servo-controlled incubator. Kangaroo with mother yesterday.\n\nRemains with ventilation requirement out of proportion to oxygen requirement. CXR 36 hours ago shows small lung volumes. Will repeat CBG and determine if higher pressures needed. Inordinate weight gain over last 2-3 days. Will administer one dose of furosemide with CBG to follow. Tolerating feeds well. Keeping updated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744448,
"text": "Respiratory Care Note\nCBG:7.34/57/32/32/2. Weaned rate to 28.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744449,
"text": "Respiratory Care Note\nCBG:7.34/57/32/32/2. Weaned rate to 28.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744450,
"text": "Respiratory Care Note\nPt remains on IMV 24/6, RR 30, FiO2 21-33%. BS clear after suctioning. Suctioned for large amount cloudy secretions from ETT. Nares suctioned for large amount yellow bloody secretions. RR 30-40. Pt rides vent rate at times. On caffeine. One brady today. Given Lasix. CBG pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744451,
"text": "Respiratory Care Note\nCBG:7.34/57/32/32/2. Weaned rate to 28.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744452,
"text": "NPN 0700-1900\n\n\nRESP: Received infant in IMV 24/6 R30 - weaned rate to 28\nafter 1800 CBG of 7.34/57. LS coarse-->clear after\nsuctioning q cares. IC/SCR. On caffeine, 1 spell this shift\n(').\n\nFEN: Tolerating feeds gavaged over 1 hour, venting tube in\nbetween feeds. Spit X1, no aspirates. Abdomen soft/round, no\nloops, good bs, girth stable. Received lasix this AM - u/o\nfor 8 hours since lasix 6.0cc/kg/hr. Stooling heme negative\ngreen stool. On Vitamin E and Iron.\n\nG/D: Temp stable nested in sheepskin in servo isolette.\nDrowsy w/cares, but getting more alert as the day went on.\nSleeps well in between.\n\n: Both in for most of day, updated by this\nRN, asking appropriate questions. Had family meeting w/\nand this RN. Mom called x1 since leaving here.\n\nSEPSIS: Continues on Vanco and Gent. Vanco levels due this\nevening. BC remain negative.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744453,
"text": "NEonatology- PRpgress Note\n\nPE; remsins in her isolette, on 24/6 X30 .22-.35 bbs cse=, rrr s1s2no murmur,a bd soft, nontender, V&S, afso, feeding tube in place, piv\n\nSee attending note for plan\n\nUpdated at bedside, will continue to keep informed\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-09 00:00:00.000",
"description": "Report",
"row_id": 1744536,
"text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 24-33% this shift. BS coarse. sxn x1 for mod amt blood-streaked secretions. RR mostly 40's-60's with mild IC/SCR. No bradys noted, but infant has sat drifts/ desats occasionally requiring increased 02. On caffeine. Plan cont CPAP, monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-09 00:00:00.000",
"description": "Report",
"row_id": 1744537,
"text": "Newborn Med Attending\n\nDOL#40. Cont on CPAP5, 24-30%. No spells. AF , clear BS, + murmur, abd soft, MAE. Wt=1175 up 45, on 150 cc/kg/d, SC32 with PM.\nA/P: Growing infant with residual CLD. Wean from CPAP as tolerated. Cont current feeding plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-09 00:00:00.000",
"description": "Report",
"row_id": 1744538,
"text": "NPN 0700-1900\n\n\nRESP: Received infant in Prong CPAP 5 - no changes made.\nFiO2 remains 29-30% thus far. LS C/=, mild SCR. On caffeine,\nno spells thus far, 0/24'.\n\nFEN: Tolerating full gavage feedings well, no spits or\naspirates. Abdomen soft/round, good bs, no loops, girth\nstable. V&S (heme negative). On Vitamin E & Iron.\n\nG/D: Temp stable swaddled in off isolette. A&A w/cares,\nstarting to wake for feeds. Sleeps well in between. Sucks\nactively on pacifier and brings hands to face for comfort.\n\n: Both in for midday cares, updated at\nbedside by this RN, asking appropriate questions.\nIndependent w/cares, Mom currently holding .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-09 00:00:00.000",
"description": "Report",
"row_id": 1744539,
"text": "Resp care\nPt remains supported on 5cm/h2o of NCPCP, 28-30%\nRR- 40-60's w/ mild retractions\nB/S clear, Baby receiving caffeine, no spells documented\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1744618,
"text": "NPN 1900-0700\n\n\n#1Resp. Pt. remains on bubble CPAP of 5 via prongs. FiO2\n23-25%.O2 sat 94-97. RR 40-60s, LS clear and equal, SC\nretractions present. Remains on caffeine, no spells. Plan to\ncontinue CPAP, monitor resp. status.\n\n#3FEN. Wt. 1635 gms, up 20 gms. Pt. on TF of 150cc/k/day of\nSCsim32 withPM, 41cc q 4 hrs over 1 hour. Abd.very round,\nsoft, active BS. No loops, girth stable. No spits, minimal\naspirates. Voiding. No stool. Remains on vitamin E and iron.\nPlan to continue current feeding plan, monitor for tolerance\nof feeds, monitor wt. gain.\n\n#4G/D. Pt. swaddled in OAC, cobedding with twin. Temp.\nstable. Pt. with cares, settles easily between cares.\nPlan to continue to support dev. needs.\n\n#5Parents. Mom here for evening ccares, held infant during\nfeeding, independent with cares.Updated by and RN. Mom\ncalled x1, updated. Plan to continue to support .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1744619,
"text": "Respiratory care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 24-25%. BS are clear. On Caffeine. Pt. sx'd for mod. cloudy secretions. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1744620,
"text": "NICU Attending Note\n\nDOL # 54 = 35 5/7 weeks CGA with CLD, issues of growth and nutrition\n\nPlease see full \n\nCVR/RESP: Baseline soft systolic murmur (structurally normal heart by echo), BS clear/=, CPAP @ 5, 25% FiO2, lasix x 1 yesterday with no effect, also on caffeine with no A/B. Will continue CPAP.\n\nFEN: Weight today 1635 gm, up 20 gm, abd slightly distended but soft with stable AG, on 150 cc/kg/d SC 32 with PM, all PG, tolerated well. Will continue current diet.\n\nOPTHO: eye exam : immature zone 3, f/u in 3 weeks.\n\nNEURO: grade I IVH on head U/S. f/u prior to transfer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-19 00:00:00.000",
"description": "Report",
"row_id": 1744384,
"text": "Neonatology Attending\nDOL 19 / CGA 30-5/7 weeks\n\nOn CPAP 6 cm H2O in 21% FiO2. On caffeine with two bradycardias in 24 hours.\n\nNo murmur (echo showed only PFO). BP 64/39 (48).\n\nWt 720 (+22) on TFI 150 cc/kg/day BM26/SSC26PM, tolerating well. Abd full secondary to CPAP but benign. Voiding and stooling (guiac negative).\n\nTemperature stable on servo isolette.\n\nA&P\n28 week GA twin with respiratory and feeding immaturity\n-Continue with CPAP\n-Advance to 28 kcal/oz\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-19 00:00:00.000",
"description": "Report",
"row_id": 1744385,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt. remains on NP CPAP of 6, in RA. Occasionally\nrequiring increase in FIO2 to approx 29% with\ncares/suctioning. Please refer to flowsheet. Remains on\ncaffeine. No spells noted this shift thus far. A/Resp status\nappears stable on NP CPAP at this time. P/Cont. to monitor\nfor evidence of resp distress and A/B.\n\n3. F/N. O/TF remain at 150cc/k/d of SC28PM/BM28PM. Diet\nadvanced to 28cal/oz this afternoon. Please refer to\nflowsheet for examinations of pt from this shift. Voiding.\nPassed a trace amt of stool this am. A/Advanced calories\ntoday. P/Cont. to monitor for intolerance to feedings.\n\n4. G/D. O/Temp stable on servo control, nested in sheepskin\nin a covered isolette. Awake and very alert with cares.\nOccasionally sucking on pacifier. PT noted to be active at\ntimes in between cares and was able to change her\npositioning in bed. A/Alt. in G/D. P/Cont. to support pt's\ngrowth and dev. needs.\n\n5. . O/Mother called this am. Mother updated on pt's\nstatus and plan of care. Mother stated that she would be in\nfor th 4pm cares today. A/Parent are known to be involved in\npt's care. P/Cont. to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-19 00:00:00.000",
"description": "Report",
"row_id": 1744386,
"text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable on NPCPAp 6, fio2 21%. Breath sounds clear and equal. Occ spells on caffeine. She is tolerating full volume feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-19 00:00:00.000",
"description": "Report",
"row_id": 1744387,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21%. Pt's respiratory rates 30's to 60's. Pt suctioned for a mod amt of thickish yellow secretions. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-20 00:00:00.000",
"description": "Report",
"row_id": 1744388,
"text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS ON CPAP 6. FIO2 21%, INCREASED TO 30% DURING\nCARES/SUCTIONING. BS COURSE TO CLEAR. RESP RATE 36-64 WITH\nIC/SC RETRACTIONS. SATS 95-100% IN 21%. BRADY X1 OVERNIGHT\nWITH SLEEP.\nA:STABLE\nP:CONTINUE TO MONITOR RESP STATUS AND SPELLS\n\n#3F/E/N\nO:TF AT 150CC/KG SCF28/BM28 18CC Q4HR GAVAGE OVER 40\".\nABDOMEN SOFT, ROUND AND FULL WITH GOOD BS. NO ASPIRATES AND\nNO LOOPS. AG 18-18.5CM. WT UP 1 GM. VOIIDNG WELL; SMALL\nGREEN HEME NEG STOOL X1\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR WT GAIN AND TOLERANCE TO FEEDS\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH STABLE TEMPERATURE.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. NESTED ON\nSHEEPSKIN W/BOUNDARIES. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\nL#5PARENTING\nO:MOM X1 FOR UPDATE\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744289,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt remains on Nasal Prong CPAP of 5, RA\nconsistently this shift. No spells or desaturaions noted.\nA/Resp status stable on CPAP. P/Cont. to monitor.\n\n2. CV. O/no murmur noted this shift thus far. See flowsheet\nfor BP results. A/CV status appears stable. P/Cont. to\nmonitor.\n\n3. F/N. O/Team aware of dstick results from noc shift and\nthis am. TF decreased to 160cc/k/d. Presently TPN D10/IL\nrunning at 140cc/k/d via intact DLUVC. Enteral feeds of\nBM/PE20 at 20cc/k/d PNGT over 30min. Please see flowsheet\nfor examinations of pt from this shift. See urine output. No\nstool passed this shift as of yet. NGT vented in between\nfeeds. A/Alt. in F/N. P/Monitor for evidence of intolerance\nto feeding advancement. Monitor I/O.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744290,
"text": "Nursing NICU Note\nPt had 2 spells noted this shift. Please refer to flowsheet for detail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744291,
"text": "Nursing NICU Note\nPt had 2 spells noted this shift. Please refer to flowsheet for detail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744292,
"text": "Nursing NICU Note\nPt had 2 spells noted this shift. Please refer to flowsheet for detail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744293,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744294,
"text": "Respiratory Care Note\nPatient remains on +5 prong CPAP, FiO2 21%. BS clear. RR 40-60's. On caffeine and Vitamin A. 2 bradys this shift as of this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744295,
"text": "NNP On-Call/Procedure Notes\n#1 P-CVL\n\nIndication: long-term IV access\n\n#1.9 Neo-Picc catheter advanced to 17 cm via introducer in right saphenous vein at the ankle. Draws and flushes easily. Secured with sterile occlusive dressing. Aseptic technique with betadine/alcohol skin prep. Infant tolerated procedure well, no complications. Babygram x-ray shows tip in IVC.\n\n\n#2 UVC removal\n\nUVC removed without incident. No bleeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744296,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. No spells thus far. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744297,
"text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCONTINUES ON PRONG CPAP AT 5CM. NO O2 REQUIREMENT. BBS\nCLEAR, RR 30-60'S. NO APNEA OR DESATS.\n3. F/N\nTONIGHT'S WEIGHT DOWN 2 GRAMS TO .54KG. TOTAL FLUIDS AT\n160CC/KG. 140CC/KG OF D8PN AND IL INFUSING VIA NEW CENTRAL\nPICC. LINE PLACED AND PN HUNG AT 2200. ONETOUCH AT 0500\n226, NNP AWARE. OUTPUT 3CC/KG/HOUR FOR 24 HOURS.\nTOLERATING 20CC/KG OF FSBM. ABD BENIGN. ACTIVE BOWEL\nSOUNDS, NO STOOL.\n4. G&D\nTEMP STABLE ON SERVO MODE. ALERT WITH CARE. TOLERATED PICC\nPLACEMENT WELL, GIVEN SUCROSE PACIFIER.\n5. PARENTS\nMOM CALLED AND UPDATED. WILL BE IN TODAY.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744260,
"text": "Nursing Status/Progress Note 7A-7P\n\n\n#1 Infant currently on 21% r14 p16/5. Sao2 >98%. No brady's,\nand will start on caffeine in preparation for CPAP. Has\ntransient desat's with handling but returns to baseline when\nsettled. LS = and slightly coarse but improve with sx'ing.\nMild retractions noted (wt 612 gms). Will assess for wean to\nCPAP.\n\n#2 Remains on Dopamine, concentration changed to 60mg in\n50cc's (of D10W w/0.5uhep/cc)for TF balance. Target BPm\n33-37, and is requiring 15mcg/kg/min. Had also been given\n6cc's NS bolus for BPm slow decrease to 26. Has remained\npink and well perfused throughout. HR 140's, no murmur\naudible. Curretn blood out ~2.6cc's. Will con't o montior\nclosely.\n\n#3 TF at 105cc/k/d (for min rate to maintain umbi line\nintegrity). UAC: 1/2 ns w/0.5uhep/cc, DUV #1:D10W\nw/0.5uhep/cc and #2 D10W w/0.5uhep/cc + piggyback of\nDopamine (60mg/50cc's) in D10W. D/S:58. Is voiding well, no\nstool though active bowel sounds. Tummy is pink and soft\nwith uniform color. Will con't to monitor I&O.\n\n#4 Maintaining temp on servo-warmer, transient desat's with\nhandling but returns to baseline. Reactive to touch. Wt 612\nat 28wks. Skin intact.HUS scheduled for Friday . Will\ncon't present appropriate interventions (decrease touch,\ndarkened room, low noise).\n\n#5 Mom stopped by NICU on gurney when brought to post-partum\nthis AM. Was updated (along with dad) at bedside. Mom seemed\nvery tired and somewhat uncomfortable but smiled when\ndiscussing infant's observed comfort and quietness. Will\ncon't to update, plan for Family meeting.\n\n#6 On amp and gent, planning to repeat CBC w/diff (low\nwbc)at 24hrs. Planning for 48hr rule-out if blood cultures\nremain neg. Will con't to assess for S&S of sepsis.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744261,
"text": "Clinical Nutrition\nO:\n28 wk gestational age BG, SGA w/ IUGR (discordant twins), now on DOL 1\nBirth wt: 612 g (<10th %ile)\nHC: 23 cm (<10th %ile)\nLN: 30 cm (<10th %ile)\nMeds include dopamine gtt.\nLabs to be checked @~24 hrs of age\nNutrition: TF @ 105 cc/kg/day. NPO. UAC infusing 1/2 NS @ 0.9 cc/hr. Dopamine gtt @ 0.8 cc/hr in D10. Remainder of IVF via DUVC @ D10. Plan to change IVF to PN tonight; projected intake for next 24 hrs ~19 kcal/kg/day, ~1.5 g pro/kg/day, no lipids yet. Glucose infusion rate from all sources ~4.8 mg/kg/min.\nGI: Abdomen soft and full; no BM yet.\n\nA/Goals:\nTolerating IVF w/ good BS control so far although last dstick down to 58. Remains NPO. Plan to change IVF to PN tonight via DUVC. Labs due to be checked @ ~24 hrs of age. Initial goal for PN is ~90 to 110 kcal/kg/day, ~3 to 3.5 g pro/kg/day , and ~3 g fat/kg/day. PN will advance as per protocol. Plan to add lipids tomorrow. When able to start EN feeds, initial goal is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. Expect PN to taper as EN advances towards goal. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain, and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744444,
"text": "NPN 0700-\n\n\n1. Intubated, 24/6 x30, FiO2 30-32%. RR 20-40's, rides the\n vent. LS coarse, clearer after suctioning. IC/SC\nretractions. Sputum culture sent this afternoon- results\npending. Suctioning every 4 hours for mod-lg amount cloudy\nwhite secretions. Continues on caffeine. No spells thus\nfar this shift, occasional drifts in sats. Continue to\nmonitor resp status, monitor for spells, will obtain CBG\nthis afternoon.\n\n3. TF 150cc/kg/day, SC 32 with promod, gavaged over 1 hour\nsecondary to reflux. Belly soft, +BS, no loops, med spit\nthis AM. Max aspirate 1.6cc- leaving NG vented between\nfeeds. Voiding, stooling, heme neg. 8 hr u/o 2.8cc/kg/hr.\nAG stable at 19.5cm. Continue to monitor tolerance to\nfeeds.\n\n4. Temp stable in servo isolette. Awake, opens eyes with\ncares, but quiet. AFSF, sutures smooth. Continue to\npromote growth and development.\n\n5. Mom here at noon, updated on progress, plan of care.\nMom plans to kangaroo this afternoon. Mom and\nattentive, asking appropriate questions. Continue to\nupdate, educate and support .\n\n10. Infant remains on vanco and gent, vanco levels to be\ndrawn with this evenings dose, gent levels in AM. Sputum\nculture sent- results pending. No growth to date on blood\ncultures. Team to obtain consent for LP to be done\nbefore antibiotics dc'd. Continue to monitor for s/s of\ninfection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-27 00:00:00.000",
"description": "Report",
"row_id": 1744445,
"text": "Nursing progress note\n\n\n#1 O: Remains orally intubated in 25-35% O2, 24/6, X's 30.\nBreath sounds equal & coarse to clear after suction. Mod\nIC/SC retractions. Suctioned q4h for mod-lg wh secretions\nfrom ETT & OP. Remains on caffeine. No A's or B's this\nshift. Occasional desats requiring inc O2 &/or suction. CBG\nto be drawn. A: Unchanged. P: Cont to assess.\n#3 O: Wgt up 33 gms. Remains on 150cc/k/d 32 cal SSC w/PM.\nFeeds given PG, q4h, over 1 hr. Abd soft, full with active\nbowel sounds & no loops. UOP until midnoc was 1.92cc/k/h.\nBaby X's 2. Guaiac neg. Baby has had sm-med spit\nwith ea feed. Max aspirate was 1.1cc. A: Continues to spit.\nP: Inc duration of feed.\n #4 O: Remains in servo isolette. temp 98.3-99.8. Quietly\nalert with cares. Nested in sheepskin with H2O pillow. A:\nAGA. P: Cont to assess.\n#5 O:Mom phoned for update. A: Involved . P: Support.\n#10 O: Remains on antibiotics. Sputum culture pending. Blood\nculture neg to date. peak Vanco & trough Gent levels drawn.\nA: Sepsis suspect. P: Antibiotics as ordered.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744520,
"text": "NICU NSG NOTE\n\n\n#1. Resp. O/ Conts on Prong CPAP 5 in 25-30%. LS clear and\nequal. IC/SubC retractions. RR 40-70's. On caffeine. No\nspells. A/ Stable on CPAP. P/ Cont to monitor resp status\nclosely. Monitor for increased effort/support/spells.\n\n#3. FEN. O/ Wt up 15g. TF 150cc/k/d SC32 with PM. REceiving\nq4h volumes via gavage over 40 mins. Abd soft and round.\nVoiding and stooling. No spits or loops. Max asp 1.2cc. AG\n22cm. Conts on VitE and Fe. A/ Tolerating feeds. Full feeds.\nGaining wt. P/ Cont to monitor for feeding intolerances.\nDaily wts.\n\n#4. G&D. O/ Awake and quietly alert with cares. temps stable\nin off isolette. Nested on sheepskin. Boundaries in place.\nA/ AGA. P/ Cont to support developmental needs of infant.\n\n#5. Parenting. O/ Mom called x1 for update. Asking\nappropriate questions re: # of spells. Updated over phone.\nA/ Involved. P/ Cont to provide info and support to family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-08 00:00:00.000",
"description": "Report",
"row_id": 1744529,
"text": "NPN 1900-0700\n\n\n1. RESP\nO: Remains in Prong CPAP 5, FiO2 25-36% (mainly 25%).\nBreathing 30-60s, sats 92-98%. Mild baseline IC/SCR noted.\nLS clr/=. TB suctioned x1 for sm amt plus old plugs. No\nA&B's. On caffeine. A: Stable in current resp support. P:\nCont to monitor for s/s resp distress, wean O2 as tolerated.\n\n3. FEN\nO: Current wgt= 1130g (+35). TF 150cc/kg/day of SC32 + PM.\nGavaging 28cc over 40 mins via OG tube. Abd full, +BS, no\nloops. A/G 22.5-24cm. No spits. Max asp= 1.4cc (nonbilious).\nVoiding and stooling trace amts. On FeSO4, Vit E. A:\nTolerating feeds. P: Cont to monitor FEN status, wgt gain.\n\n4. G&D\nO: is alert/active with cares. Temps stable swaddled\nin off isolette. ,. Sucks on pacifier, brings hands\nto face. Sleeping well b/w cares. A: AGA. P: Cont to provide\ndev appropriate care.\n\n5. \nO: Mom called for update x1. Spoke w/this RN. Pleased\nw/'s progress. Asking appropriate questions. Plans to\nvisit later today. A: Attentive, family. P: Cont to\nsupport and educate family.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-08 00:00:00.000",
"description": "Report",
"row_id": 1744530,
"text": "Respiratory care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-08 00:00:00.000",
"description": "Report",
"row_id": 1744531,
"text": "Neonatology Attending\nDOL 39 / CGA 33-4/7 weeks\n\nOn CPAP 5 cm H2O in 28-35% FiO2. No apneas/bradycardias, on caffeine.\n\nMurmur (PFO on echo). BP 60/27 (40).\n\nWt 1130 (+35) on TFI 150 cc/kg/day SC32PM, tolerating well over 40 minutes. Abd full at baseline but soft. Voiding and stooling appropriately (guiac negative).\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with CLD, feeding immaturity\n-Continue current management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-08 00:00:00.000",
"description": "Report",
"row_id": 1744532,
"text": "Respiratory Care Note\nPt continues on prong CPAP +5, .30-.35FiO2. BBS ess clear. RR 40-70. NARD. Slightly increased FiO2 requirement -monitoring closely. Will continue to follow and wean FiO2 as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-08 00:00:00.000",
"description": "Report",
"row_id": 1744533,
"text": "Neonatology- Progress Note\n\nPE: remains in her isolette, on prong CPAP 5, >28-.35 bbs cl=, nasal bridge slightly red (improved) with less edema, rrr s1s2no murmur, abd soft, full + bs, V&S, afso, gavage tube in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-08 00:00:00.000",
"description": "Report",
"row_id": 1744534,
"text": "NPN 7a7p\n\n\nResp\nInfant conts on CPAP 5 Fio2 of 30-36% thru day. Needing\nincreased os during cares and when held by father. \nspells. Caffiene conts. LSC. I/C S/C rtxs. Monitor and\nsupport resp status.\nF&N\nInfant on Tf 150 cc/k/d SC32PM gavaged via OG q 4 hrs for\n40\". No spits. Min asps. Thick dry trace stool. Abd soft but\nfull, no loops. Active BS. Gaining wt and tolerating TF.\nMonitor weight and exam.\nG/D\nInfant in off isolette with stable temps. A/A for cares.\nUses pacifier with support around CPAP. MAEs. FS&F. AGA.\nMonitor and support G/D.\n\nBoth in for cares of this infant today. Asking\nquestions. Dad held infant for 40 mins. Understood infants\nneed to go back to conserve energy. Witnessed increased o2\nneed during hold time. anxious for both infants to\ngrow and interact. . Support and educate around\ndevelopmental needs of premies.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1744621,
"text": "Respiratory Care\nPt currently on prong CPAP. Fio2 .24-.27. bs clear, rr 40-60. On caffeine. No spells noted this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1744622,
"text": "Nursing Progress Note\n\n\n1. Resp O/A Rec'd inf in prong CPAP 5. Inf remains on\nbubble CPAP 5. FIO2 requirements have been 21-27% thus far.\n SCR noted. No spells thus far. Inf remains on caffeine as\nordered. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of SC32w/PM. All feedings\nPG over 1 hour. Tol well. No spits thus far, min asp.\nBelly full round, soft, no loops noted. Inf voiding,\nstooling guiac neg. P cont to assess FEN needs.\n4. DEV O/A remains in an OAC cobedding with her\ntwin. TEmp stable. A/A with cares. P cont to assess dev\nneeds.\n5. O/A Mom and Grandmother in for visits and\ncares. Mom independent with temp taking and diapering.\nUpdates given. P cont to support, educate.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-23 00:00:00.000",
"description": "Report",
"row_id": 1744623,
"text": "Neonatology NP Note\nPE\nswaddled in open crib, cobedding with twin\nAFOF, sagital very slightly split\nmild subcostal retractions on CPAP, lungs clear/=, good air entry\nl/VL SEM at LSB, pink and well perfused\nabdomen soft/full, nontender\nactive with good tone\nslight erythema over nasal bridge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744351,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on NP CPAP 6 FiO2 21%. Suctioned NP tube for sm amt of clear secretions. Breath sounds are clear. Baby is on caffeine. RR 30-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744352,
"text": "Attending Note\nDay of life 14 CGA 30\nCPAP 6 FiO2 21% RR 40- 60 on caffeine\non vit E as well\nHR 130-150 BP 55/37 mean 43\non Day of vanco/gent\ndose adjusted for low level yesterday\nweight 665 grams up 13 on 150 cc/kg/day of BM 20 at 140 cc/kg/day pg\nmax aspirated 2 cc\nin servo controlled isolette\n\nImp-making good progress\nwill check levels with new dose of vanco\nwill continue to advance enterals\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744353,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. Breath sounds clear and equal. nl S1S2, no audible murmur. Pink and wel perfused. Abd benign, no HSM. active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744354,
"text": "NPNote\n\n\n#1.Remains on NP CPAP of 6cm, Fio2 21%, BBs clear, coarse,\nmild intercostal/subcostal retractions present, on Caffine,\nspell x1 during kangaroo care,On Vit A given today.cloudy Et\nsecretions suctioned, whitish oral secretions suctioned.A;\nNeeded cPAP support. p; cont resp support as needed.\n\n#3. Tf=150cc/kg/day, On feeds at 150cc/kg/day,MBM20, Pg fed\nover 40mts, PICC line hep locked,BS+, no loops, voided,no\nstool A; Feeds tolerated. P; cont current feeding plan.\n\n#4.Alert,active with care, temp stable in a servo control\nisolette, nested in sheepskin, mae,A; AGA p; cont dev\nsupport.\n\n#5. visited, updated at the bedside by , Dad\nkangarooed the baby for 60mts, are independent with\ncare,A; p; cont update and teaching.\n\n#8. On Vanco and Gent given as ordered, D4/7. PICC line hep\nlocked in situ.A; Asymptomatic. P; cont to monitor for s/s\nof sepsis.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744355,
"text": "Clinical Nutrition:\nO:\n~30 wk CGA BG on DOL 14.\nWT: 665g(+13)(<10 %ile); birth wt: 612g. Average wt gain over past wk ~21g/kg/day.\nHC: N/A\nLN: N/A\nNutrition: 150cc/kg/day as BM 20; pg over 30 mins. Just reached full feeds; projected intake for next 24hrs ~150cc/kg/day, providing ~100kcal/kg/day & ~1.6g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; all pg. Current feeds & supps not yet meeting recs for kcal/pro/vits/mins; just reached full feeds. Feeds to advance as per growth & tolerance. Growth is slightly exceeding recs of ~15-20g/kg/day for WT gain. Will monitor trends. HC/LN measurements N/A for comparison. Will cont. to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744356,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21%. Pt suctioned for a mod amt of thickish cloudy secretions. PT'S respiratory rates 30's to 60's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-15 00:00:00.000",
"description": "Report",
"row_id": 1744357,
"text": "Respiratory Care\nBaby remains on cpap 6 21%.NPTube changed,sx for copious thick yellow/bld tinged secs.Unable to pass nptube down opposite nare.BS clear throughout,RR 40-50.On caffeine no spells documented thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744521,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 5 FiO2 26-30%. RR 40-70's baby is on caffeine. No spells or desat's so far tonight. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744522,
"text": "Attending Note\nDay of life 38 CGA 33 3/7\nCPAP 5 FiO2 26-30% RR 30-70 on caffeine no spells in 24 hours\nHR 150-160 64/ 40 mean 48\nweight 1095 up 25 on 150 cc/kg/day of SSC 32 with promod\nvoiding and stooling\nin iron and vit E\n\nImp-stable making slow progress\nwill continue CPAP for the moment\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744523,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF\nmild subcostal/intercostal retractions, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft/full, nontender and nondistended, active bowel sounds\nactive with good tone\noverall vigorous and active./\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744524,
"text": "Addendum\n\nnasal bridge with minimal erythema and decreased edema since yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744525,
"text": "Addendum\n\nnasal bridge with minimal erythema and decreased edema since yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744526,
"text": "Addendum\n\nnasal bridge with minimal erythema and decreased edema since yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744527,
"text": "NPN 7a7p\n\n\nResp\nInfant on prong CPAP of 5 at 24-32% o2. Needing slight\nincrease of Os for caretimes. LSC. S/C I/C rtxs. Sats steady\nabove 90% when at rest. No bradys. On caffiene. Monitor and\nsupport resp status.\nFEN\nInfant on TF 150 cc/k d SC32PM, gavaged q 4 hrs/40\" via OG\ntube. Min benign asps. Abd full, round but soft, CPAP like.\nLrg heme - stool this am. Voiding. Tolerating TF gavaged.\nMonitor weight and exam.\nG/D\nInfant in off isolette since last night with stable temps.\nSwaddled loosly. A/A with cares, settles easily between.\nMAEs. FS&F. Report of normal 30 day HUS. AGA. Monitor and\nsupport G/D.\n\nSpoke with Mom x 3 today and updated. Mom appearing very\nanxious. Will be in for visit and cares. Discussed with Mom\nthe need for infants to rest between cares so as not to\nstress them and so they could use all of their calories.\nAgreed that would benifit from short holds, <60 min\nq/o day until she has gained more weight. Mom stated\nunderstanding. Support . Encourage participation\nwhere they can and encourage quiet hands off when\nappropiate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-07 00:00:00.000",
"description": "Report",
"row_id": 1744528,
"text": "Respiratory Care\nPt currently on prong CPAP. Fio2 .25-.30. bs clear, rr 40-60. On caffeine. No spells noted. Plan to support as needed. Will consider trial off CPAP next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1744606,
"text": "NPN 1900-0700\n\n\n1. RESP: Infant continues on bubble prong CPAP 5, FiO2\n25-27%. O2Sats 93-99% with occ drifts to 80s; self\nresolving, some required brief inc O2s. RR 50-60s, SC/IC\nretractions which can become moderate with cares. Lungs\nclear/=. No spells. Pt is on caffeine.\n\n3. FEN: Current wt 1580g (+35g). Pt is on TF 150cc/k/d,\nSC32 with PM (40cc Q4H), gavaged over 1hr. Feeds are\ntolerated well, no spits, min asp. Abd exam benign, abd\ngirth 27-28cm. voiding/no stool so far this shift.\n\n4. G&D: Maintaining temps while swaddled in OAC, cobedding\nwith sister. and awake with cares, brings hands to\nface, sucks on pacifier. MAE, FOS & Full - last HUS ,\nresults normal.\n\n5. PAR: Mom called at 2200 and updated by this RN. Asking\nappropriate questions. Plans to be in today for cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1744612,
"text": "NPN 1900-0700\n\n\nRESP: Remains in bubble CPAP 5, mostly 27%. LS C/=, mild\nSCR. On caffeine, 2 spells this shift (w/prongs in), '.\n\nFEN: Tolerating full enteral feeds well, no spits or\naspirates. Abdomen full/round, good bs, girth stable. V&S\n(heme negative). On Vit E & Iron.\n\nG/D: Temp stable swaddled in OAC, cobedding w/sibling. A&A\nw/cares, sleeps well in between. Brings hands to face for\ncomfort.\n\n: Mom called X1, updated by this RN, asking\nappropriate questions. Verbalized being very concerned about\n being back on CPAP again and afraid she won't come\noff for a long time. Per Mom, s/w & MD today and feels a\nlittle better.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1744613,
"text": "Respiratory Care\nBaby remains on cpap 5 27-31%.BS clear throughout.2 spells dcoumented thus far this shift, ^ in fio2.On caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1744614,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. breath sounds clear and equal. Mild retractions noted. Nl S1S2, grade murmur appreciated. Generalized edema noted. Abd benign, no HSM. Active bowel sounds. Infant irritable with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1744615,
"text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 23-27% 02. RR 40's-60's with baseline SCR. No bradys noted, occ sat drifts. On caffeine. Plan cont CPAP @ present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1744616,
"text": "Neonatology Attending\nDOL 53 / CGA 35-4/7 weeks\n\nRemains on CPAP 5 cm H2O in 21-28% FIO2. On caffeine with two braycardia/apnea today.\n\nMurmur persists. Generalized edema as at baseline. BP 75/37 (52).\n\nWt 1615 (+35) on TFI 150 cc/kg/day SC32PM, tolerating well by gavage.\n\nA&P\n28 week GA infant with CLD\n-Given edema we will start trial of furosemide. Consider increase in caffeine dose if bradycardia persists\n-Cranial ultrasound shows right grade 1 hemorrhage, despite two prior normal ultrasounds. This is unlikely to be of any clinical significance\n-Continue to await maturation of oral feeding skills\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-22 00:00:00.000",
"description": "Report",
"row_id": 1744617,
"text": "Nursing Progress Notes.\n\n\n#1 O; Baby continues on prong CPAP 5, 23 to 27% oxygen. No\ndesats or 's. Breath sounds clear and equal, mild\nretractions. 1 dose lasix given Po with good urine output\nat next diaper. A: Continues on Prong CPAP 5. No spells\ntoday. P: Consider trial off CPAP on MOnday.\n#3 o: Total fluids 150cc/kg/day of SC32 with promod.\nFeeds given every 4 hours over 1 hour. No spits or large\naspirates. Abdomen soft, but large and round. Voiding\nwell, Stool guiac negative. A: tolerating feeds well. P:\nContinue with current feeds.\n#4 O: Temp stable in open crib while cobedding with\nsibbling. Pacifier taken when offered. Baby is with\ncares but otherwise sleeps well. A: Appropriate for age.\nP: Continue to support development.\n#5 O: Mother called for updated and father was in to visit\nthis afternoon. A: Involved family. P: Continue to keep\ninformed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744439,
"text": "Neonatology Attending Progress Note\nNow day of life 26, CA 5/7 weeks.\n\nBaby re-intubated yesterday because of increased apnea/bradycardia of increased severity - current vent support - 24/6 rate 30 FIO2 21-34%\nCBG 7.34/55\nRR 30-40s.\nOn caffeine.\nNo episodes of bradycardia in the past\n\nHR 120-150s BP 63/35 42\n\nID - sepsis evaluation performed because of worsened status - on vancomycin and gentamicin\ncbc - wbc 10,800 17P 4B L39 1 met 2 myelo Hct 33% plat 329,000\nBlood culture sent\n\nWt. 845gm up 28gm on 150cc/kg/d of SSC 32 with Promod by slow gavage\nNormal urine and stool output\nUO 3.2cc/kg/hr\nDS 107\n\nLytes 137 5.4 103 24\n\nAssessment/plan:\nWorsened status with question of sepsis - will continue antibiotic coverage.\nWill send trach aspirate and complete sepsis evaluation with LP.\nVent support to be weaned as tolerated - repeat blood gas today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744440,
"text": "Neonatology Attending Progress Note\nAddendum - PE\nBaby slightly , breathing with vent.\nAF soft and flat.\nBreath sounds equal, fair air entry.\nCVS - S1 S2 normal intensity - no murmur\nAbd - soft with normal bowel sounds, slightly full\nNeuro - tone AGA\nExt - moving upper and lower extremities equally\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744441,
"text": "Neonatology Attending Progress Note\nAddendum - PE\nBaby slightly , breathing with vent.\nAF soft and flat.\nBreath sounds equal, fair air entry.\nCVS - S1 S2 normal intensity - no murmur\nAbd - soft with normal bowel sounds, slightly full\nNeuro - tone AGA\nExt - moving upper and lower extremities equally\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744442,
"text": "Neonatology Attending Progress Note\nAddendum - PE\nBaby slightly , breathing with vent.\nAF soft and flat.\nBreath sounds equal, fair air entry.\nCVS - S1 S2 normal intensity - no murmur\nAbd - soft with normal bowel sounds, slightly full\nNeuro - tone AGA\nExt - moving upper and lower extremities equally\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744443,
"text": "Respiratory Care Note\nPt. remains on IMV 24/6, RR 30, FiO2 26-32%. BS coarse to clear after suctioning. Suctioned for large amount white secretions. Trach aspirate sent for culture. RR 30-40's. On caffeine. No bradys noted this shift. On Vitamin A. Plan CBG this pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-06 00:00:00.000",
"description": "Report",
"row_id": 1744514,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on prong CPAP 6 in mostly 30%\novernight. RR 30's-60's. Breath sounds are clear and equal.\nMild IC/SC retractions noted. Occaisional O2 sats QSR drifts\nnoted to high 80's, otherwise no spells. Remains on\ncaffeine. A: Stable on prong CPAP. P: Continue to monitor\nresp status.\n\n#3. O: Infant remains on TF's of 150cc/k/d of SC32PM. PG fed\nover 1 hour. No spits. Minimal aspirates. AG stable. Abd\nsoft and round with active bowel sounds. Voiding qs. No\nstools thus far. A: Tolerating feeds. P: Continue to monitor\nfeeding tolerance.\n\n#4. O: Infant remains in low heat isollette with stable\ntmep. She is alert and active with cares. MAEW. A: AGA P:\nContinue to assess and support developmental needs.\n\n#5. O: Mom and \"\" here this evening. Mom independent\nwith cares. Asking lots of apropriate questions. A: Involved\nfamily. p: Continue to inform and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-06 00:00:00.000",
"description": "Report",
"row_id": 1744515,
"text": "Respiratory Care Note\nPt. continues on 6cmH2O of nasal prong CPAP. FIO2 has been 25-30%. BS clear. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1744607,
"text": "Respiratory Care\nBaby remains on cpap 5 24-27%.BS clear throughout.RR 50-70's.Occ drifts in sats.On caffeine,no spells.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1744608,
"text": "Neonatology Attending\nDOL 52 / CGA 35-3/7 weeks\n\nOn CPAP 5 cm H2O in 24-28% FiO2, with mild intermittent tachypnea. On caffeine.\n\nMurmur persists. BP 59/29 (39).\n\nWt 1580 (+35) on TFI 150 cc/kg/day SC32PM, tolerating over 1 hour. Abd benign. Voiding, no stool in 24 hours. On iron and vit E.\n\nTemp stable in open crib.\n\nA&P\n28 week GA infant with CLD, respiratory and feeding immaturity\n-Continue on CPAP for now (bradycardia when temporarily off)\n-Slightly full fontanelle; screening cranial ultrasound due\n-Otherwise no changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1744609,
"text": "Nursing Progress Notes.\n\n\n#1 O: Baby remains on Bubble, prong CPAP 5. Breath sounds\nclear and equal and baby had no spontaneous spells. She does\nnot tolerate any disconection and quickly desats to 60's or\n70's requiring increased oxygen and stimulation after\nreplacing CPAP prongs. A: Doing well on CPAP, Considering\ntrial off next week. P: Continue to monitor and assess\nreadiness to trial off next week.\n#3 O; Total fluids 150cc/kg/day of SC32 with promod.\nFeeds given every 4 hours over 1 hour. No spits or large\naspirates. Abdomen soft, bowel sounds active, no loops,\ngirth stable. Voiding and stooling. A: Tolerating feeds\nwell over 1 hour. P: Continue with current feeds and follow\nweight gain.\n#4 O: Temp stable in open crib while cobedding with\nsibbling. Baby is and active at times but mostly\nslept well today while swaddled and with boundaries. A:\nAppropriate for age. P: Continue to support development.\n#5 O: Mother in to visit and care for baby this morning.\nMother was updated by MD. A: Involved family. P: Continue\nto keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1744610,
"text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 23-27%. BS clear. RR mostly 30's-60's with baseline retractions. On caffeine. No bradys noted, occ sat drifts, no desats documented as of this writing. Will cont present management, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-21 00:00:00.000",
"description": "Report",
"row_id": 1744611,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr 1-2/6 murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-06 00:00:00.000",
"description": "Report",
"row_id": 1744516,
"text": "Attending Note\nDay of life 37 CGA 33 2/7\nCPAP 6 FiO2 25-32% RR 30-60 on caffeine no spells\n64/40 mean 48\nweight 1070 no change on 150 cc/kg/day of SSC 32 cal/oz with promod\nvoiding but not stool\non vit E and iron\nin air controlled isolette\n\nImp-stable currently\nwill wean CPAP to 5\nwill continue current calories\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-06 00:00:00.000",
"description": "Report",
"row_id": 1744517,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sagital sutures slightly split\nmild subcostal retractions on CPAP, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft,/full, nontender and with active bowel sounds\nactive with good tone\n0.5 cm ribbon of erythema over nasal bridge, no edema\n\n updated at bedside\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-06 00:00:00.000",
"description": "Report",
"row_id": 1744518,
"text": "NPN 0700-1900\n\n\nRESP: Received infant on prong CPAP 6, decreased to 5.\nFiO2's 25-27% at rest and up to 33% while out holding. LS\nC/=, mild SCR. On caffeine, no spells this shift (0/24').\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/full, good bs, no loops, girth\nstable. V&S (heme negative). On Vitamin E & Iron.\n\nG/D: Temp stable swaddled in low air isolette (isolette kept\non at room temp due to humidity from CPAP inside). A&A\nw/cares, sleeps well in between. Brings hands to face and\nsucks on pacifier for comfort. Infant currently being held\nswaddled by Mom. is to hold everyday swaddled as long\nas infant tolerates.\n\n: Both in for midday cares, updated by this\nRN and , asking appropriate questions. Independent\nw/cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-06 00:00:00.000",
"description": "Report",
"row_id": 1744519,
"text": "Respiratory Care Note\nBaby was weaned to +5 prong CPAP, from +6. FiO2 25-29%, slightly higher when being held. BS clear. RR 40-60's. On caffeine. No bradys this shift as of this writing. End of nose continues to be red. aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1744600,
"text": "NPN 1900-0700\n\n\n1. RESP: Infant on bubble prong CPAP of 5, FiO2 24-29%. O2\nSats >95%. She occ. drifts down to mid-upper 80s but\nresolves with brief inc. of O2s. RR 50-70s with SC\nretractions, which can become moderate with cares. No\nspells. Infant is on caffeine.\n\n3. FEN: Current wt 1545g (no chg). TF= 150cc/k/d with SC32\nwith PM (32cc Q4H). Feedings are gavaged over 1hr.\nTolerated well, no spits, min asp. Abd soft, abd girth\nmeasures 28-29cm, +BS. Voiding/stooling QS.\n\n4. G&D: Continues to maintain temp while swaddled in OAC\nsharing crib with sister. and active with cares, MAE,\nFOSF. Sucks on pacifier. Needs to be woken for feeds.\n\n5. PAR: Mom called at and updated by this RN. Asking\nappropriate questions. Plans to be in for afternoon cares.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1744601,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 5 via Prongs FiO2 24-29%. RR 40-70's breath sounds are clear. Occasional drifts on the sat monitor requiring increased FiO2. Baby is on caffeine. Stable on CPAP cont follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1744602,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\naFOF. breath sounds clear and equal> nl s1S2, grade murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infnat AGA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-04 00:00:00.000",
"description": "Report",
"row_id": 1744283,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sutures approximated, dolicocephalic\nmild subcostal/intercostal retractions, examined off CPAP, lungs clear/= with good air entry bilaterally\nRRR, no murmur, pink and well perfused\nabdomen soft/full, nontender, with active bowel sounds, uvc in place\nexcellent tone for GA\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-04 00:00:00.000",
"description": "Report",
"row_id": 1744284,
"text": "NPN 0700-1900\n\n2 CV\n7 alt in Bilirubin\n\nRESP: Prong CPAP 5 21%, breathing comfortably. LS C/=,\nIC/SCR. On caffeine, no spells thus far, 0/24'.\n\nCV: No murmur, normal pulses, BP WNL. P/WP. Problem\nresolved.\n\nFEN: Started on 10cc/kg/day of feeds today. No spits, 1.2cc\nvery bilious aspirate (prior to starting feeds). NNP aware,\ndiscarded and started feeds. PN, IL, & IV fluids infusing\nvia DLUVC. Last D/S 184 - NNP aware. Abdomen soft/flat to\nround, good bs, girth stable. Voiding, no stool thus far.\n\nG/D: Temp stable nested in sheepskin in servo mode isolette,\ngel pillow under head. Very alert and active w/cares, calms\nwell after cares. Sucks on pacifier for comfort. Had HUS\ntoday - NNP = WNL.\n\nPARENTS: Both parents in to visit this AM, updated at\nbedside by this RN, asking appropriate questions. Mom D/C'd\nhome today, family meeting planned for this afternoon.\n\nBILI: Phototherapy remains off, bili level remains stable\nand WNL. Plan to recheck on Sunday. Problem resolved.\n\nREVISIONS TO PATHWAY:\n\n 2 CV; resolved\n 7 alt in Bilirubin; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-04 00:00:00.000",
"description": "Report",
"row_id": 1744285,
"text": "Respiratory Care\nPt conton prong CPAP. Fio2. 21, bs clear, rr 40-60, sx for scant amt. Rec'ing caffeine and Vit A. No spells noted. Plan to support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744286,
"text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. RR 30's-60's with mild IC/SCR. No spells noted. On caffeine, vitamin A. Will cont CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744287,
"text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCONTINUES ON PRONG CPAP AT 5CM. NO O2 REQUIREMENT. NO\nAPNEA OR DESATS. BBS CLEAR, RR 30-60'S.\n3. F/N\nTONIGHT'S WEIGHT UP 10 GRAMS TO .542KG. TOTAL FLUIDS AT\n160CC/KG ALL D10PN AND IL VIA UVC. ONETOUCH 168. OUTPUT\n4.1CC/KG/HOUR FOR 24 HOURS. NO STOOL. ABD BENIGN.\nTOLERATING 10CC/KG OF FSBM. NO ASPIRATES.\n4. G&D\nTEMP STABLE ON SERVO MODE. ALERT WITH CARE. LOVES\nPACIFIER.\n5. PARENTS\nMOM CALLED AND UPDATED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1744603,
"text": "Neonatology Attending\nDOL 51 / CGA 35-2/7 weeks\n\nRemains on CPAP 5 cm H2O in 24-29% FIO2, with no distress. No apneas/bradycardias (on caffeine).\n\nSoft murmur. BP 74/42 (48).\n\nWt 1545 (unchanged) on TFI 150 cc/kg/day SC32PM, tolerating well by gavage. Voiding and stooling normally.\n\nTemp stable in open crib. Ophthalmology examination zone 3 ou on Monday.\n\nA&P\n28 week GA twin with CLD, respiratory and feeding immaturity\n-Continue on CPAP through weekend then trial off\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1744604,
"text": "NPN Days\n\n\n#1 Pt received and cont on Prong CPAP of 5 FiO2 20's.\nLS C+=. IC SC retrac. Pt cont on caffeine. No spells so far\nthis shift. P- Will cont to monitor resp status.\n#3 FEN- TF=150cc/kg/d of SC 32 with PM. abd benign. voiding\nand stooling hem neg. ag-26 cm. 4.2cc asp, partially\ndigested, refed. no spits. P- Will cont to monitor FEN.\n#4 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. sucking on pacifier. P- Will\ncont to monitor G&D.\n#5 - visiting this shift. and caring.\nasking approp ques. updates given. independent with cares.\nP- Will cont to encourage parental visits and calls.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-20 00:00:00.000",
"description": "Report",
"row_id": 1744605,
"text": "Resp care\nPt remains supported w/ 5cm/h2o of NCPAP, 21-30%\nRR- 30-70's w/ mild retractions\nB/S clear, Baby receiving caffeine, no spells documented\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-05 00:00:00.000",
"description": "Report",
"row_id": 1744288,
"text": "Neonatology Attending Note\nDay 5\nCGA 28 5\n\nCPAP Pr 5 21%. RR30-60s. BS cl and =. On caffeine, Vit A. No A&Bs. HR 140-150s. BPO 56/44, 48.\n\nWt 542, up 10 gms. TF 170 cc/k/day at 160 PN10/IL and enteral feedings at 10. Tol well. Nl voiding and stooling.\nu/o 4.1\nd/s 168, 163\n\nIn isolette.\n\nA/P:\n-- maintain cpap\n-- monitor for aop on caffeine\n-- TF to 160 - PN down to D8, inc enteral to 20 then advance 10 \n-- bili, lytes and bili in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-18 00:00:00.000",
"description": "Report",
"row_id": 1744377,
"text": "NPN 1900-0700\n\n8 Infant with Potential Sepsis\n\nRESP: Remains on NP CPAP 6, 21%. LS C/=, IC/SCR. On\ncaffeine, no spells thus far this shift ('). Suctioned\nw/every cares.\n\nFEN: Tolerating full enteral feeds, no spits, minimal\naspirates. Abdomen soft/round, good bs, girth stable. V&S\n(heme negative).\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between cares. Soothes well w/hand\ncontainment and pacifier.\n\n: Mom called x1, updated by this RN, asking\nappropriate questions. Plans to be in on day shift.\n\nSEPSIS: 7 day course of antibiotics completed, BC remains\nnegative. PICC out. Problem resolved.\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-18 00:00:00.000",
"description": "Report",
"row_id": 1744378,
"text": "Attending Note\nDay of life 18 CGA 30 4/7\nCPAP 6 21% RR 40-60 on caffeine no spells\nHR 140-160 BP 53/39 mean 44\n698 up 18 on 150 cc/kg/day of BM or SSC 26 cal/oz\nvoiding and stooling\non vit A, Vit E and iron\ns/p abx course\n\nImp-doing well currently\nwill continue to monitor for spells\nwill add promod\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-18 00:00:00.000",
"description": "Report",
"row_id": 1744379,
"text": "Respiratory Care\npt cont on prong CPAP. Fio2 .21, bs clear, rr 40-60, sx for mod amt. On caffeine. No spells noted thus far this shift. Plan to cont with current resp. management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-18 00:00:00.000",
"description": "Report",
"row_id": 1744380,
"text": "Nursing Progress Note\n\n\n#1-O/A- Received infant on NP CPAP 6cm. Infant remains on\nCPAP, FIO2 21%. 1 Desat w/o brady so far this shift. Cont\non Caffeine. Sxn q4hrs for mod cloudy sec from NP tube. P-\n Cont to assess for Resp needs.\n#3-O/A- TF=150cc/kg/d of BM26w/ProMod via NGT. Abd exam\nbenign. Voiding and stooling, heme neg. Cont on Vit e,\niron and vit a. P- Cont to assess for FEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Sucks on pacifier\nTemp stable in isolette on servo. Temp cool x1 this shift\nwhen had doors on isolette open, warmed up quickly.\nP- Cont to assess for G&D needs.\n#5-O/A- in to visit with updates given. Dad\nkangaroo'd with infant. Mom held sister. P- Cont to enc\nparental calls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-18 00:00:00.000",
"description": "Report",
"row_id": 1744381,
"text": " ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant on CPAP, NP-tube, in isolette\nSKin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear, equal; well-aerated; mild intercostal retractions\nCV: RRR without murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds\nExt: moving all\nNeuro: appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-19 00:00:00.000",
"description": "Report",
"row_id": 1744382,
"text": "NPN 1900-0700\n\n\nRESP: Remains on NP CPAP 6, 21%. LS C/=, IC/SCR. Suctioned\nw/every cares. On caffeine, 1 spell thus far (').\n\nFEN: Tolerating full enteral feeds well, no spits or\naspirates. Abdomen soft/round, good bs, no loops, girth\nstable. V&S (heme negative).\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Loves pacifier!\n\n: Mom called x1, updated by this RN, asking\nappropriate questions. Plans to call again in AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-19 00:00:00.000",
"description": "Report",
"row_id": 1744383,
"text": "Respiratory Care\nBaby remains on cpap 6 21%.RR 30-60.BS clear throughout.Sx nptube for lg thick cldy secs.1 spell,on caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744459,
"text": "NPN 0700-1900\n\n\nRESP: Received infant in IMV 24/6 R24 - weaned PIP to 22. LS\nCoarse-->clear (after suctioning), mild IC/SCR. Suctioning q\ncares. On caffeine, no spells thus far ('). Received\nlast dose of Vitamin A today.\n\nFEN: Tolerating full gavage feedings well, no spits, minimal\naspirates. Abdomen soft/round, good bs, no loops, girth\nstable. Voiding, no stool thus far. On Vit E & Iron.\n\nG/D: Temp stable/warm nested in sheepskin in servo isolette.\nA&A w/cares, sleeps well in between. Calms well w/hand\ncontainment. HUS planned for Wednesday.\n\n: Mom in for most of day, updated at bedside by this\nRN, asking appropriate questions. Plans on kangaroo'ing\nw/next cares.\n\nSEPSIS: Continues on Vanco & Gent, BC remain negative.\nSputum culture results pending. Plan to check Vanco levels\nw/am dose.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-28 00:00:00.000",
"description": "Report",
"row_id": 1744460,
"text": "Respiratory Care\nPt currently on IMV. Weaned PIP by 2 cmH2O. Presently on settings 22/6, f 24, Fio2 .25. bs coarse, rr 20's-40. sx for mod amt. On caffeine. No spells. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-29 00:00:00.000",
"description": "Report",
"row_id": 1744461,
"text": "Respiratory Care\nBaby continues on 22/6, R 24 with 02 21-30% this shift. BS with coarse rhonchi, clears briefly after sxn. Sxn frequently as per flowsheet for mod-lg amts thick white seceretions. RR 30's-50's with mild IC/SCR. CBG: 7.29/57/32/29/-1; no changes made at this time. ETT retaped without incident. No bradys noted, occ sat drifts/ desats. On caffeine. Will cont to follow closely, wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-29 00:00:00.000",
"description": "Report",
"row_id": 1744462,
"text": "NPN\n\n\n#1 Resp- Remains on vent in 21-30%,22/6,24.BS coarse. RR=\n40-70. Sxn q 2-3 hrs for mod to lg\namts.CBG=7.29/32/57/29/-1.Remains on Caffeine.\n#3 F/N- Abd soft,+bs, no loops. Tolerating ng feeds of SC32\ncals w/Promod w/sm spit x1. Minimal asps.Wt up\n52gms.Voiding+ stooling in adeq amts.Tf= 150cc/kg/day.Feeds\ngiven on a pump over 1 hr.\n#5 Mom called x1. updated.\n#10 Sepsis- Remains on Vanco+ Gent day 5 of 7.New vanco\nlevels drawn.See labs.Gent dose increased.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-29 00:00:00.000",
"description": "Report",
"row_id": 1744463,
"text": "Attending Note\nDay of life 29 CGA 32 \nIMV 22/6 rate 24 FiO2 21-30% RR 30-50 large thick white secretions\nCBG 7.29/57 on caffeine no spells\n150-170\nday vanco and gent\nweigth 909 up 52 grams of SSC 32 with promod at 150 cc/kg/day pg over 1 hour\nvoiding and stooling heme positive stool\nalert with cares\n\n\nImp-making progress still on high settings\nwill obtain a CXR today\nwill increase the vanco dose\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-29 00:00:00.000",
"description": "Report",
"row_id": 1744464,
"text": "Neonatology- Progress Note\n\nPE: Remains in her isolette, on 21/6 X25 <.30, bbs cse=, nasal irritation with edema, large secretions noted, abd soft, full +bs,, rrr soft systolyc murmur, continues on vanco and gent, piv in place\n\nSee attending note for plan\n\nID consult in progress\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-29 00:00:00.000",
"description": "Report",
"row_id": 1744465,
"text": "Respiratory Care\nPt cont on IMV. Settings 22/6, f 24, fio2 .24-.30. bs coarse, rr 40-60. sx for mod thick secretions from ett, copious yellow from nares. Plan to send nasal culture and gram stain. ID consulted. On caffeine. No spells noted. cxr done. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-10 00:00:00.000",
"description": "Report",
"row_id": 1744540,
"text": "NPN 1900-0700\n\n\n#1Resp. O: Pt. remains on prong CPAP of 5, FiO2 25-29%. RR\n50-60, LS clear and equal, SC retractions present. Suctioned\nx1 for thick yellow blood tinged secretions. Remains on\ncaffeine. No spells. A: Stable FiO2 on CPAP. P: Continue\nCPAP, wean O2 as tolerated.\n\n#3FEN. O: Wt. 1180 gms, up 5 gms. Pt. on TF of 150cc/k/day\nof SCSimilac 32 with pm, 30cc q4 hrs over 40 minutes via OG\ntube. No spits, minimal aspirates. Abd. full, active BS, no\nnoted loops, stable girth. Voiding, no stools so far\ntonight. A: Appears to be tolerating enteral feeds. P:\ncontinue to monitor for tolerance of feeds.\n\n#4G/D. Pt. swaddled in off isolette.Temp. stable. Pt. alert,\nactive with cares, settles easily between cares. AFF. MAE.\nPt. takes pacifier occasionally. A: AGA. P: Support\ndevelopmental needs.\n\n#5Parents. O: Mom called, updated, asking appropriate\nquestions. A: Involved family. P: Continue to update and\nsupport .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-10 00:00:00.000",
"description": "Report",
"row_id": 1744541,
"text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 23-29%. BS clear. sxn x1 for lg amt thick yellow blood-tinged secretions. RR 50's-60's with baseline SCR. No spells, occ sat drifts. On caffeine. Plan cont CPAP @ present, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-10 00:00:00.000",
"description": "Report",
"row_id": 1744542,
"text": "Neonatology Attending Note\nDay 41\nCGA 33 6\n\nCPAP5, 23-30%. RR40-60s. BS clear. Mod secretions. On caffeine. No A&Bs. HR 140-160s. BP 67/33, 42. Pink, well perfused.\n\nWt 1180, up 5. TF 150 cc/k/day SC32 w promod.\nNl voiding and stoolong.\nOn Vit E and Fe.\n\nIn isolette.\n\nA/P:\nGrowing preterm infant. Will maintain cpap. Cont to follow on caffeine. No change to nutritional plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-10 00:00:00.000",
"description": "Report",
"row_id": 1744543,
"text": " Care\nPt recieved on nasal prong CPAP +5cm's with the fio2 25 to 32%. Pt respiratory rates 40's to 70's, on caffine. Plan is to follow on CPAP, trial off later in the week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-10 00:00:00.000",
"description": "Report",
"row_id": 1744544,
"text": "NPN 0700-1900\n\n\nRESP: Remains in Prong CPAP 5, 28-32%. LS C/=, mild SCR. On\ncaffeine, no spells thus far (0/24').\n\nFEN: Tolerating full gavage feedings well, no spits or\naspirates. Abdomen soft/full, good bs, girth stable.\nVoiding, no stool this shift. On Vitamin E & Iron.\n\nG/D: Temp stable swaddled in off isolette. A&A w/cares,\nsleeps well in between. Sucks on pacifier and brings hands\nto face for comfort.\n\n: Mom in for 2 cares, updated at bedside by this RN,\nasking appropriate questions. Plans to call this evening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-10 00:00:00.000",
"description": "Report",
"row_id": 1744545,
"text": "NEonatology- Progress Note\n\nPE: remains in her isolette, on CPAP 5 <.30 bbs sl cse=., rrr soft systolyc murmur, abd soft, nontender, V&S, gavage tube in place afso, active with care\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1744624,
"text": "NPN\n\n\n1. Resp: Infant remains in NP CPAP at 5cm, in 23-30% FIO2,\nsats 92-99%. Noted to have 2 desats to 60's during\nfeed,prongs were in place, with no change in HR. O2 was\nincreased briefly and sats returned to baseline.\nBBS clear with mild SCR, RR 40-70's.\nA/P: Cont with CPAP, on caffeine, monitor for spells.\n\n3. FEN: WT 1.690kg, up 55 gr. Some generalized edema.TF\n150cc/kg/d of Similac SC 32 w/ PM 42cc q4hr OG. Feeds given\nover 1hr. No spits, min aspirates, abd round/soft, no\nstools, voiding.\nA/P: Tolerating feeds, gaining wt, monitor for fluid\noverload.\n\n4. G&D: Swaddled in crib co-bedding with twin. Sleeping in\nbetween cares, when awake, takes pacifier at times.\nTemps WNL.\nA/P: Growing premie on CPAP, cont to support\ndevelopment-tolerating co-bedding.\n\n5. : Mom called for update, asking appropriate qs.\nA/P: Cont to provide support and info as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1744625,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 5 via Prongs FiO2 23-30%. Occasional drifts on the sat monitor requiring increased FIO2. Breath sounds are clear. Baby is on caffeine. RR 40-70's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1744626,
"text": "Neonatology Attending\nDOL 55 / CGA 35-6/7 weeks\n\n remains on CPAP 5 cm H2O in 23-30% FIO2 with no distress. On caffeine with drifting saturations during feed but no bradycardias/apneas. Lasix trial on Friday without effect.\n\nFlow murmur. BP 60/37 (45)..\n\nWt 1690 (+55) on TFI 150 cc/kg/day SC32PM, tolerating by gavage. Abd full but benign. On iron and vit E. Voiding and stooling normally.\n\nA&P\n28 week GA twin with respiratory and feeding immaturity, reflux\n-Continue to await maturation of oral feeding skills\n-Continue with 3-day trial of furosemide, monitoring respiratory status closely in the interim\n-Lytes tomorrow in light of diruetic therapy\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1744627,
"text": "Nursing Progress Note\n\n\n1. Resp O/A Rec'd inf in CPAP 5. Inf remains in prong\nCPAP 5. FIO2 requirements have been 23-29% thus far. LS\nCL=, SCR noted. Dose 1 of 3 of Lasix given today as\nordered. P cont to assess resp needs.\n3. FEN O/A TF=150cc/kg/day of SC32w/PM. All feedings\nPG over 1 hour. Tol well, no spits, min asp thus far.\nBelly full, round, and soft, no loops. Inf voiding,\nstooling guiac neg. P cont to assess FEN needs.\n4. Dev O/A remains in an OAC with stable tmep\ncobedding with her twin. A/A waking for cares. P cont to\nassess dev needs.\n5. O/A Mom in for visit. Updates given. P cont\nto support, educate.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1744628,
"text": "Respiratory Care\nPt recieved on nasal prong CPAP +5cms' with the fio2 23 to 28%. Pt's respiratory rates 50's to 60's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-24 00:00:00.000",
"description": "Report",
"row_id": 1744629,
"text": "Neonatology NP Note\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small infant nestled in open crib with twin, on nasal prong CPAP.\nAFOF, sagital suture open, approximated. intact, MMMP\nChest is clear, fair exchange, comfortable resp pattern on CPAP\nCV: RRR, Gr 1/6 systolic murmur, pulses+2=\nABD: soft, protruberant, active bs\nGU: swollen labia\nEXT: MAE, WWP\nNeuro: symmetric tone and reflexes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744257,
"text": "NPN 11p-7a\n\n\n#1: Infant currently on settings of 16/5x16, FIO2 21% all\nshift. Weaned to these settings from ABG drawn at 0300,\nplease see flow sheet for details. Infant received\nsurfactant x2. BS are sl. coarse, with mild IC/SC\nretractions. RR 40-50s. No spells or desats noted. Sx'd for\nsm clear secretions. A: stable on current settings. P: cont\nto monitor closely.\n#2: HR 140-150s. Color is pink and well perfused with good\ncap refill, pulses WNL. Infant started on dopamine drip\n(30/50 mix) at 0030 for means drifting to mid-high 20's\nrange. Has required 12.5mcg/hr since that time to maintain\nmeans between 32-38. Means very labile, does not handle\nhandling/stimulation well. Recieved two 6cc boluses earlier\nin evening. A: Labile means. P: cont to monitor closely,\ntitrate dopa as able.\n#3: TF105cc/kg/d. Infant with UAC/DUVC. D10Ww/.5unit heparin\ninfusing through each port to meet TF w/o incident. Dopa\npiggybacked into secondary UVC. D/s 89. Pt remains NPO.\nBelly is soft and round with active bowel sounds. No stool\nyet, has voided 5cc so far. A: Stable. P:Cont with plan.\n#4: Temp is stable on open warmer. Infant opening eyes,\nactive with cares. Sleeping well, nested on sheepskin.\nInfant recieved hepB (full dose in total) and immunogloblin\nvaccines. Fontanelles are soft and flat. A: AGA. P: Cont to\nsupport.\n#5: Dad in this morning to visit. Oriented to unit and\nequipment. Asking appropriate questions, took pictures of\ninfant and her twin. A: dad. P: cont to support.\n#6: CBC/Diff sent earlier in shift, w/results pending. On\namp and gent as ordered. A/ P: cont with plan.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744258,
"text": "Neonatology - NNP Procedure Note\n\nProcedure: UVC/UAC placement\nIndication: prematurity/IUGR\n\n\nInfant positioned on warmer and prepped in sterile fashion. #3.5 UVC inserted and advanced to 7cms. Good blood return/ flushes easily.#3.5 UAC inserted and advanced to 10cms. Also good blood return and easily flushes. Babygram showed UAC in good position. UVC high. Withdrawn 1 cm to 6cms. Procedure tolerated well by infant.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744259,
"text": "Neonatology Attending Note\nDay 1\n\ns/p 2 dose surfactant. 16/5 x 14, RA. RR40-50s. Last gas 7.36/40/110/-2. No murmur. HR 130-140s. NS x 3 plus on dopamine at 14 mcg.\n\n4.9 (3n,0b)/43/123\nNeutropenia\nOn amp/gent\n\nWt 612. TF 105. UAC/DL UVC. NPO. d/s 70-90.\n\nOn radiant warmer.\n\nRec'd HBV/HBIG.\n\nA/P:\n-- minimal vent settings, will look to transition to CPAP soon\n-- maintain mean BPS 33-37, weam dopa as allowed\n-- cont abx for a probabale 48 hr course\n-- begin PN/IL\n-- check cbc w lytes, bili in 24 hrs\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-13 00:00:00.000",
"description": "Report",
"row_id": 1744348,
"text": "NPN 0700-1500\n\n\n1.RESP: Infant on NP (2.5) CPAP/peep6, RA. Monitoring O2\nsats and episodes of apnea/bradydesat. On Caffeine for h/o\napnea. Suctioning NPT & nare PRN. A: Resps 40-60s with mild\nretractions, Lungs CTA & equal, O2 sats >94, no episodes\nthis shift. Suctioned small cloudy/brownish secretion from\nNPT. P: Continue POC/ monitor for changes.\n\n2.FEN: On TF 150cc/kg/day, advancing enteral feeds (BM) via\nNGT by 15 cc/kg . Increased to 125cc/kg/day at 1300,\nheplocked R leg PICC per order. Monitoring for s/s intol.\nWeight today = 652 (+22). A: Residuals trace, no spits, abd\nsoft/round, BS present, girth stable 18-19cm, stooling hem\nneg. Dex = 100. UO = 2.9cc/kg/hr. P: Continue to advance\nfeeds as tol/monitor for changes. Flush PICC q4-6 per order\nuntil full course antibx in.\n\n4: : Today is DOL 13 for , CGA 29 . Infant\nnestled with boundaries on sheepskin in covered isolette in\nservo mode. Changed probe cover once today d/t temps not\ncorrelating. A: Temps stable. Infant active/alert/AGA with\ncare. P: continue to monitor\n\n5:PARENTS: Both parents called today/updated of infant\nstatus/verbalized no questions/concerns at present. Dad\nvisited, participated in care & kangaroo of infant's twin.\nMom to come visit this afternoon and kangaroo . A:\nstable/participative parents P: continue to update parents\nand invole in POC.\n\n8: SEPSIS: Infant on day 3 of 7 day antibx course for\npresumed sepsis. Both Vanvo & Gent does increased today d/t\nlow levels. Blood cultures from remain negative. LP\ndone last PM -- CSF culture pending. A: Stable, no s/s\ninfection at present. PICC line to remain for antibx. P:\ncontinue to monitor, follow CSF culture.\n\n9: C/V: echo on WNL MD . No C/V issues\nat present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-13 00:00:00.000",
"description": "Report",
"row_id": 1744349,
"text": "Respiratory Care\nPt cont on NP CPAP. Fio2 .21, bs clear, rr 40-60. sx for sm tan secretions. Rec'ing caffeine. No spells noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-14 00:00:00.000",
"description": "Report",
"row_id": 1744350,
"text": "NICU NSG NOTE\n\n\n#1. Resp. O/ Conts on NPT CPAP 6 in 21%. LS clear and equal.\nRR 30-50's. IC/SubC retractions. On caffeine. No spells\nthusfar. A/ Stable on CPAP. P/ Cont to monitor for increased\neffort/support.\n\n#3. FEN. O/ Wt up 13g. Goal of TF at 150cc/k/d. Enteral\nfeeds advanced to 140cc/k/d at 0100. Receiving q4h volumes\nBM via gavage over 30 mins. Abd soft and round. No loops.\nMax asp 0.8cc. Trace amts seedy yellow stools. UO 3cc/k/h\nfor 24h. PICC hl'd. A/ Tolerating feeds. Advancing to full\nfeeds. P/ Cont to monitor for feeding intolerances. Daily\nwts. Advance to full feeds at 1300 as tolerated.\n\n#4. G&D. O/ Awake and alert with cares. Temps stable in\nservo isolette. MAE. AFOF. Nested on sheepskin. Cares\nclustered. A/ AGA. P/ Cont to support developmental needs of\ninfant.\n\n#5. Parenting. O/ Mom called x1 earlier this shift. States\nshe will call back for update on wt/# of spells. A/ Involved\nmom. P/ Cont to provide info and support to family.\n\n#8. Sepsis. O/ Temps stable. Alert and active. On vanco and\ngent. Day . BC ngtd. A/ 7d course abx for shifted cbc. P/\nCont to monitor for s/s sepsis. Cont abx as ordered.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744254,
"text": "Admission Note\nNursing Admit Note\n Infant is a 28 wk twin B with growth restriction noted in utero. Mom is a 22 yo G 4 P0-2.(Please see Dr. note for antepartum details.).\n Infant arrived at NICU intubated with good aeration. Present vent settings RA 17/5 rate 20(weaned from rate 25) recieved initial dose of survanta, tol well. No desats or bradys. RR 40-60, mild ic/sc retractions.\n HR 130-40, no murmur, pink well perfused. Initial BP MAPs 35-45 according to NBP. UA placed and BP Maps on UAC only 23-26. 2 NS boluses given within 1/2 hr. BP on cuff 10 points higher than UAC. UAC recal. several times and flushed to double check BP' NNP aware.\n\n CBC and BC sent. Ampi and Gent given . Bath given sec. to Maternal Hep B positive status. 1/2 dose hep B vaccine given. Awaiting to hear from team dosage on Hep IMG.\n\n Initial D/S 70. Double lumen UVC and UA placed. Fluids infusing at 105cc/k/d. D/S 80. abd. soft , full, no stools.No voids\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744255,
"text": "RESPIRATORY CARE NOTE\nBaby girl #2 via C/S apgars 6 & 7. Weight 612 grams intubated in the DR a 2.5 ETT taped at 6.5cm. Transport to the NICU being bagged with 50% O2. Once in the NICU survanta 2.4cc given at hrs. CxR taken ETT in good position. Placed on vent settings 17/5 Rate 25 FiO2 25%. Baby received 2 N/S boluses for BP. Venous gas PO2 33 CO2 47 PH 7.38. Rate decreased to 20. Second dose of survanta 2.4cc given at 0145 hrs. Repeat abg PO2 77 CO2 41 PH 7.36 24 -1 Vent settings decreased to 16/5 Rate 16 FiO2 21%. Baby was started on dopamine. Will cont to wean as tolerated. Will cont to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-01 00:00:00.000",
"description": "Report",
"row_id": 1744256,
"text": "1 Respiratory\n2 CV\n3 F&N\n4 G&D\n5 Parents\n6 I&D\n\nREVISIONS TO PATHWAY:\n\n 1 Respiratory; added\n Start date: \n 2 CV; added\n Start date: \n 3 F&N; added\n Start date: \n 4 G&D; added\n Start date: \n 5 Parents; added\n Start date: \n 6 I&D; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744434,
"text": "NPN 0700-\n\n\n1. Remains on IMV. Weaned pressure from 26 to 24. Current\nsettings at 24/6 X30. FiO2 23-30% with occassional desats\nto the 80's. Lungs coarse, clears slightly after\nsuctioning. Sxn for moderate to large cloudy secretions\nQ4hr. Infant riding vent most of the day, RR 30-34. Mild\nIC/SC retractions. On caffeine. No A&B's thus far. CXR\nshowed good lung inflation today. Plan to obtain CBG at\n1700. Cont to monitor resp. status closely and support/wean\nas tolerated.\n\n3. TF 150cc/k/d SC32 w/PM. Abd full, soft, +BS, pink, no\nloops. Girth stable at 19.5-20cm. 8hr urine output=\n4cc/k/hr. One heme negative stool thus far. 0.8-2cc\npartially digested yellow aspirates. No emesis. KUB showed\ndilated loop NP . Plan to obtain lytes and\ndstick at 1700 and will repeat KUB at 2100. Cont to monitor\ntolerance to feeds closely.\n\n4. Temp stable nested in servo isolette. Infant more awake\nand alert with 1300 cares. Opening eyes today and MAE.\nCont to promote G&D.\n\n5. Mother called and updated on plan of care. Mother\nplanning to visit today at 1600 today. Invested and\nconcerned . Cont to support and update .\n\n10. Remains on vanco and gent as ordered. CBC with +Left\nshift; see lab flowsheet for details. Blood cultures\nnegative to date. Plan to repeat CBC with diff tomorrow\nmorning. Will cont to monitor for worsening s/sx of sepsis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744435,
"text": "Respiratory Care\nPt cont on IMV. Weaned PIP today.\nCurrently on settings 24/6, f 30, Fio2 .25-.30.\nbs coarse, rr 30-40.\nsx for mod amt. lg from nares.\nOn caffeine. No spells.\ncxr today shows fair expansion.\ncbg on current settings 7.34/61\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744436,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sagital sutures slightly split\nmild subcostal retractions in IMV, breathing predominantly in sync with ventilator, lungs clear/=\nRRR, no murmur appreciated, pink and well perfused\nabdomen soft, full, nontender, active bowel sounds\nquiet with exam, does suck on pacifier.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744437,
"text": "NPN 1900-0700\n\n\nRESP: Received infant in IMV 24/6 R30 - no changes made. LS\ncoarse/rales, clearer after suctioning. Babygram taken\nw/first cares - = poor expansion (tube adjusted and\nretaped by RT). On caffeine, no spells thus far - occasional\ndrifts to mid-80's (QSR).\n\nFEN: Tolerating full gavage feedings, no spits, minimal\naspirates. Abdomen soft/round, good BS, girth stable. V&S\n(heme negative).\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleepy at times, sleeps well in between. Soothes\nwell w/hand containment.\n\n: Mom called x1, updated by this RN, asking\nappropriate questions. Mom very concerned infant's\ncondition.\n\nSEPSIS: Infant remains on Vanco & Gent for L-shifted CBC. BC\nremain negative at this time.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-26 00:00:00.000",
"description": "Report",
"row_id": 1744438,
"text": "Respiratory Care\nBaby continues on 24/6, R 30 with 02 21-34%. BS with coarse rhonchi clear after sxn; coarse crackles x1. Sxn q2-q4h for mod-lg amts cldy/white secretions. CXR done- ETT high, pushed in cm and retaped @ 7cm @ lip. CBG: 7.34/55/35/31/1; no changes made. Hct 32.8. RR 30-40's. No bradys noted, but 02 sats labile. On caffeine, abx. Will cont to follow closley, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-04-30 00:00:00.000",
"description": "Report",
"row_id": 1744253,
"text": "NICU Attending Admission Note\n\nID: 28 0/7 weeks gestation twin B, delivered preterm due to severe PIH and IUGR of this twin.\n\nPre/perinatal Hx: Mother is 22 y.o. G 4 SAb 2, P 1 ->3. PNS: AB+, Ab-, +, RPRNR, RI, GBS?. Pregnancy notable for di-di spontaneous twin gestation, progressive growth discrepancy ( EFW 1223 gm for twin A and 523 gm for this twin). Also complicated by PIH, Admitted in transport from hospital, in house since. U/S showed absent end diastolic flow, BPP x 2, followed weekly, Beta complete. Today visual changes and increased BP so decision to deliver by C section. ROM at delivery, no maternal fever or intrapartum antibiotic prophylaxis. This twin emerged with spontaneous cry, HR > 100, but + G/F/R, improved with CPAP. Apgars 6 and 7. Intubated (see procedure note below), transferred to NICU without incident.\n\nPEx: Weight 612 gm (<10%), L 30 cm (<10%), HC 23 cm (<10%), O2 sat 94% intubated on SIMV and 23%. Nondysmorphic with overall appearance c/w EGA except by size. AFSOF, RR present bilaterally, palate intact, BS diminished bialterally with G/F/R, RRR without murmur, 2+ peripheral pulses including femorals, abd benign with 3 vessel cord, no HSM or masses, normal female external genitalia for gestational age, normal back and ext, skin pink and well perfused, appropriate tone and strength.\n\nD stick 70\n\nCXR: Well expanded (on positive pressure, lungs fairly clear, slight ground glass appearance and rare air bronchograms, normal cardiothymic silouette, ETT tip just below carina. UAC in good position, UVC 1 cm too high.\n\nA/P: 28 week gestation, symetric IUGR infant, twin B with respiratory distress, overwhelmingly likely due to surfactant deficiency, +/- componenet of retained fetal lung fluid, can not r/o sepsis/pneumonia, despite lack of perinatal risk factors. Mother +, baby at risk. Also at risk for other complications of moderate prematurity and SGA incluing A/B, PDA, hypoglycemia, hyperbili, feeding intolerance, NEC, IVH/PVL, ROP.\n\n-Mech vent, surfactant, wean with permissive hypercapnia approach\n- UVC, UAC, D10W at 100 cc/kg/d, monitor gluciose, lytes, bili, treat as indicated\n-CBC, blood cx, amp and gent pending lab results and clinical course\n- Bath, HBIG, HepBvaccine.\n-head U/S and eye exam per routine\n\nI spoke with parents prenatally and again in OR, will keep updated/supported, contact PMD when name identified.\n\nProcedure Note:\n\nProcedure: Intubation\nMonitoring and premdication: None (in OR)\nTechnique: cords visualized with 00 , 2.5 ETT inserted to 6.5 cm at lips. BS equal bilterally, taped.\nNo complications, baby tolerated procedure well.\nCXR obtained in NICU, ETT tip in good position.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744339,
"text": "Addendum:Infant with 1 brady at 0600 HR 67 with a desat to 82%.Noted apnea,QSR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-13 00:00:00.000",
"description": "Report",
"row_id": 1744345,
"text": "Nursing Note\n\n\n1. Recieved infant on NP CPAP of 6 FiO2 21%. Infant cont on\nthese settings thus far. One spell HR 72, 94% while\nsleeping, no drifts. Sats 93-100%, RR mainly 30's-50's. BLS\nc/=, mild sc/ic retractions. Sx q4h. See flowsheet for\ndetails and amounts. No ^WOB noted. P/COnt to monitor and\nsupport resp req.\n3. WT=652g up 22g. TF=150cc/kg/d. IVF is PND12.5 @ 40cc/kg/d\nvia central PICC infusing without incident. Enteral feeds of\nBM 20 @110cc/kg/d via NGT. Enteral feeds advanced at\n0100/1300 by 10cc/kg/d. Tolerating feeds with min asp, no\nspits, v/trace stools thus far. Heme neg. Abd presents full\nand soft, stable girths, pink well perfused. Occassional\nloops. aware. Abd nontender. P/Cont to monitor and\nsupport FEN req.\n4. Temps stable in servo iso, nested on sheepskin. A/A with\ncares, sleeps well between. MAE, AFOSF, PFOSF. Sucks paci.\nHands to face. P/Cont to support and monitor dev milestones.\n5. Mom called x1 for update. Asking approp quest. Updated by\nthis RN. Plans to visit at 1130 for cares and kangaroo.\nP/Cont to update, edu, monitor and support family.\n8. Infant cont on d of abx treatment. LP performed by\n without incident. Infant without signs of sepsis.P/Will\ncont to monitor for s/s of sepsis.\n9. Infant without murmur thus far. Pink well perfused, +cap\nrefill, +pulses bilat. BP 51/33 (35). One spell. P/Cont to\nmonitor and support CV req.\n\nSee flowsheet for additional details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-13 00:00:00.000",
"description": "Report",
"row_id": 1744346,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on NP CPAP 6 FiO2 21%. Suctioned ETT For sm amt of clear secretions. Breath sounds are clear. One brady so far tonight. RR 30-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-13 00:00:00.000",
"description": "Report",
"row_id": 1744347,
"text": "Neo attending\nDOL 13 for this IUGR now 29 week infant in CPAP of 6 in RA.\nContinues on caffeine for and on vanco/gent for presumed sepsis.\nNow day of vanco/gent\nWeight is 652 gms up 22 gms on TF of 150 cc/kg/day on feeds at 110 cc/kg/day with PN/IL running.\n\nPE:\n\nRRR no m\nClear BS\nSoft abdomen + BS\n+ 2 pulses\n\n\nA/P: Preterm infant with presumed line infection and CPIP with advancing feeds.\n\nContinue to advance feeds and plan to heplock PICC when full feeds attained.\n\nNl HUS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744509,
"text": "Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 36.\nWT: 1070 g (+35)(<10th %ile); birth wt: 612 g. Average wt gain over past wk ~21 g/kg/day.\nHC: 26.5 cm (<10th %ile); last: 25.25 cm\nLN: 34.5 cm (<10th %ile); last: 34.5 cm\nMeds include Fe and Vit E\n noted\nNutrition: 150 cc/kg/day SSC 32 w/ promod, all pg over 60 min due to hx of spits. Average of past 3 day intake ~150 cc/kg/day, providing ~160 kcal/kg/day and ~3.9 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is exceeding recs for wt gain of ~15 to 20 g/kg/day and HC gain of ~0.5 to 1 cm/wk; represents catchup growth. LN shows no change over past wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744510,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sutures opposed\nmild subcostal retractions on CPAP, some upper airway rhonchi, lung bases clear\nRRR, no murmur, pink and well perfused\nabdomen soft/full, nontender, active bowel sounds\nactive with good tone\nsuperficial excoriation betweeen .\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744511,
"text": "Attending Note\nDay of life 36 CGA 33 1/7\nCPAP 7 FiO2 23-33% RR 30-60's on caffeine one spell overnight\nHR 150-160's BP 58/29 mean 39\nweight 1070 up 35 grams on 150 cc/kg/day of SSC 32 with promod pg over an hour\nno spits minimal aspirates\nvoiding and stooling heme negative\nstable in off isolette\nalert and active with cares\n\nImp-making progress\nwill try to wean CPAP to 6\nwill continue currentl calories\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744512,
"text": "NPN 0700-1900\n\n\nRESP: Received infant on Prong CPAP 7, decreased to 6.\nFiO2's 24-28 thus far. LS C/=, mild SCR. On caffeine, no\nspells thus far (').\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, no loops, good bs, girth\nstable. Voiding, no stool thus far. On Vitamin E & Iron.\n\nG/D: Temp stable swaddled in off isolette. A&A w/cares,\nslightly irritable when adjusting prongs. Sleeps well in\nbetween cares. Brings hands to face for comfort.\n\n: Mom called X1, by this RN, asking\nappropriate questions. Plans to visit later this evening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744513,
"text": "Respiratory Care\nPt recieved on nasal prong CPAP +7cm's with the fio2 24 to 30%. Pt weaned down on CPAP from 7 to 6cm's this shift. Pt's respiratory rates 30's to 60's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744595,
"text": "Neonatology Attending\nDOL 50 / CGA 35-1/7 weeks\n\nOn CPAP 6 cm H2O in 24-27% FIO2. No bradycardias, on caffeine.\n\nIntermittent murmur. BP 57/24 (36).\n\nWt 1545 (+55) on TFI 150 cc/kg/day SC32PM, tolerating well by gavage. Abd benign. Voiding and stooling (guiac negative). On vit E and iron.\n\nTemp stable in open crib.\n\nNow day of topical erythromycin for conjunctivitis.\n\nA&P\n28 week GA infant with CLD,\n-Continue to follow on CPAP until oxygen requirement again resolves; wean to 5 cm H2O pressure\n-Complete course of erythromycin\n-Otherwise continue current management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744340,
"text": "Neonatology Attending\n\nDay 12 CGA 29 5/7 weeks\n\nRemains on CPAP at 6cm with fio2 0.21-0.23. RR 45-65. Has had two bradycardia episodes over last 24 hours. No murmur. Remains on vancomycin and gentamicin for presumed infection- day . Blood culture no growth. Weight 630 gms (+13). TF at 150 cc/kg/d. Enteral feeds now at 90 cc/kg/d. PN and lipids at 60 cc/kg/d. Stable abdomen. Alert, active. Stable temperature in incubator.\n\nDoing well overall with improved clinical picture on antibiotics. Will continue to monitor closely on CPAP. Plan to continue feeding advance at 10 cc/kg/d twice daily. Monitoring abdominal exam. Continuing antibiotics. Consent obtained for lumbar puncture. Keeping family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744341,
"text": "NPN\n\n\n#1 Resp: infant remains on NP CPAP=6 Fi02=21-13%. RR\n30-50's, sats 92-100%. BBS clear/=. Sxn Q4h for thick mod\nsecretions. X2 A/B so far this shift. on caffeine. cont to\nclosely monitor.\n\n#3 FEN: infant TF remain 150cc/kg/d. IV fluids PN/IL\n@50cc/kg/d via central PICC. Enteral feeds Br20@100cc/kg/d\n=11cc NG Q4h. tolerating feeds well, abd rounded, soft, +BS,\nstooling with each diaper change. voiding. min residuals no\nspits. dstik=95. cont to monitor and advance feeds 10cc/kg\n.\n\n#4 G&D: infant remains nested in covered servo isolette.\ntemps stable, more active and alert than yesterday. cont to\nprovide developmental support.\n\n#5 Parents: Mom called this AM, updated on infant status and\nplan to do LP today. asking appropriate questions, plans to\nbe here for a visit this afternoon. cont to provide updates\nand support.\n\n#8 Sepsis: infant cont on day 2 or 7 vanco and gent. levels\ndrawn today -> pending. temps stable, infant more active.\nplan to do LP this afternoon. cont to closely monitor.\n\n#9 CV: no murmur heard, HR 130-160s, pink and well perfused,\ncont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744342,
"text": "Respiratory Care\nPt cont on +6cm NP CPAP. Fio2 .21, bs clear, rr 30-70. sx for sm amt. On caffeine. 2 spells noted this shift. Plan to support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744343,
"text": "Neonatology- PRogress Note\n\nPE; Rmeains in her isolette, on CPAP, bbs cl=, rrr soft systolyc murmur, abd soft, nontender, V&S, afso, gavage & picc in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-12 00:00:00.000",
"description": "Report",
"row_id": 1744344,
"text": "Neonatology- Procedure Note\n\nProcedure: Lumbar Puncture\nIndication: Completion of sepsis evalution\n\nParental consent in chart. Infant given 20% sucrose pacifier prior to procedure. Infant placed in left lateral decubitus position with cardio-respiratory monitor in place. Infant prepped and draped in sterile fashion. Using sterile tachnique, a 22G spinal needle was inserted into L4-5 interspace. Clear spinal fluid was obtained and sent for usual studies. The infant tolerated the procedure without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744432,
"text": "NPN 11p-7s\n\n\n#1 Received infant on prong CPAP 6cm. FIo2 had been ranging\nfrom 21-31%. Had ^ severity of desats during evening to the\n50-70% range requiring ^ O2, suctioning, and mod stim to\nresolve. Chest xray done-unremarkable but\ndecision to intubate followed based on desats. Intubated\nwithout incident. Initial settings 26/6 x 25. ^ rate to 30\nafter CBG: 7.20 PCO2 70. Repeat ABG ~ 1hr after changes:\n7.29 PCO2 55. Settings unchanged. BBS difficult to\nauscultate immediately after intubation-only 6 ribs expanded\non f/u x-ray. Lg amts air in belly also. Improved aeration\nas noc progressed with vent adjustments. On caffeine. A:\nreintubated d/t worrisome desats P: monitor resp exam very\nclosely\n\n#3 Tf's 150cc/k. Received 20cc of SC32+PM q 4hrs on a pump\nover 1 hr. Abdomen is soft with active BS but full s/p\nintubation. ~ 5cc of air removed via ngt. NGT vented after\nfeeds. DS ^ 187. aware. Decrease to 168 after 1hr.\nWeight ^ 7g. A: tolerating feeds, elevated DS P: Follow BS\nand tolerance to feeds\n\n#4 Mx'd in servo control isolette. Temps slightly warm\ninitially. Probe readjustments made-otherwise stable.\nSomewhat drowsy overnoc but active. MAE. Nested on sheepskin\nwith gel pillow and boundaries in place. A: tired out infant\nP: Support developmental needs\n\n#5 Mom and Dad came in overnoc d/t infant's continued desats\nand threat of intubation. Spoke at length with mom and dad\nreviewing events of noc and plan for dtr. Asking thoughtful\n?'s. A: worried folks P:Cont to support and involve\n\n#10 Temps stable. CBC and blood cx sent-results pending.\nStarted on gent and vanco. BP's stable. Reintubated for ^\ndesats. DS elevated ? r/t stress vs illness. Not opening\neyes and somewhat quiet but active. A: r/o sepsis P Abx as\nordered, follow labs and exam\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744433,
"text": "Attending Note\nDay of life 25 CGA 31 \nintubated for spells 24/6 rate 30 FiO 25% coarse breath sounds\non caffeine ABG 7.29/55/83/28\nHr 140-160 BP 63/28 mean 38\nhct 33.3\nweight 817 up 7 on 150 cc/kg/day of SSC 32 with promod over 1hr\nfull abdomen soft active bowel sound venting NG tube\nhad 2 cc aspirate this am partially digested\n\nno spits\ntrace stool\ndstick 187 and 168\non vanco gent\n10.8 (17P 4B 39L)\nblood culture pending\nhad temp 100.1 believed to be environmental\n\nImp-worrisome for infection this am\nwill check x-ray today and will wean the vent as tolerated\nwill continue feeds for now\nwill check lytes today\nwill continue antibiotics\nwill follow blood culture\nwill consider repeat CBC tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-04 00:00:00.000",
"description": "Report",
"row_id": 1744504,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOf, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur,pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744596,
"text": "NICU nursing note\n\n\n1. Resp=O/Presently on bubble prong CPAP of 5. FIO2\n24-26%. No spells. (Please refer to flowsheet for resp\nassessment and changes.) Cont on caffeine. A/Stable\non CPAP. P/Cont to monitor for resp distress.\n\n3. FEN=O/TF cont at 150cc/k/d of SC32PM gavaged over\n60min. Abd benign. (Please refer to flowsheet for\nassessment.) No spits. Voiding/stooling. Cont on Vit E\nand iron. A/Tolerating current regime. P/Cont to monitor\nfor feeding intolerance.\n\n4. G&D=O/Temp stable swaddled cobedding in open crib.\nAlert and active with cares. Sleeping well between feeds.\nNow day 9:10 emycin oint to ou. Sm amt yellow dng noted\nfrom OD. A/ in G&D. P/cont to monitor and support G&D.\n\n5. =O/Mom in to visit. Updated by this nurse.\nParticipating in all care. A/appropriate and actively\ninvolved. P/Cont to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744597,
"text": "Respiratory Care\nBaby rec'd on bubble CPAP 6 via INCA prongs. CPAP decreased to 5. 02 24-26% this shift. RR 30's-70's with baseline SCR. No spells noted. On caffeine. Plan cont present management. Follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744598,
"text": "Clinical Nutrition:\nO:\n~35 wk CGA BG on DOL 36.\nWT: 1545g(+55)(<10 ile); birth wt: 612g. Average wt gain over past wk ~25g/kg/day.\nHC: 28.5cm(<10 %ile); last: 27.5cm\nLN: 36.5cm(<10 %ile); last: 35.5cm\nMeds include Fe & Vit.E.\n not needed.\nNutrition: 150cc/kg/day as SSC 32 w/promod; pg. Average of past 3-day intake ~150cc/kg/day, providing ~160kcal/kg/day & ~3.9g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; pg. Current feeds & supps meeting recs for pro/vits/mins. Kcals exceeding our recs of ~120-150kcal/kg/day d/t SGA status. Growth is exceeding recs of ~15-20g/kg/day for WT gain; discussed w/ team & agreed to c/w current feeds d/t SGA. HC/LN gains meeting recs. Will cont. to follow w/ team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-19 00:00:00.000",
"description": "Report",
"row_id": 1744599,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, alert in an open crib, AFOf, sutures opposed, good tone. BBS clear and equal with good air entry, mild SC retractions. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744429,
"text": "Clinical Nutrition:\nO:\n~31 wk CGA BG on DOL 24.\nWT: 810g(+25)(<10 %ile); birth wt: 612g. Average wt gain over past wk ~23g/kg/day.\nHC: 24.75cm(<10 %ile); last: 21.5cm()\nLN: 32.5cm(<10 %ile); last: 31.5cm()\nMeds include Fe, Vit E & Vit A\nLabs due next wk.\nNutrition: 150cc/kg/day as SSC 32 w/promod; pg over 1hr. Average of past 3-day intake ~153cc/kg/day, providing ~160kcal/kg/day & ~4g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; all pg. Labs due next week. Current feeds & supps meeting recs for pro/vits/mins. Kcal exceeding recs of ~120-150kcal/kg/day d/t SGA status. Growth is slightly exceeding recs of ~15-20g/kg/day for WT gain; will c/w current feeds & if continues to gain excess WT gain in the next few days, would consider decreasing caloric density. Average of 2-week HC gain is exceeding recs of ~0.5-1.0cm/wk & LN gain is not meeting recs of ~1.0cm/wk. Will monitor long term growth trends. Will cont. to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744430,
"text": "Neonatal NP-Procedure\n\nProcedure: Intubation\nIndication: Airway\n\nInfant with increased severity of desats over past few hours. Infant intubated with 2.5 fr ETT without difficulty. ETT secured at 6.5 cm at lip. Awaiting Xray confirmation of placement.\n\n\n visiting at time of intubation, they are fully informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-25 00:00:00.000",
"description": "Report",
"row_id": 1744431,
"text": "Respiratory Care\nBaby received on cpap 6,had increase in severity of spells,. intubation with 2.5 ett taped at 6.5cm.Baby higher pip's and R to auscultate bs.Current vent settings 26/6 R 25 fio2 labile.cxr 6 ribs expanded with large amt air in belly.Will follow with cbg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744498,
"text": "NPNote\n\n\n#1> remains on NProng CPAP 7cm, FIo2 30-40%, BBS coarse,\nwhitish oral secretions suctioned, mild intercostal/\nsubcostal retractions present,on caffine, no spells thus far\nthis shift.Occassional desats to 70's QSR.on caffine.CBG\n7.31/63, team aware,A; required CPAP support. p; cont resp\nsupport as needed.\n\n#3. TF=150cc/kg/day,SC32 with promod, pg fed tolerated,BS+,\nno loops, voided, , gauaic negative. d'stix 79,A;\nFeeds tolerated.P; cont current feeding plan.\n\n#4. alert,active with care, temp stable in a air mode\nisolette, swaddled with blanket, MAE. Hep B vaccine given as\nordered.A; AGA p; cont dev support.\n\n#10. On Oxacillin as ordered,alert,active. A; asymptomatic\nP; cont to monitor, cont antibiotics today as advised by\nteam.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744499,
"text": "NEonatology- PRogress Note\n\nPE: remains in her isolette, on CPAP 7 ~.30 bbs sl cse =, nasal bridge irritated and slightly red, reportedly moderate secretions, rrr s1s2 soft systolyc murmur, abd soft ,nontender, V^S< afso, iv in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-03 00:00:00.000",
"description": "Report",
"row_id": 1744500,
"text": "NPNOte\nAddendum: Alert, active with care, BBS coarse,mild subcostal retractions present, not in distress.iv hep lock in situ without any redness.MOm visited.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-04 00:00:00.000",
"description": "Report",
"row_id": 1744505,
"text": "0700- NPN\n\n\nRESP: Currently on prong CPAP-7, fi02 21-29%. LS clear/=,\n suctioned x1 for small amt yellow/blood-tinged\nsecretions. RR 40s-60s, mild SC/IC retractions noted. No\nbradys, occasional drifts/desats. Continues on Caffeine.\n\nFEN: TF 150cc/kg/d SC32 with pm, given via gavage q4hrs over\n1hr. No spits, min asp. Abdomen soft, full, no loops, active\nBS. Voiding and stooling, guiac negative. Continues on vitE\nand Fe.\n\nDEV: Temps stable, dressed and swaddled in air control\nisolette. MAE, fontanels soft and flat. Alert and active\nwith cares, sleeping between cares. AGA.\n\nPARENTING: Mom called x2 for updates, stated that she plans\nto be in to participate in this afternoon's cares. RN\ninformed Mom of results of today's eye exam.\n\nSEPSIS: Oxacillin D/C'd per order. BC negative to date, no\nevidence of sepsis at this time.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-04 00:00:00.000",
"description": "Report",
"row_id": 1744506,
"text": "Respiratory Care Note\nPatient remains on +7 prong CPAP, FiO2 21-29% this shift. BS clear. suctioned for old bloody secretions. RR 40-50's. On caffeine. No bradys noted this shift as of this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744507,
"text": "NPN 7p-7a\n\n10 Infant with Potential Sepsis\n\nResp: Infant remains on nasal prong cpap 7cm. Fi02 23-32%.\nRR 40-60's. Ls clr/=. Mild sc retractions noted. x1 so\nfar this shift. Mild stim. Conts on caffiene. NO sxn thus\nfar. Cont to wean 02 as tol.\n\nFen: Conts on tf 150cc/kg of ssc 26. Tol feeds well gavaged\nover 60 mins for hx of spits. No spits thus far. Minimal\naspirates. Ag stable 21-22cm. Med green stool x1. Quaic neg.\nVoiding with each diaper change. Conts on vite and fe. Conts\non vite and fe. Cont with current plan.\n\n: Mom called x1 for update. Cont to support and\nupdte.\n\nDev: Temp stable swaddled in airmode isolette. Boundries in\nplace. Active with cares. Sleeps well between. Cont to\nsupport developmental milestones. Cont to support\ndevelopmental milestones.\n\nSepsis: Oxacillian complete. No new signs of sepsis noted.\nIssue resolved\n\nREVISIONS TO PATHWAY:\n\n 10 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-05 00:00:00.000",
"description": "Report",
"row_id": 1744508,
"text": "Respiratory Care Note\nPt. continues on 7cmH2O of NPCPAP and 23-33% FIO2. Pt. on Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-18 00:00:00.000",
"description": "Report",
"row_id": 1744590,
"text": "Nursing NICU NOte\n\n\n1. Resp. O/Pt remains on nasal prong CPAP of 6, FiO2\nprimarily 29-31% this am. Please refer to flowsheet. A/Resp\nstatus appears comfortable on CPAP. P/Cont. to supply and\nwean fiO2 as pt needs/tolerates.\n\n3. F/N. O/TF remain at 150cc/k/d of SC 32PM pngt over 1\nhour Q 4 hours. PLease refer to flowsheet for examinations\nof pt from this shift. Voided. No stool passed during this\nnurses shift thus far. A/Appears to be tolerating present\nfeeding regimen. P/Cont. to monitor for s/s of feeding\nintolerance.\n\n4. G/D. O/Temp remains stable swaddled, cobedding with\nsibbling. Awake and alert at am care time. Appears to have\nmore vigorous compared to yesterday's behavior. Sucks on\npacifier. A/. in G/D. P/Cont. to support pt's growth and\ndev. needs.\n\n5. . O/Mother and father of infant in this am.\n updated on pt's status and plan of care. Mother\nchanged pt's diaper and took pt's temp. A/ are\nactively involved in pt's care. P/Cont. to support and\neducate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-12 00:00:00.000",
"description": "Report",
"row_id": 1744553,
"text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in Nasal Prong CPAP-5,FIO2 21-26%.RR\n40-60's with IC/SC retractions.LS coarse to clear after\nsxn'ing.Sxn'd small clear secretions orally and moderate tan\nnasally.Infant with occ. drifts in sats however no A's abd\nB's thus far.Cont's on Caffiene as ordered.A:. Resp. d/t\nPrematurity P:Cont. to assess resp. status.\n\nF/N:Infant cont's on TF 150cc's/kg/day rec.Similac SC 32\nwith Promode 32cc's q 4 hrs. gavaged over 40\nmin.Weight=1.270kg up 40 grams.Abd.soft with pos bs,no loops\nor spits minimal aspirates.Girth=23.5-24.OGT in place.Infant\nvoiding no stool thus far.A:Tolerating Feeds Well.Adequate\nWeight Gain.P:Cont. to assess toleerance of feeds and\nmonitor weight gain.\n\nG/D:AFOF.Infant is alert and active with cares;Sleeping well\nb/t cares.Infant remains in off isolette,swaddled with\nnested boundaries.Temp. stable.Infant bringing hands to face\nand mouth,sucking intermitently on pacifier.MAE.A:AGA\nP:Cont. to support growth and dev.\n\nParenting:Mom called x 1 updated by this RN asking\nappropriate questions.Plans to be in today will call prior\nto visit.A/P:Cont. to update,support,and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-12 00:00:00.000",
"description": "Report",
"row_id": 1744554,
"text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 21-27% this shift. BS clear. sxn x1 for mod amt tan secretions. RR 40-60 with mild retractions. No bradys noted, occ sat drifts. On caffeine. Plan cont CPAP, will follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-12 00:00:00.000",
"description": "Report",
"row_id": 1744555,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. Breath sounds clear and equal with good CPaP transmission. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active with exam\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-12 00:00:00.000",
"description": "Report",
"row_id": 1744556,
"text": "Neonatology Attending\nDOL 43 / CGA 34-1/7 weeks\n\nOn CPAP 5 cm H2O in 21-26% FiO2, with no significant distress. On caffeine with no cardiorespiratory events.\n\nIntermittent murmur. BP 68/28 (42).\n\nWt 1270 (+40) on TFI 150 cc/kg/day SC32PM, tolerating well. Abd benign. Voiding and stooling normally.\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with CLD, feeding immaturity\n-Continue on CPAP for another 48 hours\n-No changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-12 00:00:00.000",
"description": "Report",
"row_id": 1744557,
"text": "Nursing nICU Note.\n\n\n1. Resp. O/Pt remain on CPAP of 5, FiO2 21-29% primarily\nthis shift. No A/B noted. On caffeine. A/Requires CPAP to\nmaintain adequate oxygenation. P/Cont. to monitor. Cont. to\nsupply and wean fiO2 as pt needs/tolerates.\n\n2. F/N. O/TF remains a 150cc/k/d of SCsim32PM PNGt over\n40min. Please refer to flowsheet for examinations of pt from\nthis shift. Voiding. Passed stool. A/Appears to be\ntolerating present feeding regimen. P/Cont. to monitor for\ns/s of feeding intolerance.\n\n4. G/D. O/Temp stable swaddled in an off isolette. Awake and\nvery alert with cares and sleeping well in between. A/.\nin G/D. P/Cont. to support pt's growth and dev. needs.\n\n5. . O/MOther called and stated that she would be in\nfor 8pm care times. Mother updated on pt's status and plan\nof care. A/ are actively involved in pt's care.\nP/Cont. to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-29 00:00:00.000",
"description": "Report",
"row_id": 1744466,
"text": "NPN 0700-1900\n\n\nRESP: Remains on IMV 22/6 R24, FiO2 ~21-30%. LS coarse/=,\nIC/SCR. Suctioning Q3-4' for large secretions. On caffeine,\nno spells this shift.\n\nFEN: Tolerating feeds well gavaged over 1 hour, 1 spit,\nminimal aspirates. Abdomen soft/full, good bs, no loops,\ngirth stable. V&S (heme positive - r/t bloody \nsecretion?).\n\nG/D: Temps warm nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Brings hands to face for\ncomfort. HUS planned for tomorrow.\n\n: Mom called X5, updated by this RN, asking\nappropriate questions. Very concerned regarding infant and\nsepsis issue.\n\nSEPSIS: Day of Vanco & Gent. ID from TCH over today for\nconsult. and NP cultures sent for viral work-up. Trach\naspirate shows staph aureus. Plan to wait for other cultures\nbefore making a plan (switch abx or continue current ones\nfor longer length of time?). BC remain negative. Infant A/A\nw/cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744467,
"text": "NPN/1900-0700\n\n\n#1 RESP: Infant remains orally intubated on IMV 22/6 r24.\nFiO2 25-30%. LS coarse; clear after sxn. Sxn Q2hrs for\ncopious white oral and endotracheal secretions. No spells\nor desats. On caffeine. Cont. to monitor.\n#3 FEN: Wt 891, down 18 gms. TF=150cc/k/d of SC32 w/pm.\nTolerating gavage feeds over 1hr. No spits/aspirates. Abd.\nsoft, full, +BS. Girths=20-20.5cm. Voiding; small stool\nx1. Cont. per plan.\n#4 DEVELOPMENT: Nested on sheepskin in servo mode isolette.\nTemps stable. Active/alert w/ cares; settles well b/t with\nfirm boundaries. AGA. Cont. to support developmental\nneeds.\n#5 : Mom and dad visiting this evening; updated by\nnursing. Mom participated w/ infant's cares; did not hold\ntoday (kangaroos QOD). Very and appropriate with\ninfant. Mom called before bed for another update. Cont. to\nupdate and support .\n#10 SEPSIS: Day antibx; received on Gent and Vanco,\nhowever gent dc'd per ID. Vanco levels due in AM (with\nhct); dose ^'d on days. Cont. per plan. Monitor levels.\nID involved.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744468,
"text": "Respiratory Care Note\nPt. continues on 22/6 R 24 and 24-30% FIO2. BS coarse. Pt. sx'd for mod. cloudy secretions. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744469,
"text": "Attending Note\nDay of life 30 CGA 32 \nIMV 22/6 rate 24 FiO2 24-30% RR 30-60 coarse breath sounds no spells in 24 hours\nHR 150-160\nweight 891 down 18 grams on 150 cc/kg/day of SSC 32 with promod\nvoiding and stooling heme negative\nin servo controlled isolette\nhct 27.3\nday of vanco\ngent discontinued yesterday\n\nID-consulted yesterday\nviral culture sending\ntrach aspirate gres Staph aureus with few polys sensitivities pending\n\nImp-making very slow progress still producing\nlots of nasal secretions\nwill complete 10 day course of abx\nwill consider transfusion\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1744635,
"text": "NPN NOCS\n\n\n1. Remains in NCO2 100% 50-75cc. LS clear. RR 30-70's. On\ncaffeine, no spells. LS clear. On 3day course of lasix.\nStable in NCO2. Continue to monitor.\n\n3. Wt up 45 gms. TF at 150cc/kg of SSC32 with PM. Gavaged\nover 60min. Abdomen remains round and soft. No stool.\nStarted prune juice last noc. No residual. No spits.\nVoiding, uop: 2.1cc/kg/hr x 12hrs.\n\n4. Temp stable in open crib. and active with cares.\nAGA.\n\n5. Mother called and updated. Will be in later today for\ncares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1744636,
"text": "Clinical Nutrition\nAddendum:\nTF decreased to 130 cc/kg/day due to respiratory issues. Will provide ~139 kcal/kg/day and ~3.4 g pro/kg/day. Infant also started on diuril. Will monitor wt gains on new TF regimen. Prune juice started as infant has not been stooling regularly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1744637,
"text": "Clinical Nutrition\nO:\n~36 wk CGA BG on DOL 57.\nWT: 1725 g (+45)(<10th %Ile); birth wt: 612 g. Average wt gain over past wk ~15 g/kg/day\nHC: 30 cm (~10th %ile); last: 28.5 cm\nLN: 38 cm (<10th %ile); last: 36.5 cm\nMeds include Fe and Vit E, and lasix x 3 days\n not needed\nNutrition: 150 cc/kg/day SSC 32 w/ promod, all pg over 60 min. feeds via ogt due to nasal breakdown. Average intake over past 3 days ~150 cc/kg/day, providing ~160 kcal/kg/day and ~3.9 g pro/kg/day.\nGI: Abdomen benign; some generalized edema.\n\nA/Goals:\nTolerating feeds without GI problems over extended feeding times. not needed. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain. HC and LN gain are exceeding recommended ~0.5 to 1 cm/wk for HC gain and ~1 cm/wk for LN gain. Overall trends on HC and LN growth charts are acceptable. Will follow long term trends. WIll continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1744638,
"text": "Neonatology\nREmains in NCo2 since yesterday afternoon. Tolerating wean from CPAP although Fio2 flow slightly increased this am. Will follow. Is comfortable appearing. Continues on trial of LAsix. Will monitor response and consider rx with diuril in am.\n\nTF at 150 cc/k/d of 32 cal. Abdomen benign. Will decrease TF to 130 c/k/d and monitor weight gain.\n\n apparently interested in transfer to when stable off CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1744639,
"text": "Neonatology- Physical Exam\n\nInfant remains in NC. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur radiating to the back, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744546,
"text": "NPN 1900-0700\n\n\n#1Resp. O: Pt. remains on CPAP of 5 via nasal prongs, FiO2\n26-30%. RR 40-60s, LS clear and equal, SC retractions\npresent. Pt. remains on caffeine. No spells. Suctioned x1\nfor large amount tan colored secretions nasally. A: Stable\nresp. status on CPAP. P: Continue CPAP, plan to attempt to\nwean on Thursday.\n\n#3FEN. Wt. 1230gms, up 50 gms. Pt. on TF of 150cc/k/day of\nSCSimilac32 with PM, now 31cc gavaged via OG tube.Abd. soft,\nactive BS, no noted loops, stable girth. No spits, minimal\naspirates. Voiding with each care. No stool. Remains on\nvitamin E and iron. P: to continue current feeding\nplan,monitor for tolerance of feeds.\n\n#4Dev.O: Pt. swaddled in off isolette, temp. stable. Pt. not\nwaking for cares, is alert with cares. MAE. AFF.A: AGA. P:\nContinue to support developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744547,
"text": "NPN 1900-0700 continued\n\n\n#5Parents. O: Mom called x2, updated, asking appropriate\nquestions. A: Involved family. P: Continue to update and\nsupport .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744548,
"text": "Respiratory Care\nBaby continues on prong CPAP 5 with 02 26-30% this shift. BS clear. sxn x1 for lg amt thick tan bl-tinged secretions. RR 40's-60's with baseline SCR. No spells noted. On caffeine. Will cont CPAP, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744549,
"text": "Neonatology Attending\nDOL 42 / CGA 34 weeks\n\nOn CPAP 5 cm H2O in 26-30% FIO2 with no significant distress and no cardiorespiratory events..\n\nSoft murmur. BP 65/45 (51).\n\nWt 1230 (+50) on TFI 150 cc/kg/day SC32PM, tolerating well by gavage. Abd full due to CPAP but benign. Voiding and stooling (guiac negative).\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with CLD and feeding immaturity\n-Continue on CPAP through this week\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744550,
"text": "Nrusing NICU Note.\n\n\n1. Resp. O/Pt. remains on prong CPAP of 5, FiO2 24-29%\nprimarily this shift. Please refer to flowsheet. No A/B\nnoted this shift thus far. Remains on caffeine. A/Requires\nCPAP to maintain adequate oxygenation. P/Cont. to monitor\nfor s/s of resp distress. Cont. to suppy and wean FiO2 as pt\nneeds/tolerates.\n\n3. F/N. O/TF remain at 150cc/k/d of SC Sim32PM pngt over\n40min. Please refer to flowsheet for examinations of pt from\nthis shift. Voiding. Passed heme neg stool. A/Appears to be\ntoleratin present feeding regimen. P/Cont. to monitor for\ns/s of feeding intolerance.\n\n4. G/D. O/Temp remains stable swaddled in an off covered\nisolette. AWake and very alert with cares. Sucks on pacifer\neagerly. Held by mother. A/. in G/D. P/Cont. to support\npt's growth and dev. needs.\n\n5. . O/Mother took pt's temp and changed pt's diaper.\nMOther updated on pt's status and plan of care. Mother held\ninfant. A/ are actively involved in pt's care.\np/Cont. to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744551,
"text": "Resp care\nPt remains supported on 5cm/h2o of NCPAP, 24-29%\nRR- 40-60's w/ mild retractions\nB/S clear, Baby receiving caffeine, no spells documented\nPlan: Continue support\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-11 00:00:00.000",
"description": "Report",
"row_id": 1744552,
"text": "Neonatology- Progress Note\n\nPE: remains in her isolette, on CPAP5 .25-.30. bbs sl cse=, rrr soft systolyc murmur, abd soft, nontender, full V&S, afso, active with care\n\nSee attending note for plan\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1744630,
"text": "NPN NOCS\n\n\n1. Infant remains on bubble prong CPAP of 5. FiO2 24-28%. LS\nclear with mild SC retractions. RR 40-60's. No spells. On\ncaffeine. Stable on CPAP. Continue to monitor.\n\n3. Wt down 10gms. TF at 150cc/kg of SSC32 with PM. Gavaged\nover 60min q4hrs. Abd benign. No residual. No spits. On a\n3day course of lasix. Voiding, no stool. Continue to\nmonitor.\n\n4. and active with cares. Temp stable in open crib.\nCobedding with sibling. AGA.\n\n5. Parent called and updated. Asking appropriate questions.\nWill be in for am cares. Involved family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1744631,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 5 via Prongs FiO2 24-28%. Suctioned for sm amt of yellow secretions. Breath sounds are clear. Baby is on caffeine. RR 40-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1744632,
"text": "Neonatology\nDoing well. REmains on CPAP. Comfortable apeparing. Low2 FIo2. Spells not problem on caffeine. Begun on lasix yesterday for 3 day trial. WIll observe effects.\n\nWT 1680 doen 10. Tolerating feeds at 150 cc/k/d of 32 cal. Abdomen benign. All gaveg being tolerated. Lytes in reasonable rangfe except for hemolyzed K.\n\nTemp stable in isollette.\n\nEye fu in 2 weeks.\n\nAwaiting weaning from CPAP. Will consider trial of diruil rx beased on effects from Lasix.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1744633,
"text": "NPN 0700-1900\n\n\n#1Resp: Recieved pt. this am on prong CPAP 5, FIO2 24-28%.\n pt. off CPAP to NCO2 @ 1400 today after pt. recieved\nlasix. Currently pt. on NCO2 100% 50-100cc/min. RR 30-70's\nw/ mild SCR. No desats or spells so far this shift. Pt.\ncont on caffeine. LS clear bilaterally. P: cont to\nmonitor off CPAP & cont on caffeine & lasix.\n\n#3F&N: TF @ 150cc/kg/d of SC 32 w/ promod OG Q 4hrs\ngavaged over 1hr. Abd soft & full, +BS, no loops. AG\n27-28cm. Pt. had lg diaper after lasix. Pt. has not\n yet but is working on one. No spits & min asp. Pt.\ncont on Fe & vit E. P: check lytes in 2 days after\nfinishes lasix & cont to monitor FEN.\n\n#4G&D: Temps stable swaddled in OAC. Pt. awake & for\ncares, MAE's approp. Pt. irritable at times but settles\nnicely w/ pacifier. . P: cont to support dev needs.\n\n#5Parents: in today for cares & to take sister\nhome. very independent w/ cares. Both asking approp\nquestions. Updates given. Both sad to leave pt. here since\nsister is going home. Discussed possibility of transfer to\n hosp once pt. off CPAP. p: cont to support &\nudpate.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-25 00:00:00.000",
"description": "Report",
"row_id": 1744634,
"text": "Neonatology NP Exam NOte\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small infant nesled in open crib, transitioned from CPAP to nasal canula. AFOF, sutures split along sagital line. Eyes clear, ng in place, MMMP\nChest is clear, mild SCR.\nCV: RRRsoft systolic gr1/6 murmur, pulses+2=\nAbd: protruberant, active bs\nGU: normal external female genitalia\nNeuro: active, irritable butr consoles easily with holding.\n\n updated at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744329,
"text": "NPN Days continued\n\n\n(#6) A: increased lethargy and ^ number of spells> sepstic\nw/u showed shifted CBC. P: Continue to moniter and give\nantibioitics per plan.\n#7 O: \"new\" murmur heard this afternoon, with full\nperipheral pulses, no palmar pulses felt. Hr regular,\nrates mostly 140s-160s, stable B/Ps. Skin warm and pale.\nHCT 27.6 Echo was done this afternoon - no PDA seen MD\n. A: nwe murmur today, with stable B/Ps. P: Continue\nto moniter.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744330,
"text": "8 Infant with Potential Sepsis\n9 C/V\n\nREVISIONS TO PATHWAY:\n\n 8 Infant with Potential Sepsis; added\n Start date: \n 9 C/V; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-11 00:00:00.000",
"description": "Report",
"row_id": 1744331,
"text": "NPN 1900-0700\n\n\nRESP: Received infant on prong CPAP 6, switched to NP CPAP 6\nafter a large cluster of spells. Infant was suctioned for a\nvery large amount of thick white secretions X2 at that time.\n received a caffeine bolus and has had 3 spells\nsince. LS C/=, IC/SCR.\n\nFEN: Remains NPO, D10 w/2,1,Hep infusing via central picc in\nright leg. Abdomen full/soft, good bs, girth remains stable.\nV&S.\n\nG/D: Temp stable nested in sheepskin in servo isolette. Very\nsleepy/lethargic w/cares - slightly irritable at times.\nsleeping well in between. Not showing any interest in\npacifier (very unusual for her). Doing better while lying\nsupine as opposed to prone.\n\nPARENTS: Both parents in at change of shift, updated by this\nRN at bedside, both parents asking lots of appropriate\nquestions. Mom called when parents arrived home and was\nagain updated by this RN and Dr. . Mom continued to\ncall throughout the night requesting updates on 's\ncondition. Very concerned, parents. Plan to be in\ntoday to visit.\n\nSEPSIS: Infant received first dose of Vanco this shift.\nRemains on Vanco & Gent. CBC left shifted, BC remain\nnegative at this time.\n\nCV: Murmur heard w/ cares. Pulses normal, no palmar\npulses, active precordium. Infant received 20cc/kg of PRBC's\nthis shift for a low Hct - tolerated well.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-11 00:00:00.000",
"description": "Report",
"row_id": 1744332,
"text": "Respiratory Care\nBaby remains on cpap 5 21%.Switched to an nptube after having cluster os spells and req. ~ 30%.Sx nares for lg thick cldy secs.Place 2.5 nptube.Reamins on cpap 6 21.Has had a few spells this shift,on caffeine and received caffeine bolus\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-11 00:00:00.000",
"description": "Report",
"row_id": 1744333,
"text": "NICU Attending Note\nDay of life 11 CGA 29 \nResp-CPAP 6 FiO2 21% on caffeine RR 40-60 CBG 7.29/47\neleven spells overnight none since three am\nCV murmur ECHO no PDA yesterday\nHR 130-160 hct 27 s/p PRBC's last night MBP 42\nCBC 10.3 plt 419 29P 11B hct 27\nweight 615 up 15 on 160 cc/kg/day made NPO last night\nD10 PN\nUO 3.5 cc/kg/hr no stool\nthis am not very vigourous\n\nBlood culture pending\n\nImp- infant worrisome for infection\nwill consider intubation\nwill continue antibiotics\nwill decreased total fluids to 150 cc/kg/day\nwill restart feeds at 50 cc/kg/day and will advance her\nback to the 90 cc/kg/day.\nwill treat for seven days with antibiotics\nwill obtain consent for LP\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744416,
"text": "NPN 0700-\n\n\n4. Temp stable nested in servo islotte. Infant awake and\nactive with cares and rest well inbetween cares. MAE. Cont\nto promote G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744417,
"text": "Respirat6ory Care Note\nPt. had a significant brady and desat(40's). NPtube was pulled----completely occluded. I then sx'd lrg. thick sticky yellow plugs. Pt. therefore was changed to prongs. Pt. may need to increase to 7cmH2O. If pt. requires nptube suggest using mod.amt.s of saline with each sx'ing. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744418,
"text": "Respirat6ory Care Note\nPt. had a significant brady and desat(40's). NPtube was pulled----completely occluded. I then sx'd lrg. thick sticky yellow plugs. Pt. therefore was changed to prongs. Pt. may need to increase to 7cmH2O. If pt. requires nptube suggest using mod.amt.s of saline with each sx'ing. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744419,
"text": "Respirat6ory Care Note\nPt. continues on 6cmH2O of NPCPAPand 21-35% FIO2. BS are clear. Pt. sx'd for mod. cloudy secretions. On Caffeine. Pt. continues to have occ. drifts. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744420,
"text": "Respirat6ory Care Note\nPt. had a significant brady and desat(40's). NPtube was pulled----completely occluded. I then sx'd lrg. thick sticky yellow plugs. Pt. therefore was changed to prongs. Pt. may need to increase to 7cmH2O. If pt. requires nptube suggest using mod.amt.s of saline with each sx'ing. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744421,
"text": "NPN 1900-0700\n\n\nRESP: Received infant on NPCPAP 6 - switched to prong CPAP 6\ndue to tube being completely clogged off and infant\ndesatting. Suctioned w/every cares. LS coarse-->clear (after\nsuctioning). IC/SCR. On caffeine, 2 spells thus far ').\n\nFEN: Tolerating full gavage feedings over 1 hour, venting NG\ntube in between feedings. No spits, minimal aspirates.\nAbdomen soft/round, good bs, no loops, girth stable.\nVoiding, no stool this shift. D/S 102\n\nG/D: Temp stable nested in sheepskin in servo isolette.\nAlert w/cares, slightly sleepy. Sucks on pacifier for\ncomfort, soothes well w/hand containment.\n\n: Mom visiting shortly after change of shift, updated\nby this RN, asking appropriate questions. Participated in\nsiblings cares, but left before was due. Called x1\nsince returning home. Plans to visit on day shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744422,
"text": "Neonatology NP Note\nPE\nswaddled in isolette\nAFOF, sagital sutures slightly split\nmild subcostal retractions on CPAP, lungs clear/=, good air entry\nRRR,no murmur, pink and well perfuse\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-09 00:00:00.000",
"description": "Report",
"row_id": 1744321,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, grade II/VI murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-09 00:00:00.000",
"description": "Report",
"row_id": 1744322,
"text": "NPN\n\n\n#1 Resp: infant remains on NCPAP=5 FiO2=21% with sats\n97-100%. RR 40-60's. X3 spells so far this shift. BBS\nclear/=, mild SC/IC retractions. on caffeine. cont to\nmonitor\n\n#3 FEN: infant TF remain 160cc/kg/d. IF fluids PN/IL\n@80cc/kg via PICC. Enteral feeds Br20 @80cc/kg/d =8cc NG\nQ4h. tolerating feeds well, abd full, soft, +BS, voiding, X2\ntrace transitional stools. min residuals, no spits. cont to\nclosely monitor and advance feeds 10cc/kg .\n\n#4 G&D: infant remains nested in servo isolette, temps\nstable. active and alert, irritable at times. cont to\nprovide developmental support.\n\n#5 Parents: Mom and Dad at bedside this afternoon. Updated\non infant status and aware of 3 spells so far this shift.\nAsking appropriate questions, cont to provide updates and\nsupport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-09 00:00:00.000",
"description": "Report",
"row_id": 1744323,
"text": "Resp care\nPt remains supported & stable on 5cm/h2o NCPAP, 21%\nRR- 30-50'S W/ mild retractions\nB/S clear, Sx small amount of cloudy/tan secretions,\nblood tinged in Rt. nare\nBaby receiving caffeine, 4 spells documented thus far\nrequiring mild stimulation\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744324,
"text": "NPN\n\n\n#1 Resp-Remains on Prong CPAP of 5cms in 21%. BS clear.Mild\nretractions. RR- 40-60.Sxn x1.Continues to have some A's+\nB's,x3 so far tonight. See flowsheet.Remains on caffeine.\n#3 F/N- Abd soft,+bs, no loops.Tolerating advancing feeds of\nBM 20 cals w/o spits. Minimal asps.Feeds are now at\n90cc/kg/day and advancing at 10cc/kg/ as tolerated.Tf=\n160cc/kg/day. TPN infusing per patent PIC line at\n70cc/kg/day.AG stable.Wt up 15 gms.\n#4 Dev- Temp stable in servo iso nested in sheepskin.\n#5 Mom called x1.Updated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744325,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of prong CPAP and 21%. BS are clear. On Caffeine. Pt. sx'd for mod. thick white secretions. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-24 00:00:00.000",
"description": "Report",
"row_id": 1744423,
"text": "Attending Not\nDay of life 24 CGA 31 \nNP CPAP 6 FiO2 21-25% RR 40-70 on caffiene and vit A she had 11 spell in 24 hours none so far today\n\nHR 150-170 BP 66/42 50\nweight 810 up25 on 150 cc/kg/day SSC 32 with promod all pg\nUO 3.6 cc/kg/hr\ndstick 106\nNa 136 K5.5 Cl 103 CO2 21\nsome stool today\n\nImp-much better today\nshe seems to be better since she had her transfusion\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744489,
"text": "Neonatology Attending\nDOL 33 / CGA 32-5/7 weeks\n\nRemains on IMV 20/6 x 20 in 32-43% FIO2. On caffeine. CBG 7.36/49.\n\nSoft murmur (PFO on echo). BP 57/23 (35).\n\nOn oxacillin now day 9 of planned 10-day course.\n\nWt 973 (+15) on TFI 150 cc/kg/day SC32PM, tolerating well. Abd benign. Voiding and stooling.\n\nTemp elevated overnight and this morning in off isolette; otherwise asymptomatic.\n\nA&P\n28 week GA infant with pneumonia\n-Continue oxacillin to 10-day course. Fever today may represent recrudescent infection, new process or environmental effect. There is no clinical evidence of an abscess; the nasal discharge is not as prominent as previously. Of note, the likelihood of HSV is negligible given that viral culture is negative and that we would expect much more severe illness at this point in the prolonged course. We will repeat bacterial culture today, and consider investigations for occult source of infection if fever persists. This will include an LP\n-Increased oxygen requirement slightly in past 48 hours but otherwise no respiratory changes; will defer wean until stability on current settings is confirmed. Repeat CBG later today\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744490,
"text": "NPNOte\n\n\n#1. Remains orally intubated, rate 22/mt, 24/6,Fio2 30-65%,\nCBG at 1pm 7.28/67, above changes made on the .BBS\ncoarse, equal, mild subcostal/intercostal retrations\npresent, on caffine, o2 requirement increased with care and\nhanding.whitish/cloudy Et and oral secretions suctioned.Team\naware of increased o2 requirement.A;O2 requirement\nincreased, needed increase in settings.\n\n#3.Tf=150cc/kg/day,SCare 32 with promod, og fed tolerated,\nBS+, no loops, voided, small stoolx1,guaic negative.D'stix\n85.A; feeds tolerated. p; cont current feeding plan.\n\n#4. Alert,active with care, ?unstable temp 101.2 at 8.30am\nwith T sirt on, temp 98-97.6, isolette turned on @7 \naware,infant alert,active, MAEA;AGA P; cont dev support.\n\n#5.Mom visited, with grand mother, updated at bedside by\n. A;, concerned. p; cont update and teaching.\n\n#10.On Oxacilline given as ordered. CBC with def, blood\nculture sent, team aware of cBC with def results.A;\nsymptomatic P; cont antibiotics as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744491,
"text": "Respiratory Care\nPt currently on IMV. Settings increased today due to increase O2 re, wob and cbg 7.28/67. Present settings 24/6, f 22. Fi2 .37.-.45. bs coarse, rr 50's, sx for mod amt. On caffeine. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744326,
"text": "Attending Note\nDay of life 10 CGA 29 3/7\nCPAP 5 FiO2 21% RR 30-50 on caffeine\nsix spells in the past 24 hours\nno murmur HR 140-160 BP 65/40 mean 49\nweight 600 up 15 gram on 160 cc/kg/day\nenteral BM 20 at 90 cc/kg/day adv 10 cc/kg/day\ntwice daily no spits and D10 PN at 70 cc/kg/day\nno IL infusing throught PICC\ndstick-139\n4.4 cc/kg/hr and a small stool\n\nImp-doing well still below birth weight\nwill continue CPAP\nwill continue to advance enterals slowly\nwill stop PN today.\nwill begin IVF for remainder of the volume\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744327,
"text": "Respiratory Care\nPt cont on prong CPAP. Increased to +6cm H2O. Fio2 .21-.30. bs clear, rr 40-60. sx for sm amt. On caffeine. Several spells noted this shift req. mod stim and increased O2. vbg 7.20/70. repeat cbg pending. Plan to support as need. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 1744328,
"text": "NPN Days 7a-7pm\n\n\n#1 O: Recieved infant on prong CPAP of 5 cms pressure, was\nincreased to 6 cms pressure this afternoon r/t ^ number of\nbradys. FIO2 need has been mostly roomair, increased to 40%\nat times after bradys/desats. Lung sounds remain clear and\nequal. Resp rates 30s-60s with continued mild retractions.\nInfant has had > 10 bradys this shift with low HR to the\n40s-60s, with apnea and needed stim for most to resolve.\nRemains on q day dose of caffeine and is ordered for a bolus\ndose this evening. A: infant in roomair most of shift but\nhaving increased spells. P: Continue to moniter. To receive\nbolus dose of caffeine. need to consider intubation if\nspells continue/increase.\n#3 O: Remains on TF of 160cc/k/day - is currently NPO on\nD10W with addeed lytes (PN was d/c'd this evening), infusing\nvia PICC line. Earlier this shift infant had advanced feeds\nto 100cc/k/day of BM 20 cals. Abd remained softly\nround/distended with good BS and no loops, minimal aspirates\nand no spits. D-stick 139. Adeq U/O, stool heme negative.\nA: adeq blood sugar and U/O. Seems to be tolerating feeds\nbut is currently NPO r/t pending echo results/sepsis issues.\n#4 O: Infant alert and active with cares this AM with\nincreased sleepiness and lethargy throughout the day. Temp\nhas remained stable on servo controlled isolette. Attempted\nkangaroo cares but infant was unable to maintain adeq HR.\nAnt font soft and flat. A: AGA, with increased # of spells.\n P: Continue to moniter for milestones.\n#5 O: Infant's parents were in this afternoon, expressing\nappr concern about infant's increase number of spells.\nParents aware of septic workup and were updated on plan of\ncare. A: involved and invested parents. P: Continue to\nsupport and keep parents updated.\n#6 O: Given infant's increased # of spells and decreased\nactivity/lethargy, a blood culture and CBC were drawn. CBC\nresults showed \"shifted\" WBC count (29N, 11B, 32 lymphs) and\nGent and Vanco were ordered. Temp has remained stable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744414,
"text": "Respiratory Care Note\nCXR in am showed low lung volumes. Bradys appear to cluster around feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744415,
"text": "NPN 0700-\n\n\n1. Received infant on prong cpap 6. During 0900 feed\ninfant having many clusters of A&B and desats to low as\n40's. NP called to bedside at that time\nand RT at bedside as well. Feeding stopped, infant\nsuctioned and NP tube placed. ABG= 7.24/57/136/26/-3, team\naware. CBC, blood culture, and babygram done. Remains on\nNP cpap 6. FiO2 briefly as low as 21% to 32%. Requires up\nto 100% with A&B's/desats. Lungs clear. RR 20-50's with\nmild IC/SC retractions. On caffeine and Vit A. Sats are\nless labile. 5 A&B with feeds and 2 A&B's while asleep; see\nflowsheet for details. CBC benign. HCT 27.9 and 1st\nalloquat of PRBC given without incident. Cont to have\nlabile sats and A&B's as noted above. Cont to monitor resp.\nstatus closely and support as needed.\n\n3. TF 150cc/k/d SC 32 w/PM. Abd full, soft, +BS, pink, no\nloops. Girth 20-21cm. 12hr urine output= 3cc/k/hr. One\ntrace stool. Min. aspirates and one medium spit after 0900\nepisode noted above. ? reflux since brady's are mostly with\nfeeds. Gavage time increased from 45mins to 1hr and 15mins.\n\nDstick 184. Plan to keep NGT open to air inbetween feeds.\nCont to monitor tolerance to NGT feeds.\n\n5. Mother called and spoke with this\nmorning after septic workup done. Father in to visit and\nupdated on plan of care and spoke with .\nConcerned and invested . Cont to support and update\n.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744492,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOf. She is pink, well perfused, no murmur auscultated. She remains vented on settings of 22/5 x 20 with fio2 40%. Attempted to wean PIP yesterday to 20, but increased O2 requirement to 60%, so increased PIP back to 22 with resultant decrease in O2 requirment. Breath sounds clear and equal. blood gas today 7.36/49. She is tolerating full volume feeds. Abd soft, active bowel sounds, no loops, voiding and stooling guiac neg stools. Temp increased to 101 this AM in off isolette and unswaddled. Rpt CBC sent. Remains on oxacillin. Discussed temp instability with Mom. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-16 00:00:00.000",
"description": "Report",
"row_id": 1744579,
"text": "Nursing NICU NOte Cont\n\n\n4. G/d. O/Temp stable swaddled in an off isolette. Awake and\nvery alert at care times and sleeping well in between.\nBrings hands and fingers to mouth. Intermittently sucks on\npacifier. A/. in G/D. P/Cont. to support pt's growth and\ndev. needs.\n\n5. . O/Mother and grandmother in this afternoon.\nMother updated on pt's status and plan of care. Mother took\npt's temp and changed pt's diaper independently. Mother\nstated that she would like the girls transfered to \nHospital when they are ready. A/ are known to be\nactively involved in pt's care. P/Cont. to support and\neducate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-17 00:00:00.000",
"description": "Report",
"row_id": 1744580,
"text": "1. CV/RESP O: Remains on 75-100cc N/C at 100 % Fio2 with\nsats > 93%. BBS clear and equal with good air entry and\nexchange. RR 40- mostly 60-70s with mild SC/IC retrx. O2\nsats drifts to hi 80s during feeds and up to 1/2h after.\nFlow ^ to 100cc with feedings. Sxn'd x1 for large thick\nlight yellow secretions per rt. nare, HRR with soft murmur.\nNSR. /pink. Pulses equal and nonbounding. Brisk cap\nrefill x4 extrem. Mild generalized edema noted. A: Stable\non N/C. P: Monitor and document. Titrate flow to keep sats\n> 93% esp. with feedings. Maintain patent airway.\n3. FEN O: Abdomen soft and full, girth stable at 25 cm.\nAssessment unremarkable. TF=150cc/kg/day. Taking 37 cc SCC\n32 with PM per NG over 1h. No aspirates or emesis. Voiding\nand stooling with diaper changes g-. Wgt: 1.465 ^ 55g. A:\n\nStable and tolerating feeds. P: Monitor for feeding\nintolerance. Advance feeds for weight gain. Encourage PO\nfeeds when indicated.\n4. G&D O: Active and alert. Lusty cry. Swaddled in\nisolette with heat off, temp stable. A: Appropriate P:\nMonitor. Comfort measures.\n5. O: Mom called and updated. Will be in\ntomorrow. A: ,well-involved parent P: Support and\nkeep updated. Encourage to ak questions and participate in\ncare.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-17 00:00:00.000",
"description": "Report",
"row_id": 1744581,
"text": "Nursing NICU Note\nPt cont. to have frequent saturation drifts and increased WOB. CXR obtained. Pt placed on CPAP of 6, FiO2 33-39% thus far.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-01 00:00:00.000",
"description": "Report",
"row_id": 1744486,
"text": "NPN 0700-2300\n\n\nRESP: Received infant on IMV 22/6 R22 - weaned to 20/6 R22.\nCXR done today - = improved. LS coarse-->clear after\nsuctioning. Suctioning with every cares for moderate to\nlarge secretions. On caffeine, no spells thus far, (0/24').\n\nFEN: Tolerating full enteral feeds gavaged over 1 hour due\nto spits, no spits this shift, minimal aspirates. Abdomen\nsoft/round, good bs, no loops. V&S (heme negative). NG tube\nremoved and placed OG due to nasal , .\n\nG/D: Temp stable/warm nested in sheepskin in servo isolette.\nInfant swaddled after kangaroo'ing and placed on air. Temp\nremains stable/warm - weaning isolette as tolerated. A&A\nw/cares, sleeps well in between. Brings hands to face for\ncomfort.\n\n: Both in during the day, updated by this RN,\nasking lots of appropriate questions. Independent w/cares.\nMom kangaroo'd today - tolerated very well.\n\nSEPSIS: Continues on day of Oxicillin. New IV placed\nthis shift. Will continue to monitor for further s/sx of\ninfection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744487,
"text": "NPN 7p-7a\n\n\n#1 Infant received on settings 20/6 x 22. Rate decreased to\n20 ~ 0530 s/p CBG: ph 7.36 PCO2 39. BBS coarse bilat-clears\nVERY briefly after suctioned. Suctioned ~ q 2hrs for\nsmall-lg amts cloudy secretions via ETT as well as orally.\nOn caffeine. No bradys but occasional drifts in sats, esp\nwith need for suctioning. A: weaning P: Follow resp\nstatus\n\n#3 TF's 150cc/k. Weight ^ 15g. Receiving 24cc of SC32+PM q\n4hrs on a pump over 1hr. Small spit x 1, residual max 0.8cc.\nAbdominal exam unremarkable. Voiding and stooling-heme neg.\nA: tolerating feeds P:Follow abdominal exam\n\n#4 Temps cont. elevated in air isolette. Isolette weaned x 2\nand infant unswaddled. Alert and pleasant with cares.\nRepositioned with cares. A:AGA P: support developmental\nneeds\n\n#5 Mom phoned x 1. Update given.\n\n#10 Conts on oxacillin. On day . Weaning on . Temps.\n^ in air isolette. Active. A: Abx therapy P: ABx as ordered\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-02 00:00:00.000",
"description": "Report",
"row_id": 1744488,
"text": "Respiratory Care\nBaby on imv 20/6 decreased R to 20 from 22 after cbg 7.36/49.BS coarse ->clearing after sxing frequently for lg cldy secs.FIO2 ranges from 32-44%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-15 00:00:00.000",
"description": "Report",
"row_id": 1744574,
"text": "Neonatology- Physical Exam\n\nInfant remains on NC. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-30 00:00:00.000",
"description": "Report",
"row_id": 1744657,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in NCO2 FIO2 100% 25-75cc/min flow. No\nspells. Occas self-resolving sat drifts to 80's. Cont on\ncaffeine and diuril. (Please refer to flowsheet for resp\nassessment.) A/Stable in NCO2. P/Cont to monitor for resp\ndistress.\n\n3. FEN=O/TF cont to be restricted at 130cc/k/d of SC32PM\ngavaged over 70min. Abd benign. Lytes sent at 1700.\n(Please refer to flowsheet for assessment and lytes.) No\nspits. Voiding. No stool. Cont on Vit E, iron, and prune\njuice. A/Tolerating current regime. P/Cont to monitor FEN\nstatus. PO's on hold for now.\n\n4. G&D=O/Temp stable swaddled in open crib. and\nactive with cares. Sleeping well between feeds. MAE. Font\nS/F. A/ in G&D. P/Cont to monitor and support G&D.\n\n5. =O/Mom and in to visit. Updated by this\nnurse. Independent with cares. A/appropriate and actively\ninvolved. P/Cont to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-01 00:00:00.000",
"description": "Report",
"row_id": 1744658,
"text": "NPN 1900-0700\n\n\nRESP: Remains on NC 100%, 50cc. LS C/=, mild SCR. On Diuril\nand caffeine, no spells, occasional drifts to high 80's.\n\nFEN: Tolerating full enteral feeds well, plan to offer\nbottle w/next feeding. Abdomen soft/round, good bs. Voiding,\nno stool thus far. Remains on Vit E, iron, & prune juice.\nStarted KCl this shift.\n\nG/D: Temp stable swaddled in OAC. A&A w/cares, wakes for\nsome feedings, sleeps well in between. had a bath\nthis shift.\n\n: Mom called X1, updated by this RN, asking lots of\nappropriate questions. Plans to call in the AM and visit\nlater in the day.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-01 00:00:00.000",
"description": "Report",
"row_id": 1744659,
"text": "Neonatal NP-Exam\n\nSee dr. note for details and plan of care as discussed in this am.\n\nAFOF. Breath sounds course with upper airway congestion. Nl S1S2, grade murmur. Pink and well perfused. abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-01 00:00:00.000",
"description": "Report",
"row_id": 1744660,
"text": "Neonatology Attending Note\nDay 62\nCGA 36 6\n\nNC 50cc. On diuril and KCL. BS clear. On caffeine. RR50-70. +soft murmur. HR 140-150s.\n\nWt 1815, up 20. TF 130 SC 32 w promod pg>po. Tol well. Nl voiding and stooling. On vit E and Fe.\n\nIn open crib.\n\nA/P:\n-- wean O2 as tol, inc maintenance diuril\n-- no change to nutritional plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-07-01 00:00:00.000",
"description": "Report",
"row_id": 1744661,
"text": "1. remains in 50-75cc flow 100% nasal cannula O2,\nRR50-70, sc retractions, BBS clear, equal, on diuril, KCl\nand caffeine A: altered respiratory related to prematurity\nP: diuril dose increased today, check on Tues.\n3. TFR 130cc/k/d SC32 with promod 40cc q4, took 35cc po well\nthis am, abd soft, no spits, minimal aspirates, on vitamin e\nferinsol and prune juice, voiding, no stool since thurs P:\noffer bottle according to cues/or x1/shift as not to tire.\n4. temp stable swaddled in open crib, with cares,\nstarting to bottle feed P: continue to support development,\n60 day immunizations on same as twin.\n5. Mom called this am, received update on baby, planning to\nvisit later today A: involved and concerned parent P;\ncontinue to update and offer support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744310,
"text": "Resp care\nPt remains supported & stable on 5cm/h2o of NCPAP, 21%\nRR- 30-60's w/ mild retractions, B/S clear\nBaby weaned off CPAP to trial NC, Tolerated for 1hr.\nPlaced back on CPAP due to spells.\nPt on caffeine, 5 spells thus far, requiring mild/moderate\nstimulation\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744311,
"text": "NPN 1900-0700\n\n\nRESP: Received infant on prong CPAP 5, no changes made.\nRemains in 21%, LS C/=, IC/SCR. On caffeine, 1 spell thus\nfar this shift (').\n\nFEN: Tolerating working up on enteral feeds well, no spits,\nminimal/no aspirates. Abdomen soft/round, good bs, girth\nstable. V&S (large transitional X1 thus far). PN & IL\ninfusing via central PICC in leg. D/S stable. Lytes sent to\nlab - pending results.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Brings hand to face and\nsucks on pacifier for comfort.\n\nPARENTS: Mom called X1, updated by this RN, asking\nappropriate questions. Plans to call again in AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744312,
"text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. Nares sxn x1 for sm-mod amt white secretions. RR 30's-50's with mild IC/SCR. On spell reported as of this writing. On caffeine. Will cont CPAP @ present, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744315,
"text": "NPN\n\n\n#1 Resp: infant remains on NCPAP=5 21% with sats 98-100%. RR\n30-60's, BBS clear/=, IC/SC retractions. sxn for small\namount clear secretions. 5 spells so far this shift,\ncaffeine dose increased. cont to closely monitor.\n\n#3 FEN: infant TF remains 160cc/kg/d - enteral intake BR20\n@60cc/kg/d =6cc NG Q4h. tolerating feeds well, no residuals\nor spits, abd soft, rounded, girth 17-18cm. X2 small mec\nstools. IV fluids of PN/IL @100cc/kg/d. U.O.~2.5cc/kg/d.\ncont to closely monitor and advance feeds 10cc/kg at\n12/12.\n\n#4 G&D: infant remains nested in heated isolette with stable\ntemps. active, awake and alert during cares, crying\nappropriately. Dad plans to come in tonight to kangaroo.\ncont to provide developmental support.\n\n#5 Parents: Mom in with family this afternoon. updated on\ninfant status and 5 spells so far today. Dad plans to come\nin tonight to kangaroo. cont to provide updates and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744316,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOf. She is pink, well perfused, no murmur auscultated. She is comfortable on CPAP of 5 with fio2 21%. Breath sounds clear and equal. 9 spells over last 24 hours on caffeine. Total fluids @ 160cc/kg/day, she is tolerating enteral feeds @ 50cc/kg/day. PN/IL infusing via intact picc line to right ankle. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744317,
"text": "Resp care\nPt remains supported & stable on 5cm/h2o of NCPAP, 21%\nRR- 40-60's w/ mild retractions\nB/S clear, Sx small amount of clear secretions\nBaby is receiving caffeine, 7 spells documented\nthus far, requiring mild stimulation\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-16 00:00:00.000",
"description": "Report",
"row_id": 1744575,
"text": "1. CV/RESPIRATORY O: Remains on 75cc N/C at 100% Fio2\nwith sats >93%. BBS clear and equal with good air entry and\nexchange. Mild SC/IC retrx noted. RR 30-70s . Mild upper\nairway congestion noted. Sxn'd for scant secretions. HRR\nwith soft audible murmur.Pink/. HR40-160s.\nWell-perfused with brisk cap refill x4 extrem. Pulses equal\nand nonbounding. Mild generalized edema noted. No spells. On\nCaffeine. A: Stable on N/C. Stable CV status P: Monitor\nand document. Caffeine as ordered.\n3. FEN O: Abdomen soft and full, girth stable at 24.5cm.\nAssessment unremarkable. TF remains at 150cc/kg/day.\nReceiving 35cc of SCC 32 wiht PM per OGT over 1h. No emesis\nor aspirates.Voiding and stooling with diaper changes\n(guiac-). Wgt: 1.410 ^55g A: Stable, tolerating feeds and\ngaining weight. P: Monitor for feeding intolerance.\nAdvance feeds for weight gain.\n4. G&D O: Active and alert. Lusty cry,soothed with\npacifier. Temp wnl inside isolette with heat off. Infant\nremains swaddled with hat on. Receiving erythromycin oint\nou for mild yellow drainage on both eyes. Eyes cleansed\nwith sterile water. A: Stable P: Monitor. Comfort\nmeasures.\n5. O: Mom came in with friends. infant.\nUpdated. O: ,concerned parent P: Support and\nupdate. Encourage to participate in care and to ask\nquestions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-16 00:00:00.000",
"description": "Report",
"row_id": 1744576,
"text": "Neonatal NP-Exam\n\nSee dr. note for details and plan of care as discussed in this am.\n\nAFOF. Left eye with purulent drainage, receiving erythro-nasal bridge reddened no swelling noted. breath sounds clear and equal. Nl S1S2, grade murmur audible. Pink and well perfused. abd benign, no HSM. Active bowel sounds. infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-16 00:00:00.000",
"description": "Report",
"row_id": 1744577,
"text": "Neonatology Attending\nDOL 47 / CGA 34-5/7 weeks\n\nOn NC 75-125 cc/min of 100% FIO2. On caffeine with no apneas/bradycardias.\n\nIntermittent murmur. BP 61/33 (39).\n\nWt 1410 (+55) on TFI 150 cc/kg/day SC32, tolerating well by gavage. Abd benign. Voiding and stooling normally (guiac negative).\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with feeding and respiratory immaturity\n-No changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-16 00:00:00.000",
"description": "Report",
"row_id": 1744578,
"text": "Nursing NICU NOte\n\n\n1. Resp. O/Pt remains on NC 100%, primarily in 100-200cc/min\nflow. RT and aware of increase FiO2 need. PLease refer\nto flowsheet. Remains on caffeine. No spells noted.\nA/Increased O2 need noted. P/ Cont. to monitor for s/s of\nresp distress and need for further resp support.\n\n3. F/N. O/TF remain at 150cc/k/d of SC 32pm pngt. PLease\nrefer to flowsheet for examinations of pt from this shift.\nA/Appears to be tolerating present feeding regimen. P/Cont.\nto monitor for s/s of feeding intolerance.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744304,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sutures slightly over riding\nmild subcostal retractions on CPAP, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft/full, nontender active bowel sounds, cord on/dry,\nactive with good tone,\nPICC line insertion site in left foot intact and without erythema or edema.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744313,
"text": "Neonatology Attending Note\nDay 8\nCGA 29 1\n\nCPAP5, 21%. RR30-50s. BS clear and =. Small secretions. On caffeine. 7 A&Bs past 24h. No murmur. HR 130-150s. Pale/pink.\n\nWt 575, up 10 gms. TF 160 cc/k/day BM20 at 50, remainder PN9/IL. Tol feedings well. d/s 100.\nu/o 2.7\n136/5.4/105/20\n\nIn isolette.\n\nA/P:\n-- maintain cpap\n-- continue to monitor , optimize caffeine for weight\n-- cont feeding advance\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-08 00:00:00.000",
"description": "Report",
"row_id": 1744314,
"text": "Clinical Nutrition\nO:\n~29 wk CGA BG on DOL 8.\nWt: 575 g (+10)(<10th %ile); birth wt: 612 g. Wt currently down ~6% from birth wt.\nHC: 21.5 cm (<10th %ile); last: 23 cm\nLN: 31.5 cm (<10th %ile); last: 30 cm\nMeds include Vit A\nLabs noted\nNutrition: 160 cc/kg/day TF. Feeds @ 50 cc/kg/day BM 20, increasing 10 cc/kg/. Remainder of fluids as PN via PICC line; projected intake for next 24 hrs from PN ~60 kcal/kg/day, ~3 g pro/kg/day and ~1.6 g fat/kg/day. From EN: ~40 kcal/kg/day, ~0.6 g pro/kg/day and ~2.3 g fat/kg/day. GIR from PN ~6.5 mg/kg/min.\nGI: Abdomen benign. Some loops noted yesterday, but infant had BM after glycerine supp and no loops since.\n\nA/Goals:\nTolerating PN with good BS control. Tolerating feeds without GI problems so far except transient loops as noted above; monitoring closely for tolerance as feeds are advanced. Labs noted and PN adjusted accordingly. Current PN +EN meeting recs for kcals/pro/fat/vits. Full mineral recs will not be met until feeds reach initial goal of ~150 cc/kg/day BM/PE 24. Growth should improve now that PN is at goal. Will continue to follow w/team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-22 00:00:00.000",
"description": "Report",
"row_id": 1744402,
"text": "Attending Note\nDay of life 22 CGA 31 1/7\nCPAP 6 FiO2 34% RR 30-60 thick yellow blood tinges six spells in twenty four hours\nHR 140-170 BP 70/56 mean 60\nweight 754 up 11 on 150 cc/kg/day of SSC 30 cal/oz with promod\nall pg\n\nvoiding and stooling\nin servocontrolled isolette\n\nactive with care\n\nImp- requiring more support today will continue to monitor\nwill increase to 32 cal/oz to improve weight gain\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-22 00:00:00.000",
"description": "Report",
"row_id": 1744403,
"text": "Neonatology - Progress Note\n\n sleeping with exam, responds appropriately to stimuli. AFOF. She is pale pink, well perfused, no murmur auscultated. She is comfortable on NPCPAP, fio2 21-34%. Breath sounds clear and equal. 6 spells noted over last 24 hours on caffeine. She is toleraing full volume feeds. Abd sot, active bowel sounds, no loops, voiding and stooling. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-09 00:00:00.000",
"description": "Report",
"row_id": 1744318,
"text": "NPN 1900-0700\n\n\nRESP: Remains on prong CPAP 5, 21%, LS C/=, IC/SCR. On\ncaffeine, 4 spells thus far ('). Suctioned X1 for a\nlarge, thick amount from both nares - no spells since.\n\nFEN: Tolerating enteral feeds well, advanced per order. No\nspits or aspirates. Abdomen soft/round, good bs, girth\nstable. PN & IL infusing via central PICC. Voiding, trace\nstool X1.\n\nG/D: Temp stable nested in sheepskin in servo isolette -\nwater pillow under head. A&A w/cares, sleeps well in\nbetween. Brings hands to face for comfort. Loves pacifier!\nKangaroo'd w/Mom for ~1 hour - tolerated very well, temp\nstable after returning to isolette.\n\nPARENTS: Mom in X1, updated at bedside by this RN, asking\nappropriate questions. Mom very about holding \nfor the first time. Plans to visit again tomorrow to\nkangaroo sibling.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-09 00:00:00.000",
"description": "Report",
"row_id": 1744319,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-09 00:00:00.000",
"description": "Report",
"row_id": 1744320,
"text": "Attending Note\nDay of life 9 CGA 29 2/7\nCPAP 5 Fio2 21% RR 40's\non caffeine 12 spell in 24 hours\nno murmur HR 140-160\nweight 585 up 10 enteral feeds 70 cc/kg/day\nIVF PN and IL at 90 cc/kg/day\nvoiding two stools\nstable temp\n\nImp-making some progress\nwill continue current management\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744408,
"text": "NPN 2300-0700\n\n#1 Alt. in Resp. Function\nO: Infant on prong CPAP 6cm, 21-29% to maintain sats 87-97, however, infant has frequent periodic breathing episodes which result in drifting sats, mostly to low/mid 80's and mostly SR, although does need increased 02 occasionally. In addition, had 2 spells tonight with HR 99 and 120 with sats in 50's, that required stim and increased 02 to recover. Breath sounds are clear and = with IC/SC retractions. RR 30's-60's. On caffiene.\nA: Infant on CPAP, with frequent periodic breathing resulting in sats drifts and A/B spells\nP: Continue close observation and monitoring. Titrate 02 as able to keep sats 87-97, document all spells. ? maximize caffiene dose.\n\n#3 Alt. in Nutrition\nO: TF=150cc/kg=20cc SC30/PM Q 4 hrs. Abd. is round and soft with transient soft loop X 1. Active BS, minimal sapirates, no spits. Girth 21.5cm. Voiding and passing guaiac -, green stools. Feeds given on pump over 45 min.\nA: Tolerating feeds well at present\nP: Continue close observation and monitoring of feeding tolerance. Follow daily wts.\n\n#4 Alt. in Development\nO: Temp 97.5 at 0100 with infant on servo control and lying on temp prove. Probe and infant both repositioned. Feeding held untill 0200 when temp back up to 98.1. Temp has been stable since.Infant is alert and active with cares. Settles easily after cares and sleeps well between. Frequent sats drift associated with periodic breathing. All gavage feeds.\nA: Immature feeding and breathing, appropriate for GA\\\nP: Continue to support developmental needs.\n\n#5 Alt. in Parenting\nO: visited on evenings and held infant. No contact overnight.\nA: Involved \nP: Keep informed and support.\nP:\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-29 00:00:00.000",
"description": "Report",
"row_id": 1744654,
"text": "NPN 7A-7P\n\n\n#1 Remains in nasal cannula 100% 50-100cc's flow. LS = and\nslightly coarse initially, but since receiving Diuril have\nbeen somewhat improved. RR 50-60's No 's, is on\ncaffeine.\n\n#3 TF remain restricted at 130cc/k/d. On all enteral feeds\nof SCF32 w/PM and infusing over 1 hr 10 min. (Not attempting\nbottles at this time until diuril established.) Tolerating\nfeeds w/o spits today. Likes to suck on pacifier. Is voiding\nwell, no stool today (is on daily prune juice).\n\n#4 Infant now corrected to 36 (is 60 days old), and\nrequiring low-flow cannula. On caffeine, rec'ing ng feeds\nuntil RR less labored (obvious w/one-time bottling episode),\nlikes to suck on pacifier and is and active w/handling\n& cares. Has a murmur, and has mild generalized edema. Mom\nhas signed vaccination consents and infant will receive them\nstarting next week (twin sister will receive her's at pedi\noffice on ). Con't present interventions.\n\n#5 in to visit, do cares and hold. Was updated at\nbedside, and is very caring toward infat. Mom called a few\ntimes today and was updated on status, also was informed of\nDiuril administration and plans for vaccinations next week.\nCon't to support.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-30 00:00:00.000",
"description": "Report",
"row_id": 1744655,
"text": "NPN/1900-0700\n\n\n#1 RESP: Infant remains on 100%NC, 50-100cc flow (generally\n75cc most of shift). RR 30-60's. LSC/=. Mild baseline\nretractions. No spells. On caffeine and diuril. Cont. to\nmonitor. Wean flow as tolerated.\n#3 FEN: Wt 1830, ^25 gms. TF=130cc/k/d of SC32 w/pm.\nGavaged over 1hr10min. Small spit x1. Abd. benign.\nVoiding; no stools thus far. Receives prune juice QD. Cont.\nper plan.\n#4 DEVELOPMENT: Swaddled in OAC w/ temps stable. Active and\n w/ cares; sleeps well b/t. Wakes around care times.\nSucks on pacifier when offered. AGA. Cont. to support\ndevelopmental needs.\n#5 : Mom called and updated. Asking appropriate\nquestions. Will be in tomorrow to visit.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-30 00:00:00.000",
"description": "Report",
"row_id": 1744656,
"text": "Neonatology Attending Progress Note:\n\nDOL #61\nin NC 25cc 100%\nDiuril started yesterday (20 mg/kg/d)\nRR=40-70's\nno spells\nHR=140-160's\nwt=1830g (inc 25g), TF=130cc/kg/d SC 32 with Promod\nall gavage.\nvoiding, no stool today (on prune juice)\n\nPE: well appearing, AFOF, normal S1S2, soft I/VI systolic murmur, breath sounds clear, abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: x-28 week infant with CLD.\n--will obtain lytes today, continue diuril\n--to obtain vaccinations closer to sibling's timing on \n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744305,
"text": "Neonatology Attending Note\nDay 7\nCGA 29\n\nCPAP5, 21%. RR30-50s. BS cl. Mod cl secretions. On caffeine. 4 A&Bs/past 24. Vit A and caffeine. No murmur. HR 130-150s. BP 56/40, 46.\n\nBili < 1.0.\n\nWt 565, up 25. TF 160 cc/k/day =PN7.5/IL via central PICC + BM20 (40). u/o 3.3.\n132/5.3/104/17\n\nIn servo isolette.\n\nA/P:\n-- will try off cpap as nose starting to breakdown\n-- monitor aop on caffeine\n-- cont cautious feeding advance\n-- can provide a little more Na in PN which will also allow for more acetate\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744306,
"text": "Nursing Progress Note\nCorrection to above note: Trialed infant off cpap d/t redenned nose. Placed infant back on cpap d/t bradys.\n\nAddendum: Gave glycerine sliver as ordered d/t soft loops and full belly. Held advancement of enteral feedings d/t abd exam as noted on flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744307,
"text": "Nursing Progress Note\n\n\nResp: Infant continues on PRONG CPAP 5cm, 21%. Trialed off\nfor 1 hr, had 2 bradys d/t redenned bridge of nose. Infant\nhad 5 bradys thus far this shift most with HR's 40-50's and\nrequring mild to mod stim. CBG pending. Continues on\nCaffeine. Will cont to support resp status closely.\n\nFEN: TF 160cc/kg/d. PN D7.5 and IL are infusing through\nCentral PICC without incident at 120cc/kg/d. Enteral\nfeedings are currently at 40cc/kg/d. 2.0cc max asperate\npartially digested. D-stick 148. Abd exam slightly full\nwith soft loops, pink with active bowel sounds. \nand both examined infant today. Urine output\n3.3cc/kg/hr past 8 hrs, one trace mec. Plan for lytes in\nthe am. Plan to cont to advance enteral feedings by\n10cc/kg/ at 1700/0500. Plan to cont to monitor abd exam\nand tolerace of feedings.\n\nG/D: Temp stable nested in servo isolette. Infant is very\nactive and alert. Infant is nested with sheepskin and\nboundaries. Infant is on gell mattress. Plan to cont to\nsupport dev needs.\n\nParents: Parents in visiting throughout afternoon. Parents\nare and involved. Plan to cont to support and\neducate.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744308,
"text": "Nursing Progress Note\nCorrection to above note: Trialed infant off cpap d/t redenned nose. Placed infant back on cpap d/t bradys.\n\nAddendum: Gave glycerine sliver as ordered d/t soft loops and full belly. Held advancement of enteral feedings d/t abd exam as noted on flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744309,
"text": "Nursing Progress Note\nCorrection to above note: Trialed infant off cpap d/t redenned nose. Placed infant back on cpap d/t bradys.\n\nAddendum: Gave glycerine sliver as ordered d/t soft loops and full belly. Held advancement of enteral feedings d/t abd exam as noted on flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-21 00:00:00.000",
"description": "Report",
"row_id": 1744395,
"text": "Respiratory Care Note\nPt. began shift on 6cmH2O of NPCPAP. Unable to clear secretions so tube pulled and pt. was sx'd for a lrg. yellow plug. Decision made to place pt. in prongs. FIO2 has been 21-24%. BS now clear. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-21 00:00:00.000",
"description": "Report",
"row_id": 1744396,
"text": "Attending Note\nDay of life 21 CGA 31 0/7\nCPAP 6 FiO2 21-26% RR 40-60 on caffeine\ndoes some drifts with cares\n\nHR 140-170 70/44 mean 53\nweight 743 up 22 grams on 150 cc/kg/day of BM or SSC 30 with promod all pg feeds\nvoiding and stooling\non iron, vit E, and vit A\nin servo controlled isolette\n\nImp-doing well currently\nwill monitor for spells\ncontinue current plan\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-22 00:00:00.000",
"description": "Report",
"row_id": 1744404,
"text": "NPN 0700-1500\n\n\n1. RESP: On NCPAP/Peep 6, FIO2 24-31%. Monitoring O2 sats,\napnea/brady/desat spells. On Caffeine. Resps mild IC/SC\nretractions, 40-60s. Lungs clear & equal. Suctioned\nmod-large brownish-clear secretions from nares this morning.\nDried/crusty secretions also removed. Fio2 requirements less\nafter suctioning. O2 sats 93-98 with no spells noted. A:\nStable in NCPAP P: Continue to monitor, wean FIO2 as\ntolerated.\n\n3: wt 754 (+11) On TF 150cc/kg/d (SC32 w/PM) (calories\nincreased at 1200) via NGT on pump over 40 minutes. NG\nplacement verifed and residuals assessed ac. Abd soft,\nlarge/round, girth stable (20-20.5), BS+. Residuals trace,\nno spits noted. Small heme neg stool today. Voiding WNL. A:\nstable on full feeds/ no s/s intol P: continue to monitor.\n\n4. G&D: Infant nestled in covered isolette (servo mode).\nSkin & axillary temps not coinciding -- changed to new probe\ncover at 1200, reduced control temp as well. Infant active &\nalert with care. A: stable/AGA P: continue to monitor\n\n5. : Mom called this morning, updated on infant\nstatus. Good questions asked. plan to visit early\nthis evening. A: stable/participative P: continue to\nupdate and encourage participation in POC.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-22 00:00:00.000",
"description": "Report",
"row_id": 1744405,
"text": "Respiratory Care\nPt cont on prong CPAP. FIO2 .24-.34, BS clear/=, rr 30-70, sx for mod thick bld-tinged secretions from nares. On caffeine. No spells noted. Plan to support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744406,
"text": "NPN (1500-2300)\n\n\n1. REsp: Remains on Prong CPAP-6 in mid-high 20's% O2. LS\nclear and equal, suctioned nasally for large thick yellow\nblood tinged secretions X1. Had 3 A's and B's, remains on\ncaffeine.\n\n3. F/N: Weight up 31gm, tolerating 150cc/kg/d of SSC 32\nw/promod well. Abd exam benign, vdg well, small heme neg\nstool X1.\n\n4. Dev: Temp stable in servo control isolette. Active,\nocasionally irritable with cares, but most likely due to\nprongs...settles easily with pacifier/nesting. Kangaroo'd\nwith Dad and tolerated well.\n\n5. Soc: Mom and DAd in, participated in routine cares of\ninfants, updated as to current status, Dad kangaroo'd this\nevening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744407,
"text": "Respiratory care Note\nPt. continues on 6cmH2O of nasal prong CPAP and 21-35%. BS clear. on Caffeine. Pt. has sat drifts, 3a/b spells overnight. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744409,
"text": "Attending Note\nDay of life 23 CGA 31 2/7\nCPAP 6 21-35% RR 30-60 on caffeine ABG this am 7.24/57/136/26\nmultiple bradys and drifts this am had formula from the back of her nose outside of this she had 6 spells in 24 hours\nHR 150-160 BP 65/34 mean 45\nwith 785 up 31 gram on SSC 32 with promod at 150 cc/kg/day\nvoiding and had heme negative stool overnight\nd-stick 185 feeding held this am Baby gram showed low lung volume and nonspecific dilated bowel c/w CPAP use\non vit A\n\nImp- in guarded status this am likely desats due to\nincrased abdominal distention\nwill still check CBC and blood culture\nwill treat if CBC abnormal\nwill tranfuse PRBC's and lasix\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744410,
"text": "Neonatology- Progress Note\n\nPE: remains in her isolette, on CPAP, bbs sl cse=, rrr s1s2 no murmur, abd soft, nontender, full, afso, alert and active\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744411,
"text": "Respiratory Care Note\nReceived pt on prong CPAP +6. Pt.had numerous bradys while examining for reddened nose. Changed to +6 NP CPAP, FiO2 23-32% this shift. Blood Cx and CBC drawn. Given PRBC's for a HCT of 27. ABG:7.24/57/136/26/-3. BS clear. RR 40-60's. On caffeine and Vitamin A. Still with O2 sat drifts, fewer bradys once NP tube in.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744412,
"text": "Respiratory Care Note\nCXR in am showed low lung volumes. Bradys appear to cluster around feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-23 00:00:00.000",
"description": "Report",
"row_id": 1744413,
"text": "Respiratory Care Note\nCXR in am showed low lung volumes. Bradys appear to cluster around feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-01 00:00:00.000",
"description": "Report",
"row_id": 1744482,
"text": "NPN:\n\nRESP: Vent-22/6 x 22 (rate decreased 24->22); 31-45% 02. CBG prior to rate change: 7.34/ 54/ 41/ 30/ 1. RR=40-60 with SC retraction. Sx'd q 3-4 h for lg amt cloudy secretions from ETT, lg amt orally. BBS =/coarse. No A&Bs. Remains on Caffeine.\n\nCV: Murmur persists. HR=150-170s. BP=60/25 (37). Color pink w/good perfusion. Trx given yesterday.\n\nFEN: Wt=958g (+ 8g). TF=150cc/kg/d; 24cc SC-32 w/promod q 4 h via NG over 1 h. Tolerating fdgs well w/o spits; 0-1cc residuals. Abd soft, full, active bs, no loops. U/O=4.1cc/kg/h over 24-h period yesterday. Yellow stool x 2; heme neg. Vit E and FeS04. Dx=90; Ca=9.1; Phos=5.2' Alk. Phos=301.\n\nID: Trach Asp of : neg for RSV, Influenza A, Influenza B. Oxacillin, day .\n\nG&D: CGA=32 wk. Temp stable in servo-controlled isolette. Active and alert w/cares. Nested in sheepskin ans resting well.\n\nSOCIAL: No contact w/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-01 00:00:00.000",
"description": "Report",
"row_id": 1744483,
"text": "Attending Note\nDay of life 32 CGA 32 \nIMV wean rate last night CBG 7.32/54 now 22/6 rate of 22 FiO2 28-40% still with lots of secretion RR 40-60 on caffeine\nHR 160-170 BP 60/25 mean 37 s/p PRBC's\non oxcillin day \n958 up 8 on 150 cc/kg/day of SSC 32 with promod no spits or aspirates over night all pg\non vit E and iron\nUO 4.1 cc/kg/hr\nCa 9.1 Phos 5.2 Alk Phos 301 dstick 90\nin isolette\n\nImp-still ill making slow progress\nResp-will attempt to wean the , get a repeat gas, and CXR.\nwill complete 10 days of oxicillin\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-21 00:00:00.000",
"description": "Report",
"row_id": 1744397,
"text": "Nursing Progress Note\n\n\n#1-O/A- Received infant on prong CPAP 6. Infant remains on\nCPAP, FIO2 21-35% this shift. 2 spont bradys so far this\nshift. Caffeine dose increased for wt. gain. Sxn for thick\nyellow, sl bl tinged sec. P- Cont to assess for Resp\nneeds.\n#3-O/A- TF=150cc/kg/d of BM/SCsim30w/ProMod via NGT. Abd\nexam benign. Voiding and stooling, heme neg. Cont on Vit\ne, iron and Vit A. P- Contto assess for FEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps between cares. Temp stable in heated\nisolette. Sucks on pacifier. P- Cont to assess for G&D\nneeds.\n#5-O/A- in to visit with updates given. Mom is\nindependent with cares. P- Cont to enc parental calls and\nvisits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-21 00:00:00.000",
"description": "Report",
"row_id": 1744398,
"text": "Neonatology- PRogress Note\n\nPE: remains in her isolette, nested, on prong CPAP 6 <.30, bbs cl=, rrr s1s2 no murmur, abd soft, full + bs, afs, sutures overriding, gavage tube and PICC in place, skin dry flaky\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-21 00:00:00.000",
"description": "Report",
"row_id": 1744399,
"text": "Respirtory Care\nRecieved on nasal prong CPAP +6cm's with the fio2 25 to 30%. Pt's respiratory rates 30's to 60's with clear B/s. Plan is to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-22 00:00:00.000",
"description": "Report",
"row_id": 1744400,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 21-28%. Suctioned nares for mod amt of yellow/blood tinge secretions. Breath sounds are clear. RR 30-60's baby is on caffeine. Occasional drifts on the sat monitor. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-22 00:00:00.000",
"description": "Report",
"row_id": 1744401,
"text": "Nursing Progress Note\n\n\n1.O: Remains on nasal prong CPAP{6) mostly in 21-25% O2 with\nO2 sats mid to high 90's. Slight drifts noted to the 80's\nself resolved. RR 40's-70's. breath sounds clear and equal,\nlips and nailbeds pink. Mild intercostal/subcostal\nretractions noted. No A's & B's noted this shift. Remains on\ncaffeine once a day.\n A: Doing well on CPAP,\n P: Monitor respiratory status. Wean O2 as tolerated.\nContinue with caffeine. Document spells.\n3.O: Weight 754gms up 11gms. On BM 30with promod or special\ncare 30with promod 19cc's q4h+ 150cc/kg/d. Gavaged over 40\nminutes and tolerated well. Abdomen soft and round, positive\nbowel sounds, no loops. Voiding, no stools this shift.\n A: Tolerating feeds. Slow weight gain.\n P: Continue with present plan. Monitor weight gain.\n4.O: Active and alert for carea. Sucking on pacifier\nintermittently. Nested on sheepskin on servo temp. Sometimes\nbecomes warm. Sleeping in betwen feeds.\n A: Small for gestational age.\n P: Continue with interventions. Monitor.\n5.O: No contact this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744473,
"text": "Neonatology- Physical Exam\n\nInfant remains orally intubated. Active, alert, AFOF, sutures opposed, good tone. BBS coarse with crackles, mild SC retractions. No murmur, pulses +2, RRR, /pink. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n\n updated at the bedside, discussed plan to give PBRC transfusion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744478,
"text": "NPN\n\n\n#1 Resp: infant remains intubated on 22/6 rate=24,\nFiO2=28-35% with sats 90-96%. RR 40-60's, BBS coarse ->\nclear with sxn. occasional desats into 80's self resolving.\nno spells so far this shift, on caffeine. Sxn Q4h for thick\nwhite secretions via ETT and cloudy thick orally. cont to\nclosely monitor, obtain blood gas with AM blood draw and\nwean setting as appropriate.\n\n#3 FEN: infant remains on TF 150cc/kg/d SC32+PM =24cc NG Q4h\nover 1h. tolerating feeds well, abd soft, full, girth=22cm,\n+BS. voiding, X1 lg stoole heme negative. min residuals, no\nspits. plan to draw nutrition labs in AM. cont to closely\nmonitor.\n\n#4 G&D: infant remains nested in servo isolette. temps\nstable, active and quiet alert with eyes open. sl lethargic\nat times. cont to provide developmental support.\n\n#5 : Mom called X2 for updates, asking appropriate\nquestions, plans to come in this evening for infant CPR and\nwill visit the girls afterwards. invested, mother.\ncont to provide updates and support.\n\n#10 Sepsis: continues on day of antibiotics, active and\nquietly alert, sl lethargic at times. stable temps. cont to\nmonitor and finish course of antibiotics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744479,
"text": "Respiratory Care\nPt currently on IMV. Settings 22/6, f 24, Fio2 .28-.35. BS coarse, rr 40-60 with mild retractions. Sx for m-l amt thick white from ett and orally. On caffeine. No spells noted. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744480,
"text": "NPN (1500-2300)\n\n\n1. Resp: Remains on IMV 22/6 X24 requiring 34-->40% 02. LS\ncoarse/equal, mild-mod IC/SC retractions. Remains on\ncaffeine, no spells this evening. Mod-lg thick white\nsecretions via ETT and large clear orally. 02 requirement\nincreasing slightly throughout shift. Plan is to retape ETT\nwith next care and check bld gas in am.\n\n3. F/N: Weight up 8gm to 958. TF's continue at 150cc/kg/d\nof SC32 w/promod. Tolerating feeds well. Abd soft and\nfull, stool heme neg. Vdg 4cc/kg/hr for 24 hrs. Nutrition\nlabs due in am.\n\n4. Dev: Temp stable in servo control isolette. Alert and\nactive with cares, stresses easily and has difficult time\nsettling afterward. Nested in sheepskin, sucking\nintermittently on pacifier.\n\n5. : Mom and Dad visited, participating in routine\ncares. took CPR.\n\n10.ID: Remains on oxicillin, day7 of 10. Will continue to\nmonitor cultures.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-01 00:00:00.000",
"description": "Report",
"row_id": 1744481,
"text": "Respiratory Care\nBaby rec'd on 22/6, R 24. 02 this shift 28-40%. Requires significant increase in 02 for handling. BS with coarse rhonchi. Sxn q1-3h for mod-lg thick white secretions from ETT and copious clear oral secrtretions. ETT retaped without incident. RR 40's-60's with mild IC/SCR. CBG: 7.34/54/41/30/1; rate decreased to 24. On caffeine, abx. No bradys noted, some sat drifts. Will cont to follow closely, wean vent as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744563,
"text": "Neonatology- physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-01 00:00:00.000",
"description": "Report",
"row_id": 1744484,
"text": "Neonatology- Physical Exam\n\nInfant remains orally intubated. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS coarse and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-01 00:00:00.000",
"description": "Report",
"row_id": 1744485,
"text": "Respiratory Care\nPt recieved on IMV, rate of 22, pressures of 22/6, with the fio2 30 to 40%. Pt's respiartory rates 40's to 60's. Pt suctioned frequently for a moderate to large amt of thick cloudy secretions. Pt's PIP weaned down from 22 to 20cm's of pressure. Pt's fio2 requirement increased this shift from 20's to 40% for oxygen to 40 to 50%. CXR obtained showing improvement of lung expansion. Pt remains on IMV, rate of 22, pressures of 20/6 with the fio2 43 to 48%. Plan is to follow with blood gas on night shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-14 00:00:00.000",
"description": "Report",
"row_id": 1744570,
"text": "NPN 7a7p\n\n\nResp\nRecieved infant on CPAP. Trialing off today onto NC.\nPresently weaned to 75-100 cc at 100%. No change in RR or HR\nor sats. LSC. S/C I/C rtxs. Suc x 1 for thick yellow and old\nblood tinged secretions. On caffiene. Some small drifts\nduring gavage, self resolving, no bradys. Tolerating trial\nto NC. Monitor and support resp status.\nFEN\nInfant on Tf 150 cc/k/d SC32PM gavaged/1'. No spits. Lrdg\ndistended abd. Active BS. x 1 heme -. Feeding\nschedule late resulted in lrger eve asp of 3 cc. infant\nplaced on abd and resolved asp and fed 30 mins later, see\ncareview. Montior weight and exam.\nG/D\nInfant in off isolette. Temps WNL but decreasing since off\nCPAP, last was 98.6. A/A for cares. Quiet and settled\nbetween although sometimes quiet with eyes wide open too.\nMAEs. FS&F. Sucks on pacifier with some support. AGA.\nMonitor and support G/D.\n\nMom called a few times over the day. Anxious about trial off\ncpap. Plans to visit tonight. Asking appropite questions.\nInvested and . Support and educate.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-15 00:00:00.000",
"description": "Report",
"row_id": 1744571,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in NC 100% fiO2 and 50-75cc flow.\nRR=40-70's. Mild to mod SCR. LS clear. Had 1 desat to 78%\nthat was qsr, otherwise, is tolerating NC well. On\ncaffeine.\n\n2. FEN: WT=1355gms (up 15gms). TF=150cc/k/day Special\nCare Similac 32 with PM. Gavaged 34cc over 1hr. Min asp/no\nspits. AG=24-24.5cm. Abd is round and soft with active bs.\nHad 1 small yellow stool. Tolerating feeds well.\n\n3. G&D: Infant is very alert and active with cares.\nSleeps well between cares. Temps stable swaddled in off\nisolette. .\n\n4. : Mom came in and participated in cares. Was\nupdated at bedside and asked appropriate questions. Called\nx1 for update. Very pleased that infant is doing well off\nCPAP. Cont to offer support and updates.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-15 00:00:00.000",
"description": "Report",
"row_id": 1744572,
"text": "Neonatology Attending\nDOL 46 / CGA 34-4/7 weeks\n\nRemains on NC 75 cc/min of 100% FiO2. One desaturation overnight but no bradycardias (on caffeine).\n\nIntermittent murmur. BP 56/30 (42).\n\nWt 1355 (+15) on TFI 150 cc/kg/day SC32PM, tolerating well by gavage. Abd benign. Voiding and stooling normally.\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with CLD, feeding immaturity\n-Continue to monitor on NC\n-Continue on current caloric density over the weekend\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744298,
"text": "NICU Attending Note\n\nDOL # 6 = 28 6/7 weeks CGA with resolving HMD, mild A/B well controlled on caffeine, issues of fluid and nutrition.\n\nPlease see full .\n\nCVR/RERSP: RRR without murmur, mild intercostal retractions, BS clear/=, CPAP @ 5, RA, on caffeine with A/B x 2 in last 24 hours. Will continue CPAP and caffeine.\n\nFEN: Abd benign, active bowel sounds, weight today 540 ,down 2 gm, on TF of 160 cc/kg/d of which 140 cc/kg/d PN/Il via central pic line, 20 cc/kg/d MM 20, tolerated well per day except for small apspirates. Advancement held overnight. 132/5.7/105/16, TG 145, hyperglycemic. Will continue to advance by 10 cc/kg q 12 hours, decrease glucose concentration in PN.\n\nGI: No phototx, Bili 0.9/0.2. Will follow clinically\n\nNEURO: Head U/S normal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744299,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt remains on nasal prong CPAP of 5, FiO2 RA\nconsistently. Please refer to flowsheet for A/B noted this\nshift. Remains on caffeine. A/Occasional A/B, otherwise resp\nstatus appears stable on CPAP. P/Cont. to monitor for\nevidence of resp distress. Cont. to monitor for A/B and\nintervene as pt needs.\n\n3. F/N. O/TF remain at 160cc/k/d. TPN D8 and IL running via\nintact PICC at 130cc/k/d. Enteral feeds of BM20 advanced to\n30cc/k/d PNGT over 30min. Please refer to flowsheet for\nexaminations of pt from this shift. Voiding. Tiny amt of\nstool passed (not enough to heme test). A/Alt. in F/N.\nP/Monitor for s/s of feeding intolerance.\n\n4. G/D. O/Temp remains stable on servo, nested in an\nisolette. AWake and alert with cares and sleeping well in\nbetween. Held by father today. Tolerated kangaroo care well.\nA/Alt. in G/D. P/Cont. to support pt's growth and dev.\nneeds.\n\n5. Parents. O/Mother, father and grandmothers in today.\nParents updated on pt's status and plan of care. Father took\npt's temp and changed pt's diaper. Father kangaroo'd with\npt. A/Parents are actively involved in pt's care. P/Cont. to\nsupport and educate parents.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744300,
"text": "Respiratory Care Note\nPt remains on +5 prong CPAP, FiO2 21%. BS clear. Nares suctioned for mod amount white secretions. RR 30-50's. On caffeine and Vit A. 2 bradys noted this shift as of this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-06 00:00:00.000",
"description": "Report",
"row_id": 1744301,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOf, sutures opposed, good tone, IUGR. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Abrasion on right arm healing. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744302,
"text": "respiratory Care\nBaby remains on cpap 5 21%.bs clear throughout.RR 30-50's.2 spells documented thus far this shift,on caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-07 00:00:00.000",
"description": "Report",
"row_id": 1744303,
"text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCONTINUES ON PRONG CPAP AT 5CM. NO O2 REQUIREMENT. BBS\nCLEAR, RR 30-60. NO APNEA OR DESATS.\n3. F/N\nTONIGHT'S WEIGHT UP 25 GRAMS TO .565KG. TOLERATING\nADVANCING FEEDINGS, CURRENTLY AT 40CC/KG OF FSBM. ABD\nBENIGN. ACTIVE BOWEL SOUNDS, NO STOOL. D7.5PN AND IL\nINFUSING AT 120CC/KG VIA CENTRAL PICC. ONETOUCH 123. OUTPUT\n3.3CC/KG/HOUR FOR 24 HOURS. AM ELECTROLYTES AS PER\nFLOWSHEET.\n4. G&D\nALERT WITH CARE. QUIET UNLESS DISTURBED. LOVES PACIFIER.\n5. PARENTS\nMOM CALLED AND UPDATED, WILL BE IN LATER THIS AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744474,
"text": "NPNOte\n\n\n#1. Remains orally intubated, 22/6, rate 24/mt, Fio2 25-29%,\nBBS coarse, crackles heard, mild subcoatl/intercostal\nretractions present, whitish et and oral secretions\nsuctioned in mod to large amount.Occasional desats to low\n80's noted, QSR.No spells thus far this shift.Pcell\ntransfusion 1st alliqot completed and started with 2nd\nalliqot 9cc over 4hrs, Lasix x1 given after ist alliqot.A;\nRequired vent support. P; cont resp support as needed.\n\n#3. Todays weight=950 up59gms, TF=150cc/kg/day, Scare 32\nwith promod, pg fed over 90mts, small spit x1, BS+, no\nloops, voided, no stool thus far this shift.A; Feeds\ntolerated. p; cont current feeding plan.\n\n#4. alert,active with care, was on servo control isolette,\ntemp 99.8, placed on Air mode isolette,nested in sheepskin,\nmae.A; AGA P; cont dev support.\n\n#5. Mom called for update.\n\n#10.On Oxacilline given as ordered. D7/10 antibiotics.A;\nsymptomatic. P; cont to monitor for s/s of sepsis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744475,
"text": "Respiratory Care\nBaby remains on imv 24 22/6 24-29%.Sx for mod white secs.BS coarse throughout.on caffeine.received prbc,s lasix x 1.no spells thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744476,
"text": "Attending Note\nDay of life 31 CGA 34 \nIMV 22/6 rate 24 FiO2 24-30% RR on caffeine\nHR 150-160 s/p PRBC's last night with lasix between\n55/31 mean 40\n\nDay of oxicillin\n950 up 59 SSC 32 with promod 150 cc/kg/day all pg\nvoided and stool heme negative\nInfluena A and B negative\nRSV negative\nViral culture pending\n\n\nImp-in stable but guarded condition\nwill continue 10 days of oxicillin\nwill check nutrition labs tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-31 00:00:00.000",
"description": "Report",
"row_id": 1744477,
"text": "Neonatology - PRogress Note\n\n is active with good tone. AFOF. She is pink, well perfused, soft murmur auscultated. She is comfortable on vent settings of 22/6 x 24 with fio2 24-30%. Breath sounds course, but well aerated to bases. Occ spells on caffeine. She is tolerating full volume feeds. Abd softly distended, active bowel sounds, no loops, voiding and stooling. Remains on Oxacillin. Stable temp in air isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744558,
"text": "NPN\n\n\n#1resp:\no; Remains on Nasal prong CPAP 5 21-27%. RR 40-60, mild-mod\nIC/sc retractions. sx'ed small-mod thick yellow. No spells.\nHct 29.5\nA/P: Cont to monitor on Cpap\n\n#3FEN:\no: wt 1.290 (+ 20) On 150cc/k/d SSC 32 with prom. Gavages\ntol well. min asp no spits. voiding qs, no stools\nNutrition sent.\nA/p: Cont to monitor wt gains\n\n#4G@D:\no; Temps on higher end of Nll in off isolette. swaddled and\nnested in bumper. alert and active with cares\nA/p: Cont to support G@D\n\n#5Parents:\nO; Mom and aunt in to visit. Aunt held baby.\nA/P: Cont to support and inform.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744559,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21-28% FIO@. BS clear. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744564,
"text": "Resp care\nPt remains supported on 5cm/h2o of NCPAP, 21-25%\nRR- 40-60's w/ mild retractions\nB/S clear, Sx moderate amount of secretions\nBaby receiving caffeine, no spells documented\nPlan: Continue support\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-14 00:00:00.000",
"description": "Report",
"row_id": 1744565,
"text": "NPN\n\n\n#1 Resp:\nO: Remains on nasal prong CPap 5 21-28% to maintain sats\n88-95. RR 40-50. lungs cl=,no spells\nA: stable on cpap\nP: Wean from cpap in am\n\n#3FEN:\no: wt 1.340 (+50 gms) On SSC 32 with promod 150cc/k/d. abd.\nsoft, active BS, no loops. abd. round. voiding qs, passed lg\ngreen stool, guiac neg.\nA/P: Cont to follow wts.\n\n#4G@D:\nO: Temps stable in off isolette. alert and active with\ncares, MAE. Ant font. soft and flat.sucking well on\npacifier.\nA: AGA\nP: Cont to support dev.\n\n#5Parents:\nO: Mom called and given update.\nA/P: Cont to support and inform.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-14 00:00:00.000",
"description": "Report",
"row_id": 1744566,
"text": "Respiratory Care\nbaby remains on cpap 5 21-25%.BS clear throughout.RR 40-70's.No spells documented thus far this shift,occ drifts in sats,On caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-14 00:00:00.000",
"description": "Report",
"row_id": 1744567,
"text": "Neonatology Attending\nDOL 45 / CGA 34-3/7 weeks\n\nOn CPAP 5 cm H2O in 21-25% FiO2. On caffeine with no apneas/bradycardias.\n\nIntermittent murmur. BP 73/33 (49).\n\nHct 29.7 (inc from 27.9).\n\nWt 1340 (+50) on TFI 150 cc/kg/day SC32PM, tolerating well. Abd distended as at baseline but benign. Ca 9.9. PO4 4.8. ALP 440.\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with CLD, respiratory and feeding immaturity\n-Will trial off CPAP today\n-Continue on current nutritional support\n-No changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-14 00:00:00.000",
"description": "Report",
"row_id": 1744568,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is pink, well perfused, no murmur auscultated. She is comfortable trialing off CPAP in NCO2. breath sounds clear and equal. she is tolerating full volume feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-14 00:00:00.000",
"description": "Report",
"row_id": 1744569,
"text": "Respiratory Care\nPt trialing off CPAP. Currently on nc 75cc/100%. rr 50-70 with mild retractions. On caffeine. No spells. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1744645,
"text": "PCA Note 11a-7p\n\n\nRESP: Infant remains in O2 NC 50-75cc; 100%. RR 40-60's.\nLS cl/= with subcostal retxns. UAC noted. Satting 92-98%.\nOccassional drifting, QSR. Will continue to monitor\nrespiratory status and wean O2 as tolerated.\n\nFEN: TF 130cc/k/d of Sim32 with promod = 38cc Q4. All\ngavage feedings; given over 1hr. Infant tolerating feeds\nwell; no spits. Abd. full, soft, good BS, no loops noted.\nMax asp .2cc. Voiding with trace stool. Continue to\nprovide nutritional needs.\n\nDEV: Infant swaddled in OAC. Temps stable. and\nactive with cares; sleeping well. Prefers prone position.\nMAE. Continue to support developmental needs.\n\n: Mom called today for update. Spoke to RN \nA. on the phone. Plan to come in for 1700 cares. Will\ncontinue to update and support as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-15 00:00:00.000",
"description": "Report",
"row_id": 1744573,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in NCO2 FIO2 100% 75cc/min flow. No spells.\nOccas self-resolving sat drifts to 80's. (Please refer to\nflowsheet for resp assessment.) Cont on caffeine. A/Stable\nin NCO2. P/Cont to monitor for resp distress. Wean O2 as\ntol.\n\n3. FEN=O/TF cont at 150cc/k/d of SC32PM gavaged over\n60min. Abd benign. (Please refer to flowsheet for\nassessment.) No spits. Voiding. No stool. Cont on Vit E\nand iron. A/Tolerating current regime. P/Cont to monitor\nfor feeding intolerance.\n\n4. G&D=O/Temp stable swaddled in off isolette. Alert and\nactive with cares. Sleeping well between feeds. Font S/F.\nMAE. Cont with sm amts yellow/green dng from OU. Team\naware. A/ in G&D. P/Cont to monitor and support G&D.\n\n5. =O/Mom and dad in to visit. Updated by this\nnurse. Mom participating in all care. Held baby during\n1300 feed. A/appropriate and actively involved. P/Cont to\nsupport and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1744650,
"text": "Nursing Progress Notes.\n\n\n#1 O; Baby remains in nasal cannula oxgyen 100%, 50 to 100cc\nflow. Crackles noted this afternoon along with slight\nincreased work of breathing. suctioned for small\nyellow secretions. A: Crackles noted this PM. P: Continue\nto monitor and continue to assess for need for diuretics.\n#3 O: Total fluids restricted to 130cc/kg/day. Feeds of\nSC32 with promod given every 4 hours. No spits, min\naspirates. Abdomen benign, voiding well, guiac negative.\nA: tolerating feeds well. P: Continue to monitor.\n#4 O; Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares. A: Appropriate\nfor age. P: Continue to support development.\n#5 O; Mother called for updates and was in to visit this\nevening. Mother was updated by . A: Involved family.\nP: Continue to keep informed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-29 00:00:00.000",
"description": "Report",
"row_id": 1744651,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in NCO2 FIO2 100% 50-100cc/min flow. Occas\nself-resolving sat drifts to 80's. No spells. Cont on\ncaffeine. (Please refer to flowsheet for resp assessment.)\nA/Stable in NCO2. P/Cont to monitor for resp distress.\n\n3. FEN=O/Current wt=1805g (^15g). TF cont to be restricted\nat 130cc/k/d of SC32PM gavaged over 60min. Abd benign.\n(Please refer to flowsheet for assessment.) No spits.\nVoiding. No stool. Cont on Vit E, iron, and prune juice.\nA/Tolerating current regime. P/Cont to monitor for feeding\nintolerance.\n\n4. G&D=O/Temp stable swaddled in open crib. and\nactive with cares. Sleeping well between feeds. MAE. Font\nS/F. A/ in G&D. P/Cont to monitor and support G&D.\n\n5. =O/Mom called x1. Updated by this nurse.\nA/appropriate and actively involved. P/Cont to support and\neducate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-29 00:00:00.000",
"description": "Report",
"row_id": 1744652,
"text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. Breath sounds with fine crackles in bases. Mod subcostal retractions. Nl S1S2, grade murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-20 00:00:00.000",
"description": "Report",
"row_id": 1744389,
"text": "Respiratory Care Note\nPt. continues on 6cmH2O of NPCPAP and 21%. On Caffeine. Pt. has had one spell thus far. Pt. sx'd for mod. yellow secretions from nare and lrg. thick white from back of throat. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-20 00:00:00.000",
"description": "Report",
"row_id": 1744390,
"text": "BABY HAD AN ADDITIONAL SPELL OVERNIGHT AND NP TUBE CHANGED BY R.T. BABY SUCTIONED LARGE AMT OF SECRETIONS. NEW NGT PLACED LEFT NARES\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-20 00:00:00.000",
"description": "Report",
"row_id": 1744391,
"text": "Newborn Med Attending\n\nDOL#20. Cont on CPAP6, RA, occ spells, on caffeine. AF flat, clear BS, soft murmur, abd soft, MAE. WT=721 up 1, on 150 cc/kg/d SC28 with PM.\nA/P: Growing infant with residual CLD. Increase to SC30 with PM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-20 00:00:00.000",
"description": "Report",
"row_id": 1744392,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21%. Pt suctioned for a mod amt of thickish cloudy secretions. Respiratory rates 30's to 60's on caffine. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-20 00:00:00.000",
"description": "Report",
"row_id": 1744393,
"text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: Infant on NP CPAP 6cm, mostly in 21% with sats 95-98. Occasionally has drifting sats to 80's requiring ~25% 02. One spell today. On caffiene. RR is 30's-60's with baseline IC/SC retractions. Breath sounds are clear and =. Suctioned several times for mod. cloudy secretions from nose and mouth, lesser amts from NP tube.\nA: Occasional sat drifts and spells on NP CPAP\nP: Continue close observation and monitoring of present resp. plan. Document all spells.\n\n#2 Alt. in Nutrition\nO: TF=150cc/kg=18cc Q 4 hrs. Increased to 30cal SC/PM or BM/PM today. Abd. is round, soft with +BS, no loops. Girth 19-20cm. Minimal aspirates, no spits. Voiding and stooled X 2, guaiac -.\nA: Tolerating feeds well at present\nP: Continue close observation and monitoring for feeding tolerance. Follow daily wts.\n\n#4 Alt. in Development\nO: Maintaining temp in servo isolette, nested in sheepskin, positioned on side or prone with high boundaries in place. Alert with cares, stresses easily. Calms with containment and pacifier. Very active and \"squirmy\" at times. Did kanagoroo care X 2 hrs and tolerated it well. Slept great during entire time with mom.\nA: Appropriate for GA\nP: Continue to support devlopmental needs.\n\n#5 Alt. in Parenting\nO: in 1030-1500. Updated and questions answered. Mom did cares with and also did kangaroo care with her. Dad held\n.\nA: Involved, \nP: Continue to keep informed and support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-21 00:00:00.000",
"description": "Report",
"row_id": 1744394,
"text": "NPN 1900-0700\n\n\nRESP: Received infant on NPCPAP 6, 21-24%. RT attempted to\nsuction NP tube w/out success resulting in tube change.\nDecision was then made by RT to switch to prongs. Tolerating\nwell thus far, LS remain C/=, IC/SCR, remains in 21-24%. On\ncaffeine, no spells thus far (').\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, no loops, good bs, girth\nstable. Voiding & trace stool X1.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Brings hands to face for\ncomfort, soothes well w/pacifier.\n\n: Mom called x2, updated by this RN, asking\nappropriate questions. Plans to call again in AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744560,
"text": "Clinical Nutrition\nO:\n~34 wk CGA BG on DOL 44.\nWT: 1290 g (+20)(<10th %ile); birth wt: 612 g. Average wt gain over past wk ~24 g/kg/day.\nHC: 27.5 cm (<10th %ile); last: 26.5 cm\nLN: 35.5 cm (<10th %ile); last: 34.5 cm\nMeds include Fe and Vit E\n noted\nNutrition: 150 cc/kg/day SSC 32 w/ promod, all pg. Average of past 3 day intake ~150 cc/kg/day, providing ~160 kcal/kg/day and ~3.9 g pro/kg/day.\nGI: Abdomen full but benign. Mild generalized edema.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range except slightly elevated alk phos level to 440; not of concern; likely represents rapid bone growth and metabolism. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for HC and LN gain. Wt gain is exceeding recommended ~15 to 20 g/kg/day; represents catch up growth. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744561,
"text": "Neonatology Attending\nDOL 44 / CGA 34-2/7 weeks\n\nOn CPAP 5 cm H2O in 21-32% FiO2. No distress and no bradycardias, on caffeine.\n\nMurmur persists. BP 74/48 (62).\n\nWt 1290 (+20) on TFI 150 cc/kg/day SC32PM, tolerating well by gavgae over 1 hour. Abd benign. Voiding and stooling appropriately.\n\nTemp stable in off isolette.\n\nA&P\n28 week GA infant with CLD, feeding immaturity\n-Will trial off CPAP tomorrow\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-13 00:00:00.000",
"description": "Report",
"row_id": 1744562,
"text": "NPN 7am-7pm\n\n\nRESP: Infant remains on Prong CPAP 5cm's in 21-25%. RR\n40-60's with sats > 94%. LS clear and equal with mild SC\nrets. Sx'd for mod cloudy secretions x 1. No spells with occ\ndrifts to 80's QSR. A: Tol CPAP wekk. P: Will cont to\nmonitor resp status. Plan to trial off CPAP tomorrow.\n\nFEN: Infants TF 150cc/kg/day of SSC32 with promod = 32cc's\ngavaged over 1hr. Abd soft, full, +bs, no loops noted.\nVoiding and no stool at this time in shift. No asp. Sm spit\nwith being held during feed. A: Tol feeds well. P: Will cont\nto monitor weight and exam.\n\nG/D: Infant is stable in off isolette, swaddled with\nboundries, on sheepskin. Alert and active with cares. Wakes\nbefore feeds. Sucks on pacifier. MAE. Fonts soft and flat.\nA: AGA P: Cont to support dev needs.\n\n: Mom was in for 12pm cares. Held infant during\nfeeds. Asking app questions. Updated on plan of care for\ninfant. A: and involved. P: Will cont to support and\neducate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-26 00:00:00.000",
"description": "Report",
"row_id": 1744640,
"text": "NPN 7a-7p\n\n\n1) Infant remains on NC with sl increased O2 requirement\n75-125cc. Infant seems to desat mostly during NG feedings.\n?reflux. BS clear. Mild s/c retractions. One desat to 50's\nneeding stim and bloby . HR dip to 108. Last dose of lasix\ngiven today. Plan to start on diuril tomorrow. continue to\nasess.\n3) TF decreased to 130cc/kg/day for a fluid restriction.\nInfant tolerating feeds of ssc32 with pm given over 1 hour.\nNo spits or asp. abdomen softly full. Diuresed well after\nlasix. No stool thus far. On prune juice. continue to asess.\n4) infant and active with cares. sleeping well between\nswaddled with boundaries. temps stable in a open crib.\nContinue to support dev.needs.\n5) mom called once. Brief update given . WIll further update\nwith new plan when she visits. Mom will be in to visit\nlater. COntinue to keep family well informed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1744646,
"text": "PCA Note 11a-7p\nI have examined pt. & agree w/ PCA's assessment above. PossPARENTS: in for 1700 cares. Mom at home with transfer to @ the end of week if tolerates beitwin sister. participated in cares and held infant. Cong off CPAP.ntinue to support and update.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1744647,
"text": "NPN 1900-0700\n\n\nRESP: Remains in NC 100%, 50-75cc. LS C/=, mild SCR. No\nspells, occasional drifts with QSR.\n\nFEN: Tolerating PG feeds well, offered bottle for the first\ntime this shift. Took 25cc PO! Tolerated well. Abdomen\nsoft/round, good bs, V&S.\n\nG/D: Temp stable swaddled in OAC. A&A w/cares, sleeps well\nin between. Starting to wake for feeds. Calms well after\ncares w/containment.\n\n: Mom called X1, updated by this RN, asking\nappropriate questions. Would like transferred to\n SCR when ready.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1744648,
"text": "Neonatology\nRemains in NCO2. Comfortable appearing. On caffeine. Off lasix for several days. WIll continue to observe with FR and off other diuretics.\n\nWt 1790 up 50. Tolerating feeds at 130 cc/k/d of 32 for FR. Continues to require gavage feeds. Abdomen benign.\n\nContinue possible transfer to at beginning of next week if resp remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-28 00:00:00.000",
"description": "Report",
"row_id": 1744649,
"text": "Neonatology NP Exam Note\nPLease refer to attending note for details of evaluation and plan.\n\nPE: small inpretrm infant nestled in open crib, on nasal canula O2.\nAFOF sutures split, eyes clear, ng in place, MMMP\nChest is clear, equal bs, comfortable resp pattern\nCV: RRR, soft gr 1/6 systolic murmur, pulses+2=\nAbd: soft, protruberant, active bs\nGU: immature female genitalia\nEXT: increasing bulk, MAE, WWP\nNeuro: symmetric tone and reflexes, active and responsive\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-29 00:00:00.000",
"description": "Report",
"row_id": 1744653,
"text": "Neonatology\nDoing well. Remains in low flow NCO2. Comfortable appearing.\nteam has spoken with mother. plan to dstart diuril. Follow lytes.\n\nWt 1790 up 90. Tolerating feeds at 130 cc/k/d of 32 cal. Abdomen benign.\n\nContinue as at present.\n\nTo consider transfer to next week as allowed by resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744470,
"text": "Clinical Nutrition\nO:\n~32 wk CGA BG on DOL 30.\nWT: 891 g (-18)(<10th %ile); birth wt: 612 g. Average wt gain over past wk ~17 g/kg/day.\nHC: 25.25 cm (<10th %ile); last: 24.75 cm\nLN: 34.5 cm (<10th %ile); last: 32.5 cm\nMeds include Fe and Vit E\nLabs due this wk\nNutrition: 150 cc/kg/day SSC 32 w/ promod, pg over 1 hr feeds due to hx of spits. Average of past 3 day intake ~150 cc/kg/day, providing ~160 kcal/kg/day and ~3.9 g pro/kg/day.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems, all pg. Labs due this wk. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN gain is exceeding recommended ~1 cm/wk, but question accuracy of measurements. Overall trend on LN growth chart is acceptable. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744471,
"text": "Respiratory Care Note\nPt remains on IMV 22/6, RR 24, FiO2 23-28%. BS coarse, will clear after suctioning. Some crackles. Suctioned for large amount cloudy secretions. RR 30-50's. On caffeine. No bradys noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-05-30 00:00:00.000",
"description": "Report",
"row_id": 1744472,
"text": "Nursing note\n\n\n#1 RESP O: Child remains on vent withthe settings as\ncharted. Fio2 between 21 and 30 percent. Increase fio2\nduring cares and suctioning to about 40 percent. Tolerates\ncares well. Breath sounds coarse before suctioning and\nclears sometimes after suctioning. Soft crackles heard after\n1300 cares. aware. Mild inter and subcostal retractions\nnoted. Suctioning q 4 hours for large amounts of cloudy\nmucus from the ett. Also obtaining large amounts from her\nmouth of cloudy mucus. Child continues on caffeine. No\ndesats or bradys noted as yet this shift. P: Will continue\nto monitor resp status and will continue on vent. Will\ncontinue with caffeine.\n#3 FEN O: Child remains on 150cc TF of sc 32 with promod.\nTolertating gavage feeds of 23cc over 1 hour without spits\nor aspirates. Ng secure and placement verified. Abdomen\nremains soft and full. Girth stable as noted. No loops\nnoted. Good bowel sounds heard. Child voiding and stooling\nwell. Stool guiac neg. Remains on vit e and iron. P: Will\ncontinue with plan of care.\n#4 G+D O: Child remains on servo in the isolette. Temp\nslightly variable with the probe loose. Child alert and\nactive. Likes to be swaddled. occasionally irritable.\nTolerated being kangarooed well for 1 hour. P: Will continue\nto cluster cares. Will continue to support the child's\ncoping skills.\n#5 Parenting O: mom and dad in for the 1300 cares and the\n1700 cares. Dad did temp and diaper at 1300 and mom did them\nat 1700. Dad the child. Both interacted\nwell witht he children. P: will continue to support and\ninform the .\n#10 Sepsis O: Child remains on ABX as ordered. ABX switched\nto oxacillin as ordered. Child continues to have copious\nsecretions and remains on servo isolette. P: Will continue\non abx for total of 10 days and will monitor closely for any\nchanges.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1744641,
"text": "NPN 1900-0700\n\n\nRESP: Remains in NC 100% 50-100% (^ w/feeds). LS C/=, mild\nSCR. On caffeine, no spells this shift (').\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, good bs. V&S (heme negative).\n\nG/D: Temp stable swaddled in OAC. A&A w/cares, sleeps well\nin between. Sucks on pacifier for comfort.\n\n: Mom in at change of shift, updated by this RN.\nCalled X1 since being home. Plans to call overnight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1744642,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in this am.\n\nAFOF. Nasal bridge slightly redened. breath sounds clear with fine crackles in bases. Nl S1S2, grade murmur audible. Pink and well perfused. Abd benign, no HSm. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1744643,
"text": "Neonatology\nRemains in low lfow NCO2. Having desats with feeds. Comfortable apeparing. Will hold on start of diuril for now and consider need over coming days.\n\nWt 1740 up 15. TF at 130 cc/k/d being tolerated via gavage. Abdomen benign. WIll coinsider po feeds in coming days as resp status stabilizes.\n\nTemp stable.\n\nSkion w/o lesions. Active and . Moving all 4.\n\nCOntinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-06-27 00:00:00.000",
"description": "Report",
"row_id": 1744644,
"text": "PCA Note 11a-7p\nI have examined pt. & agree w/ PCA's assessment above. PossPARENTS: in for 1700 cares. Mom at home with transfer to @ the end of week if tolerates beitwin sister. participated in cares and held infant. Cong off CPAP.ntinue to support and update.\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-10 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 829415,
"text": " 6:19 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: following PICC line position\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity @ 28 wks, P-CVL originating right saphenous vein at the\n ankle\n REASON FOR THIS EXAMINATION:\n following PICC line position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AND ABDOMEN ON AT 1835 HOURS:\n\n HISTORY: 28 week preemie. Check central line placement.\n\n In follow up to , previously noted UVC has been removed in the\n interval. NGT terminates in the left-sided stomach. Right femoral PICC line\n remains in place terminating at the level of L4, likely within a right iliac\n vessel. The lungs remain mildly hyperinflated with diffuse mild hazy opacity\n with no new focal areas of collapse or consolidation. The heart size remains\n normal. Examination of the abdomen demonstrates mild gaseous distention of\n multiple loops throughout with no evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-25 00:00:00.000",
"description": "BABYGRAM CHEST & ABD (TOGETHER ONE FILM)",
"row_id": 830780,
"text": " 8:55 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # \n Reason: evalaute lungs and abd\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with increased vent needs\n r/o nec\n REASON FOR THIS EXAMINATION:\n evalaute lungs and abd\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AND ABDOMEN; Comparison is made to the prior study from earlier the same\n day. Since that time, the patient has developed some collapse in the right\n upper lobe in addition to the previously noted left upper lobe collapse. The\n exam has little change otherwise. The endotracheal tube ends above the\n carina. The NG tube reaches the stomach. There is mild nonspecific dilatation\n of many bowel loops.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-04-30 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 828448,
"text": " 8:57 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: s/p ETT placement/ umbilical line placement. ? RDS\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity @ 28 wks\n REASON FOR THIS EXAMINATION:\n s/p ETT placement/ umbilical line placement. ? RDS\n ______________________________________________________________________________\n FINAL REPORT\n FINDINGS: A supine portable babygram demonstrates the presence of an ETT with\n its tip just at the thoracic inlet, a central venous catheter with its tip\n high in the right atrium and an umbilical arterial line with its tip at the\n level of T8/9. The cardiothymic silhouette is normal in size and shape. The\n lungs are moderately hyperinflated and there is a mild to moderate ground\n glass appearance of the lung parenchyma. The abdominal bowel gas pattern is\n normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-05 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 828958,
"text": " 9:24 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: ? P-CVL tip position\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity @ 28 wks, P-CVL originating right saphenous vein at the\n ankle\n REASON FOR THIS EXAMINATION:\n ? P-CVL tip position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Premature infant with new central venous line placement.\n\n PORTABLE CHEST, 9:15 P.M., : Since the study obtained 7 days earlier,\n the baby has been extubated. NGT enters the stomach. Umbilical venous\n catheter enters the right atrium.\n\n There has been interval placement of a right groin central venous line. The\n tip reaches the iliac vein/IVC confluence, but does not appear to have entered\n the IVC.\n\n Lung volumes are within normal limits and the lungs are clear. The heart size\n is normal and pulmonary vascularity is normal.\n\n The bowel gas pattern is unremarkable.\n\n IMPRESSION: New right groin central venous line reaching the IVC/iliac vein\n confluence.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-04 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 828812,
"text": " 7:24 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANTA ASSESS FOR IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 28 weeks now 3 do\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n Incongurent 28 weeks of gestation now 3 days old.\n\n There is no evidence of an intracranial hemorrhage. The ventricles, sulci and\n cistern are normal. -white matter differentiation is upper limits for the\n patient's age. There are no extraaxial fluid collections.\n\n IMPRESSION: Normal head ultrasound for the patient's age.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-25 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 830734,
"text": " 12:36 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: r/o nec, assess espansion on imv\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with increased vent needs\n r/o nec\n REASON FOR THIS EXAMINATION:\n r/o nec\n assess espansion on imv\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS:\n\n CHEST AND ABDOMEN: Comparison is made to the prior study from earlier the\n same day. Since that time, the lungs have become better inflated, though\n their volumes are still low. There is clear evidence of left upper lobe\n partial collapse at this time, though the remainder of the lungs are\n essentially clear. The endotracheal tube remains above the carina. The NG tube\n reaches the stomach. The bowel gas pattern is unremarkable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-24 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 830686,
"text": " 11:20 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lung \n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with increased spells\n REASON FOR THIS EXAMINATION:\n evaluate lung \n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n Since her last exam performed on the , there has been little\n change. Nasogastric tube has been introduced which reaches the stomach. The\n lungs remain mildly abnormal in a pattern suggestive of mild chronic lung\n disease. The bowel gas pattern is normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-25 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 830693,
"text": " 3:09 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ett placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant intubated\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n Since our last exam of the 1st the patient has been intubated. The\n endotracheal tube ends above the carina. The lung volumes are extremely low\n and there is diffuse atelectasis. There is some distention of the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-29 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 831021,
"text": " 8:33 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: 29 do ex 28 w infant on vent, inc secretions with pos trch a\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with vent dependency, pos trach asp.\n REASON FOR THIS EXAMINATION:\n 29 do ex 28 w infant on vent, inc secretions with pos trch aspirate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 29 day old ex 20 week premature infant, ventilated, with increased\n tracheal secretions and concern for aspiration.\n\n PORTABLE CHEST, 8:52 A.M., : When compared to the study obtained 4 days\n earlier, there continues to be air space disease in both upper lobes. There\n is also new air space disease in the right lower lobe. These findings are\n superimposed on diffuse lung abnormalities which are probably a reflection of\n the baby's immaturity.\n\n The heart size remains within normal limits. No pleural effusions are seen.\n\n ETT and NGT are in satisfactory position. No other changes.\n\n IMPRESSION: Persistent biapical air space disease and new right lower lobe\n disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-23 00:00:00.000",
"description": "BABYGRAM CHEST & ABD (TOGETHER ONE FILM)",
"row_id": 830502,
"text": " 10:31 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # \n Reason: assess lung expansion, assess abd\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity @ 28 wks, P-CVL originating right saphenous vein at the\n ankle\n\n on cpap , full entereal fdgs, cluster of \"spells\"\n REASON FOR THIS EXAMINATION:\n assess lung expansion, assess abd\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Infant with prematurity at 28 weeks. Assess lung expansion and\n assess abdomen.\n\n Comparison is made to previous films from .\n\n Since the prior examination, the ascending venous vascular catheter on the\n right has been withdrawn as has been the nasogastric tubes. The lung volumes\n are low on today's exam. No focal parenchymal opacity is seen. There is air\n throughout the GI tracts in nondistended loops. There appears to be fecal\n material within the colon.\n\n IMPRESSION: Lung volumes low, no specific abnormalities seen on the abdominal\n film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-06-01 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 831447,
"text": " 1:18 PM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: follow up atelectasis\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress on vent. PLEASE PERFORM EXAM AT 1PM.\n REASON FOR THIS EXAMINATION:\n follow up atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Infant with respiratory distress.\n\n CHEST: Single frontal radiograph compared to , demonstrates persistent\n left upper lobe, right upper lobe and right lower lobe atelectasis. There is\n increasing left lower lobe atelectasis. The ET tube and feedings tubes remain\n in good position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-05-30 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 831141,
"text": " 6:55 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: one month follow up\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 28 weeks now one month old\n REASON FOR THIS EXAMINATION:\n one month follow up\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Premature infant, born at 28 weeks gestation. Now 1 month of age.\n Evaluate for PVL.\n\n Comparison is made with the previous cranial ultrasound from .\n\n Since the prior study, there has been appropriate interval maturation of the\n brain. The cerebral and cerebellar architecture are within normal limits. The\n ventricles are normal in size and there is no evidence of intraparenchymal or\n intraventricular hemorrhage. The extra-axial fluid spaces are normal.\n\n IMPRESSION: Normal cranial ultrasound.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-06-17 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 833055,
"text": " 3:45 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evalaute lung fields\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, increased WOB\n REASON FOR THIS EXAMINATION:\n evalaute lung fields\n ______________________________________________________________________________\n FINAL REPORT\n CHEST @ 16:02:\n\n HISTORY: This is a 2 month old baby girl who is a twin and has increased\n work of breathing.\n\n FINDINGS: Single portable view of the chest was obtained and is compared to\n the previous film dated at 13:10.\n\n The child is no longer intubated. The NG tube tip at least reaches the left\n sided stomach. Both lungs are symmetrically under inflated and there is patchy\n opacification of the upper lobes. The central pulmonary vasculature is a bit\n illdefined. The heart size is normal given the degree of inspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-06-22 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 833526,
"text": " 7:32 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: screen for PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 28 weeks, IUGR, now two months old. Two previous normal HUS.\n REASON FOR THIS EXAMINATION:\n screen for PVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Almost 2 month old girl who is a twin and was born prematurely at\n about 28 weeks EGA. She had IUGR.\n\n FINDINGS: Portable real-time son of the neonatal head was performed in\n the NICU. The brain parenchyma has normal echogenicity without evidence for\n mass, hemorrhage, or structural abnormality. The degree of sulcation is\n consistent with the patient's EGA equivalent. There is an area of globular,\n heterogeneous, primarily increased echogenicity in the right caudothalamic\n groove. This does not extend into the ventricle and the right lateral\n ventricle is not enlarged. The remainder of the ventricles appear normal. No\n abnormal extra-axial fluid collections.\n\n IMPRESSION: Grade 1 right germinal matrix hemorrhage.\n\n Note: Discussed in person with members of the patient's treatment team on the\n morning of .\n\n"
},
{
"category": "Echo",
"chartdate": "2103-05-10 00:00:00.000",
"description": "Report",
"row_id": 77579,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease. Murmur.\nStatus: Inpatient\nDate/Time: at 18:12\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n"
}
] |
10,158 | 176,453 | Respiratory: The infant was initially tachypneic but remained in room air. He had no apnea or bradycardia of prematurity. | A/ Toleratingfeeds. Infant is nowreceving Neosure formula. Min asps. Remainder of feedsgavaged. precordium wnl. Nursing addendumO: agree w/PCA note above. Temps stable in opencrib. NPO while infant transitions with maintenance IVFs. Transitional respiratory distress (TTN), now resolved. A/ UPdatedand involved. Updated atbedside. Stooledheme-. 2.460kg (+65gms).abd benign, full. h/o +PPD. Encourage po's.G&D. BP68/39 (47). ReceivedHep. pulses wnl. Pulses wnl. + murmur. HR and BPwnl. P/ Cont to monitor. NICU NSG NOTEFEN. sucking on binki andhands.#4 parentingno contact thus far this shift.#5 cvsoft murmur heard. TO SUPPORT GROWTH ANDDEVELOPMENT.4NO KNOWN CONTACT THUS FAR THIS SHIFT.5INFANT HAS SOFT MURMUR, HR 140-150, BP 65/56 (44) P:CONT. P:CONT TO SUPPORT NUTRITIONAL NEEDS.3REMAINS SWADDLED IN OAC, TEMP STABLE, A/A WITH CARES, FONTSSOFT/FLAT, LIKES PACIFIER. Nursing Progress Note#2-O/A- TF=140cc/kg/d of Neosure via po/pg. TF 120cc/k/d SC/BM. B immunization this shift. Delivery by cesarean section. Brought in breastmilk. Re-evaluate HC. P- Cont toassess for FEN needs.#3-O/A- cont to be awake and active with clustercares q4hrs. bp 68/48 with mean 53. pinkand well perfused. wt. A/ Stable. Passed hearing screen.4 ParentingNo contact thus far this shift.5 CVAudible murmer. Abd benign. Abd soft, bs +. STools heme neg. Boundaires in place. Cont to monitor. Settles easily, temps stable in crib.A/P: AGA , cont to monitor dev. Tolerating feedings well.Alternates PO/PG. Momd/c'd home today. Abdexam benign. Tol feeds. A/A. A/ AGA. Took temp, changed diaper and bottled infantindependently.CV: Soft murmur heard on exam. A/P: Cont to monitor murmur and signs ofcompromise. Cont to encourage PO feeding as tol by infant.DEV - Stable temps while swaddled in oac. Temp stable inopen crib. Dailywts. 64/23, mean 40. well perfused. maew. MAEs. FS&F. Dev: Waking prior to feeds, swaddled, bringing hands toface. Cardiorespiratory monitoring. Abd soft, min aspirates, nospits, no stools this shift, voiding.A/P: Improving PO intake, gaining wt, evaluate need forglycerin supp.3. Asking questions regarding when infant will bedischarged. Sucks onpacifier and brings hands to face. Cap refill brisk. Neo AttendDay 9 CGA 35.5wkRespr: RA, clear =BS, 40-60s, no spells.CV: murmur noted. Will keep family updated.OB and delivering OB: Dr. Pediatrician: Dr. , G2P1 now 4 mother. TF at 140cc/kg, bottling eagerly60-80cc, NGT left in place. Neonatology Attending Progress NoteCorrection - feedings mostly Neosure 22. P/ Contto support developmental needs of infant.Parenting. Unremarkable except for mild respiratory distress and BBO2 need, which has since resolved.Impression/Plan:Preterm male newborn transitioning well. HR 130-160. hr 150's. pulses normal. P- Cont to assess for CV needs.See flowsheet for further details. Assessment unchanged from above note. O/ Pink and well perfused. VSS. Sucks on pacifier. Will investigate further maternal history of positive PPD. Abd exambenign. P- Cont to assess for G&Dneeds.#4-O/A- No parental contact so far this shift. HR 120-140's. P- Cont toenc parental calls and visits.#5-O/A- Cont with soft murmur. HR 140-160's. P/ Cont to provide info and support to family.CV. all po feeds.BM/Neosure feeding ad lib well.UOP and stool wnl. Uses yellownipple. Suckvigorously on fingers and pacifier. A: Alt po/pg/ STable. MildSC rtx. stool guaiac +, min. Received Vit. P: cont toenc. Mild ic/sc ret. A: comfortable.P: cont to follow.FENO: TF min ^to 100cc/k/d. Minimals aspirates. in Resp. in Resp. BP stable. BPstable. AG stable.Abd soft and round with active bowel sounds. P: Continiue toinform and support. BBS =/clear. refed to infant and subtracted from totalamount rn. O: Infant remains on TF's of 120cc/k/d of BM/SC20. P: cont to follow.CVO: +murmur appreciated. Active, alert, AFOF, sutures opposed, good tone. amts. max asp of 3.2cc partially digested formula.A: Stable. Wt. Calms with containmentand pacifier. A: stable. A: stable. A: Stable. PO/PGovernight. Br.sounds clear with occasional retractions. brisk caprefill. 58cc'sQ4H. P: Continue to assess.REVISIONS TO PATHWAY: 1 Alt. Calms with containment andpacifier. NNP updated, and examined. alsorefed to infant. Neonatology-NNP Physical ExamInfant remains in RA. D-stick 61/87.DEV: Temp stable, nested on servo-warmer. a:AGA P: cont to support dev. A: AGA p: cont to support dev. Calms with containment and pacifier. Bili in AM. asp. A: Murmur. NEed circ consent and PKU consent.#5 All VS stable, murmur present. A: aGA P: cont to support dev.milestones. Function; resolved tonite fairly well. P: contto follow.FENO: TF of 60cc/k/d. Gr murmur, pulses +2, pink, RRR. Active with cares.PKU done as well as bili, see flow sheet. P: cont to follow.BILIO: Sl jaundiced to ruddy, to check bili level in am.GDO: TEmp stable in oac. PIV placed in L foot. MAEW. P: cont to follow.GDO: tEMp stable on servo control on warmer. See #1 note for details. ABd pink, no loops, active bs.Voiding/ stoolingmec. is flat, soft with + BS. Bottle attempt x 1 and 3cctaken. Abd pink, no loops,active bs. Swaddled. Active and alert with cares.MAE.Fonts soft, flat. Updated at bedside. transitioning well, mild tachypneaP: Continue close observation and monitoring. NSG addendum noteCVO: Soft murmur appreciated. Breath sounds are clear and = with mild SC retractions. LS clear and equal. NPO. Tolerating gavage feeds well w/o spits; minimal residuals. Nursing Progress Note1 Alt. above MD note for maternal Hx. Colot pink w/gool perfusion.FEN: Wt=2295g (- 180g). HR unchanged. good pulses. Moved to crib; temp stable. Belly soft, voids qs,did have a lg. A: Tolerating feeds. A:murmur P:cont to monitorinfant closely pink andwell perfused. pink well perfused.Brisk cap refill. Nospits, minimal asp. P: cont to follow. P: cont to follow. Abd. BSactive, abd soft and benign, heme negative stool today. Notcomprimised. Start feeds when resp. mae. MAE. T-98 HR-170 RR-60 BP 52/24 M-36. A: breathing comfortably. BP stable, pulses normal,good perfusion. Placed on servo control warmer, on cardio-resp. Color slightlyjaundiced.#4O: No contact.#5O: Soft murmur conts, well perfused. Repeat D/S=64. O: Soft murmur heard. /NEON DOL 7 CGA 35 RA, no AOP, RR 30-40, HR 140-160, soft prob PPS m, can hear out to axilla. MAE.fonts soft, flat. Was warm (100.3)at 0100, servo weaned, now 98.7. See flow sheet for po volume and pg volume. Function#2. IVF D10W at 30cc/kg via PIV, infusing withoutincidence. | 39 | [
{
"category": "Nursing/other",
"chartdate": "2171-11-08 00:00:00.000",
"description": "Report",
"row_id": 1820326,
"text": "Neonatology Attending Admission Note\n\nInfant is a 34 week, 2475 gram male newborn (triplet II) who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 36 y.o. G2P1 now 4 mother. Prenatal screens: A+, antibody negative, HBsAg negative, RPR NR, RI, GBS negative. Prior OB history - , c/s, FT male. +tubal factor infertility, myomectomy , +fibroids. h/o +PPD. Meds: PNV.\n\nThis pregnancy notable for:\n-- IVF triplets, dichorionic, triamniotic\n-- PTL at 30 weeks, controlled with po terbutaline\n-- Presented today in OB office with 3+ proteinuria\n\nDue to proteinuria, decision made to deliver infants. Delivery by cesarean section. Apgars 8,9. Infant shown to parents then transported to NICU for further management.\n\nExam:\nVS per CareView\nMeasurements: weight 2475 gms = 50-75%, L 47.5 cm = 75%, HC 34.5 cm = >90%.\nExam noted in bedside chart on newborn exam form. Unremarkable except for mild respiratory distress and BBO2 need, which has since resolved.\n\nImpression/Plan:\nPreterm male newborn transitioning well. Cardiorespiratory monitoring. Transitional respiratory distress (TTN), now resolved. Monitor for apnea. No perinatal sepsis risk factors or concerns, so no sepsis evaluation at this time. Will investigate further maternal history of positive PPD. NPO while infant transitions with maintenance IVFs. Temperature regulation. Re-evaluate HC. Will keep family updated.\n\nOB and delivering OB: Dr. \nPediatrician: Dr. , \n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-17 00:00:00.000",
"description": "Report",
"row_id": 1820363,
"text": "Neo Attend\nDay 9 CGA 35.5wk\nRespr: RA, clear =BS, 40-60s, no spells.\nCV: murmur noted. pulses wnl. 64/23, mean 40. well perfused. precordium wnl. p 150s\nWt 2460, up 65gm\nTF: Took 178 cc/kg/day. all po feeds.\nBM/Neosure feeding ad lib well.\nUOP and stool wnl. Circ on - looks well.\npassed car seat test.\nHep B vaccine.\nInfant is MRSA colonized.\nDischarge teaching completed.\nReady for discharge this evening if feeding well.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-17 00:00:00.000",
"description": "Report",
"row_id": 1820364,
"text": "NICU Nursing DISCHARGE NOTE\n\nInfant has been po feeding ad lib and taking in excess of\nminimum daily requirement and gaining weight steadily.\nInfant nurses eagerly when Mom has put him to breast. Mom is\ndemonstrating understanding of all aspects of infant's care\nas well as formula preparation and handles infant with\nconfidence. Infant is maintaining normal temp in open crib\nand waking for feeds every 4 hrs. Murmur continues to be\naudible, but pulses are normal, VSS, precordium is quiet and\ninfant has been examined today by NNP .\n\nMom instructed in positioning in car seat and circumcision\ncare. Mom given 24 hr supply of mixed Neosure as well as WIC\nforms and prescription for Neosure. ID bands checked and\ninfant discharged home in car seat with parents.\n\nMom plans to bring infant to Pedi appt already scheduled for\nother on Tuesday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-16 00:00:00.000",
"description": "Report",
"row_id": 1820357,
"text": "NPN\n\n\n2.FEN: Wt 2.395kg, up 30gr. TF at 140cc/kg, bottling eagerly\n60-80cc, NGT left in place. Abd soft, min aspirates, no\nspits, no stools this shift, voiding.\nA/P: Improving PO intake, gaining wt, evaluate need for\nglycerin supp.\n\n3. Dev: Waking prior to feeds, swaddled, bringing hands to\nface. Settles easily, temps stable in crib.\nA/P: AGA , cont to monitor dev. needs.\n\n4. Parenting: No contact so far this shift from parents.\n\n5. CV: Soft murmur, BP 71/33 MBP 49, well perfused, warm,\ngood pulses. A/P: Cont to monitor murmur and signs of\ncompromise.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-16 00:00:00.000",
"description": "Report",
"row_id": 1820358,
"text": "Addendum\n Correction to above note, infant has been stooling, yellow seedy stoolx2, heme neg-no need for glycerin supp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-12 00:00:00.000",
"description": "Report",
"row_id": 1820343,
"text": "NICU NSG NOTE\n\n\nFEN. O/ Wt up 5g. TF 120cc/k/d SC/BM. Needs 50cc q4h. Took\nentire volume at 1630, then 25cc at . Uses yellow\nnipple. Gavaged over 30 mins. Abd exam . Voiding and\nstooling. STools heme neg. No spits. Min asps. A/ Tolerating\nfeeds. P/ Cont to monitor for feeding intolerances. Daily\nwts. Encourage po's.\n\nG&D. O/ Awake and alert with cares. Temps stable in open\ncrib. Learning to po. Boundaires in place. A/ AGA. P/ Cont\nto support developmental needs of infant.\n\nParenting. O/ Mom and dad in briefly after CPR class. Mom\nd/c'd home today. Parents will be in tomorrow. A/ UPdated\nand involved. P/ Cont to provide info and support to family.\n\nCV. O/ Pink and well perfused. + murmur. HR 140-160's. BP\n68/39 (47). A/ Stable. P/ Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-13 00:00:00.000",
"description": "Report",
"row_id": 1820344,
"text": "NPN 2300-0700\n\n\n2 Nut\nCurrent weight 2.290 kg, up 5 grams. TF remain at\n120cc/kg/day of BM/SC 20. Tolerating feedings well.\nAlternates PO/PG. Abd soft, bs +. No spits, min asp.\nVoiding and stooling.\n\n3 DEV\nTemp stable in open crib. Sleeps well between cares. Suck\nvigorously on fingers and pacifier. Passed hearing screen.\n\n4 Parenting\nNo contact thus far this shift.\n\n5 CV\nAudible murmer. HR 120-140's. Pulses wnl. Warm, pink and\nwell perfused.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-16 00:00:00.000",
"description": "Report",
"row_id": 1820359,
"text": "Neonatology Attending Progress Note\n\nNow day of life 8, CA 4/7 weeks.\n#2 of triplets\nIN RA with normal RR 40-50.\nNo apnea and bradycardia.\n\nCVS - HR 130-150, BP 71/33 49\n\nWt. 2395gm up 30gm on 140ml/kg/d of MM or Neosure 20.\nFeedings well tolerated - needed gavage supplementation last night.\nBreastfeeding attempts are going well.\nNormal urine and stool output.\n\nAssessment/plan:\nBaby continues to make nice progress.\nWill continue to support supplemental feedings as needed.\nDischarge teaching in progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-16 00:00:00.000",
"description": "Report",
"row_id": 1820360,
"text": "Neonatology Attending Progress Note\nCorrection - feedings mostly Neosure 22.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-16 00:00:00.000",
"description": "Report",
"row_id": 1820361,
"text": "NICU Nursing Progress Note\n\nNUTRITION\nO: Infant waking at times every 4hrs to feed and taking or\nexceeding minimum volume requirement po. Indwelling feeding\ntube in place still, but not necessary to use today. Abd\nexam benign. Voiding and passing stool. Mom put infant to\nbreast and he eagerly fed for >15 mins.\nA: Improving feeding behavior.\nP: Advance po feeds as tol. Removed feeding tube if infant\npo feeds well for 24 hrs.\n\nHEMODYNAMICS\nO: Loud systolic murmur appreciated throughout the shift\ntoday. VSS. Cap refill brisk. No spells noted.\nA: NO evidence of compromise.\nP: MOnitor and assess.\n\nDEVELOPMENT\nO: Temp stable in open crib. Active and alert with cares.\nTone wnl. Opens eyes in response to Mom's voice.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Parents in to visit. Dad brought car seat in for car seat\ntest tonight. Mom handles infant well and is up to date with\ndischarge teaching. She requests WIC form at discharge.\nA: Parents readying for discharge home.\nP: Support and keep informed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-17 00:00:00.000",
"description": "Report",
"row_id": 1820362,
"text": "npn 1900-0700\n\n\n#2 fen\ntf min 140cc/kg neosure po q4hours. wt. 2.460kg (+65gms).\nabd benign, full. voiding and stooling qdiaper change yellow\nguiac neg stools. no spits. po 178cc/kg in past 24hours.\ncirumcision clean, no bleeding or drainage noted.\n#3 g&d\npt in open crib with stable temps. alert and active with\ncares. maew. fontanelles soft and flat. sucking on binki and\nhands.\n#4 parenting\nno contact thus far this shift.\n#5 cv\nsoft murmur heard. hr 150's. bp 68/48 with mean 53. pink\nand well perfused. pulses normal.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-13 00:00:00.000",
"description": "Report",
"row_id": 1820345,
"text": "PCA Note 0700-1900\n\n\nFEN - TF increased to 140cc/k/d = 57cc q4. Infant is now\nreceving Neosure formula. Infant bottled for first 2 feeds\nthis shift and took 40-60cc. Infant has great coordination\nwith bottling, but tires easily at times. Remainder of feeds\ngavaged. Abd benign. No spits and min asp. Voiding. Stooled\nheme-. Cont to encourage PO feeding as tol by infant.\n\nDEV - Stable temps while swaddled in oac. A/A. Sleeps well\nbetween cares. Not yet waking on own for feeds. Sucks on\npacifier and brings hands to face. FS&F. MAEs. Received\nHep. B immunization this shift. Cont to support\ndevelopmental needs.\n\nParents - No contact from the family thus far this shift.\nCont to support and educate.\n\nCV- Soft murmur audiable. HR 130-160. Infant is pink and\nwell purfused. Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-13 00:00:00.000",
"description": "Report",
"row_id": 1820346,
"text": "Nursing addendum\nO: agree w/PCA note above. soft murmur heard on exam, MD aware. no other concerns.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-13 00:00:00.000",
"description": "Report",
"row_id": 1820347,
"text": "NURSING 7p-11p\nPArents in and updated on triplets plan of car. Assessment unchanged from above note. Agree with co-workers assessment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-14 00:00:00.000",
"description": "Report",
"row_id": 1820348,
"text": "PCA 1900-0700\n\n\n2\nBW 2475g, CW 2330G, TF 140CC/KG/D OF NEOSURE 20, 56CC Q4H,\nALT PO/PG FEEDS, BOTTLED 25CC, ABD SOFT, BS+, NO LOOPS, AG\n24-24.5CM, MAX ASP 1.0CC, NO SPITS, VOIDING/STOOLING QS HEME\nNEG. P:CONT TO SUPPORT NUTRITIONAL NEEDS.\n\n3\nREMAINS SWADDLED IN OAC, TEMP STABLE, A/A WITH CARES, FONTS\nSOFT/FLAT, LIKES PACIFIER. P:CONT. TO SUPPORT GROWTH AND\nDEVELOPMENT.\n\n4\nNO KNOWN CONTACT THUS FAR THIS SHIFT.\n\n5\nINFANT HAS SOFT MURMUR, HR 140-150, BP 65/56 (44)\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-14 00:00:00.000",
"description": "Report",
"row_id": 1820349,
"text": "I have seen this infant and agree with above documentation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-14 00:00:00.000",
"description": "Report",
"row_id": 1820350,
"text": "/NEON DOL 6 CGA 35 \nRA, RR 40-60, HR 140-150 soft G1 m, LLSB, no bounding pulses.\nWt 2330 up 40 on 140 cc/kg of Neosure, PO/PG\nTo arrange for circ within next few days.\nCalled and left message, mom not home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-14 00:00:00.000",
"description": "Report",
"row_id": 1820351,
"text": "Nursing Progress Note\n\n\n#2-O/A- TF=140cc/kg/d of Neosure via po/pg. Abd exam\nbenign. Voiding and stooling. Tol feeds. P- Cont to\nassess for FEN needs.\n#3-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nopen crib. Sucks on pacifier. P- Cont to assess for G&D\nneeds.\n#4-O/A- No parental contact so far this shift. P- Cont to\nenc parental calls and visits.\n#5-O/A- Cont with soft murmur. Pink/ perfused. HR and BP\nwnl. P- Cont to assess for CV needs.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-15 00:00:00.000",
"description": "Report",
"row_id": 1820352,
"text": "NPN 1900-0700\n\n\nFEN: wt=2365g (up 35g). TF=140cc/kg/d of BM20 or neosure22.\nEquals 58cc q4hrs, PO/PG. Bottled 38 and 60cc thus far.\nAbdomen soft, +BS, AG 27, voiding, no stool. max asp 10cc,\nbenign, refed.\n\nDEV: Temp stable, swaddled in open crib. Alert and active\nwith cares. Sleeps well between.\n\nParent: Dad in to visit. Brought in breastmilk. Updated at\nbedside. Asking questions regarding when infant will be\ndischarged. Took temp, changed diaper and bottled infant\nindependently.\n\nCV: Soft murmur heard on exam. HR 150-160's. BP 76/41 (51).\nPink, warm, well-perfused.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-15 00:00:00.000",
"description": "Report",
"row_id": 1820353,
"text": " Nurse Case Manager\nA referral was made to the VNA of Greater (phone , fax ) for a skilled nursing visit after discharge home. The baseline medical and demographic information has been called in to the agency. When the discharge date is made definite, please call and notify the agency and fax the completed page 1 and 2 referral forms to the above fax number. The mother is aware of the above referral and is in agreement with the plan of care. If you have any questions, please page me at beeper .\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-15 00:00:00.000",
"description": "Report",
"row_id": 1820354,
"text": "/NEON DOL 7 CGA 35 \nRA, no AOP, RR 30-40, HR 140-160, soft prob PPS m, can hear out to axilla. Spoke with mom about it.\nWt 2365 up 35 on 140 cc/kg MM/Neo. Starting to PO feed overnite. Was gavaged yesterday.\nDr to circ today or tomorrow.\n Sunday if feeding well.\nNeon to cover .\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-15 00:00:00.000",
"description": "Report",
"row_id": 1820355,
"text": "PCA\n\n\n#2FEN: tf remains at 140cc's/kg/d of BM/Neosure 22. 58cc's\nQ4H. infant has taken 47-55cc's thus far. abd benign, belly\nis soft and round, +bowel sounds, no loops, no spits, a/g\nstable, voiding and stooling; heme neg. at 0830, infant had\n8.0cc aspirate. refed to infant and subtracted from total\namount rn. at next care, infant had 5.8cc aspirate. also\nrefed to infant. both nonbilious partially digested formula.\nA:tol feeds well P:Cont to monitor infant and encourage po\nfeedings.\n\n#3DEVE: temp stable. infant is swaddled in the oac. alert\nand active with cares. wakes occ for feedings. likes binki.\nsleeps well in between cares. mae. A:AGA P:cont to support\ninfant\n\n#4PARENTING: Dr. called mom this am with update of\ninfant. A/P:Cont to support\n\n#5CV: infant has audible murmur heard x1 thus far. brisk cap\nrefill. good pulses. infant is pink in color. no spells thus\nfar this shift. BP=61/37(51). A:murmur P:cont to monitor\ninfant closely\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-15 00:00:00.000",
"description": "Report",
"row_id": 1820356,
"text": "I examined baby and agree with above note by R, PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-11 00:00:00.000",
"description": "Report",
"row_id": 1820338,
"text": "NPN\n\n\n#1 RA, sats stable at start of shift, sat monitor d/c'd.\nLungs clear and equal, no increased work of breathing, resp\nrate stable, see flow sheet for all details.\n\n#2 Total volume increased to 120cc/kg/day. Taking in SC 20,\npo/pg. See flow sheet for po volume and pg volume. BS\nactive, abd soft and benign, heme negative stool today. No\nspits, minimal asp. voiding.\n\n#3 Active and alert with cares, awakening q 3.5-4 hours for\nfeeds, bottling well, coordinated but tiring easily,\nremainder gavage fed. Temp stable in open crib, swaddled\nwith hands to face, sucking on pacifier.\n\n#4 Mom up to visit, held infant, questions answered, info\ngiven. NEed circ consent and PKU consent.\n\n#5 All VS stable, murmur present. BP stable, pulses normal,\ngood perfusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-12 00:00:00.000",
"description": "Report",
"row_id": 1820339,
"text": "Nursing Progress Note\n\n1 Alt. in Resp. Function\n\n#2. O: Infant remains on TF's of 120cc/k/d of BM/SC20. PO/PG\novernight. No spits thus far. Minimals aspirates. AG stable.\nAbd soft and round with active bowel sounds. No loops.\nVoiding qs, stools -heme. Wgt is up 20gms tonight to\n2285gms. A: Tolerating feeds. P: Continue to encourage po\nfeeds as tolerated.\n\n#3. O: Infant now cobedding with trip #1 in crib with stable\ntemp. He is alert and active with cares. MAEW. Tires quickly\nwith po feeds. A: AGA P: Continue to assess and support\ndevelopmental needs.\n\n#4. O: Parents up briefly this evening with visitors. ASking\nappropriate questions. A: Involved family. P: Continiue to\ninform and support. ?Mom d/c today.\n\n#5. O: Soft murmur heard. Infant pink and well perfused. Not\ncomprimised. A: Murmur. P: Continue to assess.\n\nREVISIONS TO PATHWAY:\n\n 1 Alt. in Resp. Function; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-12 00:00:00.000",
"description": "Report",
"row_id": 1820340,
"text": "/NEON CGA 35\nRA, no AOP, RR 30-40, HR 130-140\nWt 2285 up 20 on 120 cc/kg SC20 PO/PG.\nStools neg, last heme pos was on .\nMom A pos, last bili 6.2, repeat bili in am.\nMom to be discharged today, will speak with her.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-12 00:00:00.000",
"description": "Report",
"row_id": 1820341,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nFEN\nO: remains on TF of 120cc/k/d of SC or bm 20.\nBottling skills decreased r/t drowsiness. Bottles 20-30cc\nthen remainder is gavaged over 30\". Abd pink, no loops,\nactive bs. Voiding q diaper change. A: Stable. P: cont to\nenc. po feedings as tolerated.\nGD\nO tEmp stable in oac, active and alert with cares. MAE.\nfonts soft, flat. Calms with containment and pacifier. a:\nAGA P: cont to support dev. milestones.\nParenting\nPlease see trip # 1\nCV\nO: +murmur appreciated, hr 130-150's. pink well perfused.\nBrisk cap refill. A: stable. P: cont to follow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-12 00:00:00.000",
"description": "Report",
"row_id": 1820342,
"text": "NPN\nParents attended CPR class this afternoon. See #1 note for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-10 00:00:00.000",
"description": "Report",
"row_id": 1820332,
"text": "NPN:\n\nRESP: Sats 97-99% in RA. RR=40-70 . BBS =/clear. No desast or A&Bs thus far tonight; no A^Vs over past 24 h.\n\ncVL Soft murmur audible at LLSB. HR=140-160. BP=67/36 (43). Colot pink w/gool perfusion.\n\nFEN: Wt=2295g (- 180g). TF=60cc/kg/d; 25cc SC-20 q 4 h vai PO/PG. Tolerating gavage feeds well w/o spits; minimal residuals. Hep-locked IV. Attempted to bottle x 1, but baby uninterested, Abd benign. Voiding qs; trace mec stool.\n\nBILI: Bili from yesterday-4.4/ 0.2/ 4.2.\n\nG&D: CGA=34 wk. Moved to crib; temp stable. Active and alert w/cares. Swaddled, nested and resting well. Circ consent signed.\n\nSOCIAL: Father in to visit w/members of extended family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-10 00:00:00.000",
"description": "Report",
"row_id": 1820333,
"text": "Attending Note\nDay of life 2 CAG 34 \nin room air RR 40-70's sat above 95%\nno spells\nmurmur presnet 140-160's mean BP 47\nweight 2295 down 180 cc/kg/day po pg feeds minimal aspirate\non SSC 20 cal/oz\n\nvoiding and stooling meconium\nNa 149 K 5.9 Cl 115 CO2 19\nbili 4.4/0.2\n\nImp stable currently\nwill increase minimum to 100 cc/kg/day\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-10 00:00:00.000",
"description": "Report",
"row_id": 1820334,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nRESp\nO: Remains in room air, without distress breathing\ncomfortably. No desat's or drifts in sa02. A: comfortable.\nP: cont to follow.\nFEN\nO: TF min ^to 100cc/k/d. Currently bottling 40cc and\nimproving. require gavage feeding to meet min\nrequirement. ABd pink, no loops, active bs.Voiding/ stooling\nmec. No spits. max asp of 3.2cc partially digested formula.\nA: Stable. P: cont to follow.\nCV\nO: +murmur appreciated. BP stable. HR unchanged. pink and\nwell perfused. A: stable. P: cont to follow.\nBILI\nO: Sl jaundiced to ruddy, to check bili level in am.\nGD\nO: TEmp stable in oac. Active and alert with cares.\nMAE.Fonts soft, flat. Swaddled. Calms with containment and\npacifier. A: aGA P: cont to support dev.milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-10 00:00:00.000",
"description": "Report",
"row_id": 1820335,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, alert, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-11 00:00:00.000",
"description": "Report",
"row_id": 1820336,
"text": "Nursing\n\n\n#1O: In room air with no noted desats or spells. Br.\nsounds clear with occasional retractions. O2 sats > 97%.\n#2O: Wt. down 30g with fluids @ 100cc/kg, SC q 4 hrs.\nTaking min. amts. tonite fairly well. Belly soft, voids qs,\ndid have a lg. stool guaiac +, min. asp. and no spits. D-s\n74.\n#3O: In open crib with stable temp. Active with cares.\nPKU done as well as bili, see flow sheet. Color slightly\njaundiced.\n#4O: No contact.\n#5O: Soft murmur conts, well perfused.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-11 00:00:00.000",
"description": "Report",
"row_id": 1820337,
"text": "/NEON DOL 3\nRA, RR 40-70, no AOP, HR 13-140\nWt 2265 down 30, PO/PG on cc/kg > 120 cc/kg of SC 20.\nHeme: Mom A pos, bili 6.2/0.2\nDoing well, to go to parents room and speak with them.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-08 00:00:00.000",
"description": "Report",
"row_id": 1820327,
"text": " Admission Note\n\nO: Baby , #2, admitted to NICU at 1530 after C/S delivery to G-2 P 36 y.o. Apgars were 8+9. above MD note for maternal Hx. Infant virorous and crying on admission. Wt. 2.475 gms. Placed on servo control warmer, on cardio-resp. and 02 sat monitors with alarms set and audible. T-98 HR-170 RR-60 BP 52/24 M-36. Infant required BB02 to maintain sats initially, then went to RA after ~ 30 min. Initial D/S=54. PIV placed in L foot. D10W infusing at 60cc/kg=6.2cc/hr. Repeat D/S=64. Breath sounds are clear and = with mild SC retractions. Sats 98-100 in RA. RR 50's-70's. No murmur heard. BP means mid 30's-50. NPO. Received Vit. K and erythromycin eye ointment. Abd. is flat, soft with + BS. Has not voided or stooled. Parents saw infant in DR have not been to NICU yet.\nA: 34 wk. transitioning well, mild tachypnea\nP: Continue close observation and monitoring. Start feeds when resp. status WNL X 3 hrs. Keep parents updated and informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-09 00:00:00.000",
"description": "Report",
"row_id": 1820328,
"text": "NPN 1900-0700\n\n\nRESP: In RA. Initially RR 40-70's with occasional very mild\ngrunting with crying, but since 0200 RR 40-50's and no\ngrunting since 2230. O2sat 97-100%. LS clear and equal. Mild\nSC rtx. No spells or desats.\n\nFEN: TF=60cc/kg/d. Started enteral feeds at 30cc/kg of\nSSC20. IVF D10W at 30cc/kg via PIV, infusing without\nincidence. Abdomen soft, +BS, AG stable, no loops, no spits,\nvoiding, no stool. UO-4cc/kg/hr X12hrs. D-stick 61/87.\n\nDEV: Temp stable, nested on servo-warmer. Was warm (100.3)\nat 0100, servo weaned, now 98.7. Alert and active with\ncares. Sleeps well between. Takes paci.\n\nParents: Dad in at 1900, asked to come back after change of\nshift but did not return. Mom in to visit briefly going from\nL&D to the floor. Updated at bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-09 00:00:00.000",
"description": "Report",
"row_id": 1820329,
"text": "Newborn Med Attending\n\nDOL#1. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2475, on 60 cc/kg/d PG and D10W.\nA/P: Infant working up on feeds. Bili in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-09 00:00:00.000",
"description": "Report",
"row_id": 1820330,
"text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nRESP\nO: remains in room air, RR 30-50's, sat's >97%. NO a\nand b's . Mild ic/sc ret. A: breathing comfortably. P: cont\nto follow.\nFEN\nO: TF of 60cc/k/d. ENteral feeds are currently at 50cc/k/d\nSC 20cal/oz. GAvaged over 20\". Bottle attempt x 1 and 3cc\ntaken. Not well coordinated. No spits, min asp. A: Alt po/\npg/ STable. P: cont to follow.\nGD\nO: tEMp stable on servo control on warmer. Active and alert\nwith cares. MAE. Fonts soft, flat. Calms with containment\nand pacifier. A: AGA p: cont to support dev. milestones.\nParenting\nPlease refer to trip # 3 note.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-11-09 00:00:00.000",
"description": "Report",
"row_id": 1820331,
"text": "NSG addendum note\n\n\nCV\nO: Soft murmur appreciated. NNP updated, and examined. BP\nstable. P: cont to follow.\n\n\n"
}
] |
99,344 | 182,600 | In brief this is a 74 with hypertension, hyperlipidemia, coronary disease, abnormal nuclear stress test in the past and history of remote stroke who is trasfered from OSH after presenting with chest pain . # Chest pain: Initial concern for ACS with NSTEMI/troponin leak at OSH. At OSH ST depressions in inferior leads, which was consistent with reported history of RCA disease by nuclear stress in 06. His HCT at OSH was 43 (after 2 lt NS) and this precluded demand ischemia. Possibilities included ACS, GI outlet obstruction (epsecially if his history of possible gastric mass), early pancreatitis, billiary tract disease, aortic disection, or pericarditis. A CT torso with contrast was negative. LFTs, lipase, and lactate were normal. Initially was managed for ACS with clopidrogel, heparin ggt, asa and nitro ggt. Pt's CK increased to 1400 and he was taken to cath lab were he was found to have TO of Ramus. A BMS was placed. He was discharged on asa, clopidrogel and beta blocker. ACE was not started on discharge as it was not on the pre admission medication list. Please consider adding this medication unless otherwise indicated. | At OSH ED, ECG w/ 1 mm horiz to downsloping ST depressions inferiorly and V2-V4, CK flat but TnI 0.23. The ACS/NSTEMI hypothesis is somewhat challenged by the normal ECG at . The ACS/NSTEMI hypothesis is somewhat challenged by the normal ECG at . The ACS/NSTEMI hypothesis is somewhat challenged by the normal ECG at . Borderline Tn elevation Etiology of abd pain unclear at this point, with wide ddx. R groin closed w/ MINX closure device and is d/i. R groin closed w/ MINX closure device and is d/i. R groin closed w/ MINX closure device and is d/i. R groin closed w/ MINX closure device and is d/i. Pt also w/ diag lesion that was not interviened on at this time. Pt also w/ diag lesion that was not interviened on at this time. Pt also w/ diag lesion that was not interviened on at this time. Pt also w/ diag lesion that was not interviened on at this time. Pt c/o nausea prior to cath. Pt c/o nausea prior to cath. On exam significant right-sided and lower abdominal TTP (no guarding/ rebound), which he reports radiates to shoulders. Continues to c/o bloating post procedure. Pt voiding qs. Pt voiding qs. Pt voiding qs. R groin closed w/ MINX closure device Nifedipine was restarted as was lopressor po post cath. 74 yo M w/ h/o HTN, HL, presumed CAD with reported +inf defect on stress test, CVA on aggrenox, who afternoon presented with indigestion. Cardiac review of systems is notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Cardiac review of systems is notable for absence dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. His ECG demonstrated inferior ST depressions. His ECG demonstrated inferior ST depressions. His ECG demonstrated inferior ST depressions. His ECG demonstrated inferior ST depressions. Plain ECG and R sided and posterior lead ECGs here in SR, without significant ST/T wave changes suggestive of ischemia. heme+ stool EXTREMITIES: No c/c/e. heme+ stool EXTREMITIES: No c/c/e. heme+ stool EXTREMITIES: No c/c/e. DVT ppx with pneumoboots if active bleed or UFH otherwise. DVT ppx with pneumoboots if active bleed or UFH otherwise. DVT ppx with pneumoboots if active bleed or UFH otherwise. He has been having intermittent anginal symptoms for which he has been using NTG. He has been having intermittent anginal symptoms for which he has been using NTG. Response: No relief from zofran. Remainder of exam unremarkable. Possibilities include GI outlet obstruction, epsecially if his history of possible gastric mass is confirmed. LS dim bibasilar. LS dim bibasilar. Mild [1+] TR. Non-specificST-T wave changes. Simethicone prn. At OSH ED, ECG w/ 1 mm horiz to downsloping ST depressions inferiorly and V2-V4, CK flat but TnI 0.23. At OSH ED, ECG w/ 1 mm horiz to downsloping ST depressions inferiorly and V2-V4, CK flat but TnI 0.23. Off nitro ggt. Off nitro ggt. Mild mitralannular calcification. Hct stable. Hct stable. Plain ECG and R sided and posterior lead ECGs here in SR, without significant ST/T wave changes suggestive of ischemia. Plain ECG and R sided and posterior lead ECGs here in SR, without significant ST/T wave changes suggestive of ischemia. Denies nausea/pain. RR, normal S1, S2. RR, normal S1, S2. BS. Mild regional LVsystolic dysfunction. PERRL, EOMI. PERRL, EOMI. remains distended, but pt. remains distended, but pt. remains distended, but pt. remains distended, but pt. On asa, clopidrogel (x9mo for noted MI), atorvastatin, eptifibatide. presently on bowel regimen. presently on bowel regimen. HEENT: NCAT. HEENT: NCAT. heme+ stool EXTREMITIES: No c/c/e. heme+ stool EXTREMITIES: No c/c/e. pulses palp. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is dilated. No MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Trace aortic regurgitation is seen. CT was essentially negative, revealing onlygas. CT was essentially negative, revealing onlygas. IMPRESSION: 1. No abdominial bruits. No abdominial bruits. No AS. Plan: OOB in AM . Abd aorta not enlarged by palpation. Abd aorta not enlarged by palpation. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. also contin. Non STEMI Assessment: VSS HR 70-90 SR no ectopy. Non STEMI Assessment: VSS HR 70-90 SR no ectopy. Trace aortic regurgitation. R groin closed w/ MINX closure device and is d/i. R groin closed w/ MINX closure device and is d/i. Right ventricular function.Height: (in) 67Weight (lb): 158BSA (m2): 1.83 m2BP (mm Hg): 139/86HR (bpm): 66Status: InpatientDate/Time: at 09:47Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Left ventricular function. Site d/i. Pt also w/ diag lesion that was not interviened on at this time. Pt also w/ diag lesion that was not interviened on at this time. Pt also w/ diag lesion that was not interviened on at this time. SBP 190. SBP 190. Nifedipine, metoprolol. There is mild symmetric left ventricularhypertrophy with normal cavity size. Post cath fluids d/cd at 0100. SBP 190/100. had guiaic negative loose BM this a.m. Action: MI packet given. had guiaic negative loose BM this a.m. Action: MI packet given. only complains of mildbloating. only complains of mildbloating. | 27 | [
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668648,
"text": "Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 668762,
"text": "BMS placed to TO ramus. Pt also w/ diag lesion that was not\n interviened on at this time. R groin closed w/ MINX closure device and\n is d/i. Pulses +2/+3. Integrillin 2mcgs/kg/min started in cath lab and\n d/c\nd this early a.m.\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668694,
"text": "Mr. is 74 with hypertension, hyperlipidemia, coronary disease,\n abnormal nuclear stress test in the past and history of remote stroke\n who is trasfered from OSH after presenting with chest pain.\n At OSH his vitals were 97.9 80 190/84 20 98RA. His ECG demonstrated\n inferior ST depressions. His troponin I was noted to be elevated (0.74)\n and he was given ASA, NTG, and clopidrogel\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 668695,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - Cath: Pt had TO of Ramus BMS placed.\n - Wrote for home nifedipine, will start metoprolol if blood pressures\n do not come down appropriately\n - CK increased to 1400\n Allergies:\n Penicillins\n Unknown;\n Aspirin\n gi upset;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:06 AM\n Labetalol - 09:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 80 (74 - 105) bpm\n BP: 118/66(78) {92/64(73) - 165/124(131)} mmHg\n RR: 11 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,974 mL\n 61 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 1,474 mL\n 61 mL\n Blood products:\n Total out:\n 3,475 mL\n 500 mL\n Urine:\n 3,475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -501 mL\n -439 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 238 K/uL\n 13.2 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.2 %\n 11.6 K/uL\n [image002.jpg]\n 09:00 AM\n 05:14 PM\n WBC\n 11.6\n Hct\n 37.2\n Plt\n 269\n 238\n Cr\n 0.7\n TropT\n 0.40\n Glucose\n 138\n Other labs: PT / PTT / INR:13.4/40.0/1.1, CK / CKMB /\n Troponin-T:1465/179/0.40, D-dimer:792 ng/mL, Lactic Acid:1.7 mmol/L,\n Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n DIABETES MELLITUS (DM), TYPE II\n CHEST PAIN\n .H/O ABDOMINAL PAIN (INCLUDING ABDOMINAL TENDERNESS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:15 AM\n 20 Gauge - 12:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 668697,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - Cath: Pt had TO of Ramus BMS placed.\n - Wrote for home nifedipine, will start metoprolol if blood pressures\n do not come down appropriately\n - CK increased to 1400\n Allergies:\n Penicillins\n Unknown;\n Aspirin\n gi upset;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:06 AM\n Labetalol - 09:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 80 (74 - 105) bpm\n BP: 118/66(78) {92/64(73) - 165/124(131)} mmHg\n RR: 11 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,974 mL\n 61 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 1,474 mL\n 61 mL\n Blood products:\n Total out:\n 3,475 mL\n 500 mL\n Urine:\n 3,475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -501 mL\n -439 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 8cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, TTP with pain radiating to chest wall, reproduced chest\n pain that patient was experiencing duirng the day. No HSM or\n tenderness. Abd aorta not enlarged by palpation. No abdominial bruits.\n no rebound, no rosvigs no mcmurphys. heme+ stool\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 238 K/uL\n 13.2 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.2 %\n 11.6 K/uL\n [image002.jpg]\n 09:00 AM\n 05:14 PM\n WBC\n 11.6\n Hct\n 37.2\n Plt\n 269\n 238\n Cr\n 0.7\n TropT\n 0.40\n Glucose\n 138\n Other labs: PT / PTT / INR:13.4/40.0/1.1, CK / CKMB /\n Troponin-T:1465/179/0.40, D-dimer:792 ng/mL, Lactic Acid:1.7 mmol/L,\n Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n In brief this is a 74 with hypertension, hyperlipidemia, coronary\n disease, abnormal nuclear stress test in the past and history of remote\n stroke who is trasfered from OSH after presenting with chest pain\n # Chest pain: Initial concern for ACS with NSTEMI/troponin leak at OSH.\n At OSH ST depressions in inferior leads, which is consistent with\n reported history of RCA disease by nuclear stress in 06. The ACS/NSTEMI\n hypothesis is somewhat challenged by the normal ECG at . This may\n represent vasospasm but it is unlikely that it would present at such\n old age. His HCT at OSH was 43 (after 2 lt NS) and this precludes\n demand ischemia. Alternatively, this represents a GI problem.\n Possibilities include GI outlet obstruction, epsecially if his history\n of possible gastric mass is confirmed. Early pancreatitis or billiary\n tract disease may be possible. Alternative etiology includes aortic\n disection, since the pain radiates to the back. Pericarditis is remote\n posibility but no prodromal illness and pressentation would be atypical\n of this. Will trend CE and repeat ECG if chest pain. Will check CT\n torsoe with contrast and add d dimer to eval for possibility of\n dissection. Will check LFTs, lipase, and lactate (but no anion gap).\n Will continue continue management for presumed ACS with clopidrogel,\n heparin ggt, asa, nitro ggt. Will monitor.\n # Sinus tachycardia: Most likely related to pain. Will continue to\n monitor. Will give metoprolol prn for HR<100.\n # HTN: Since he initially was noted to have HTN associated with ECG\n changes when presented to OSH, most likely this represents emergency.\n His ECG changes were not present at but he still has CP. Otherwise\n no renal, retinal or CNS involvement. Nitroglycerin ggt for SBP<150.\n Will continue to monitor. Outpatient BP 140-150/80-100\n # Heme postive stool: Ddx includes upper bleed, such as PUD, gastritis,\n avms or lower gi bleed such as diverticular, hemorrhoids, mass etc. No\n history of IBD and this is remote possibility (may be associated with\n arthritis). Will monitor HCT, VS and stool guaiacs overnight. T/S and\n crossmatch two units. Large bore ivs. HCT>30. If active bleed will hold\n UFH, clopidrogel or aspirin.\n # H/O VTE (post surgical DVT, PE): Presenting symptoms are unlikely to\n be related to PE. consider D Dimer if alternative hypothesis dont\n explain CP. DVT ppx with pneumoboots if active bleed or UFH otherwise.\n # FEN: NPO overnight\n # ACCESS: PIVs\n # PROPHYLAXIS: heparin\n # CODE: Full\n # DISPO: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:15 AM\n 20 Gauge - 12:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668700,
"text": "Mr. is 74 with hypertension, hyperlipidemia, coronary disease,\n abnormal nuclear stress test in the past and history of remote stroke\n who is trasfered from OSH after presenting with chest pain.\n At OSH his vitals were 97.9 80 190/84 20 98RA. His ECG demonstrated\n inferior ST depressions. His troponin I was noted to be elevated (0.74)\n and he was given ASA, NTG, and clopidrogel\n Trop was elevated to .4 on AM of and pt. went to cath lab at\n 1030.\n BMS placed to TO ramus. Pt also w/ diag lesion that was not\n interviened on at this time. R groin closed w/ MINX closure device\n Nifedipine was restarted as was lopressor po post cath.\n Chest pain\n Assessment:\n Overnight, no c/o CP, SOB. HR 80\ns-90\ns, SR higher when awake. BP\n 120\ns-140\ns/. LS clear. Sats 99% on NC.\n Right fem. Site d/i. pulses palp.\n Action:\n Lopressor 12.5mg at . also contin. on nifedipine SR daily.\n Integrillin d/c\nd at 0500 per order. Post cath fluids d/c\nd at 0100.\n Response:\n Slept well through night. Wakes easily and w/o CP or other c/o.\n Plan:\n OOB in AM . labs pnd. Transfer to floor\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abd soft/distended. Pos. BS. Denies nausea/pain.\n Action:\n Colace and MOM given. also ordered.\n Response:\n No stool. Slept comfortably and states abd feels better.\n Plan:\n OOB, colace, senna, MOM prn.\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668691,
"text": "Mr. is 74 with hypertension, hyperlipidemia, coronary disease,\n abnormal nuclear stress test in the past and history of remote stroke\n who is trasfered from OSH after presenting with chest pain.\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668571,
"text": "74 year old male tx from outside hospital where he presented with\n substernal chest pain radiation down both arms and up to his jaw,\n associated w/ diaphoresis and palor. Symptoms also include abdominal\n pain and bloating. EKG revealed st depressions inferiorly and was\n treated with aspirin, plavix, IV NTG, heparin, lopressor and morphine.\n ( tropnin .76 )\n Upon presentation to , he complained of chest pain with no\n ekg changes. Pt. was treated with lopressor, morphine, sl nitro and\n Maalox without relief. Pt also continues to c/o bloating. CT of abd +\n for gas only.\n Chest pain\n Assessment:\n Heart rate 80\ns nsr w/ no vea. BP 150-160/80\ns. Heparin 600units/hr\n and NTG 2mcg/kg/min.\n CPK #2/MB/fraction 586/76/13. Troponin up to 0.4 from 0.2. Heparin\n increased to 700units/hr for PTT 40. Labetolol 10mg IV administered w/\n no change in BP.\n NTG dose decreased to 1mcg/kg/min without resolution of pain.\n Continues w/ pain.\n To cath lab at 1030.\n Action:\n BMS placed to TO ramus. R groin closed w/ MINX closure device and is\n d/i. Integrillin 2mcgs/kg/min started in cath lab and continues. IV\n 0.45 NS 100cc/hr started.\n Response:\n Pt tolerated procedure well and is chest pain free post. Pt voiding\n qs. HTN continues post procedure however.\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdoman distended and bloated w/ +bs. Pt c/o nausea.\n CT of abd + for gas. +belching and passing flatus. No stool\n Action:\n Zofran 4mg IV for nausea.\n Response:\n No relief from zofran. Continues to c/o bloating post procedure.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668636,
"text": "74 year old male tx from outside hospital where he presented with\n substernal chest pain radiation down both arms and up to his jaw,\n associated w/ diaphoresis and palor. Symptoms also include abdominal\n pain and bloating. EKG revealed st depressions inferiorly and was\n treated with aspirin, plavix, IV NTG, heparin, lopressor and morphine.\n ( tropnin .76 )\n Upon presentation to , he complained of chest pain with no\n ekg changes. Pt. was treated with lopressor, morphine, sl nitro and\n Maalox without relief. Pt also continues to c/o bloating. CT of abd +\n for gas only.\n Chest pain\n Assessment:\n Heart rate 80\ns nsr w/ no vea. BP 150-160/80\ns. Heparin 600units/hr\n and NTG 2mcg/kg/min.\n CPK #2/MB/fraction 586/76/13. Troponin up to 0.4 from 0.2. Heparin\n increased to 700units/hr for PTT 40. Labetolol 10mg IV administered w/\n no change in BP.\n NTG dose decreased to 1mcg/kg/min without resolution of pain.\n Continues w/ pain.\n To cath lab at 1030.\n Action:\n BMS placed to TO ramus. Pt also w/ diag lesion that was not\n interviened on at this time. R groin closed w/ MINX closure device and\n is d/i. Pulses +2/+3. Integrillin 2mcgs/kg/min started in cath lab and\n continues. IV 0.45 NS 100cc/hr started.\n Response:\n Pt tolerated procedure well and is chest pain free post. Pt voiding\n qs.\n HTN continues post procedure however. Nifedipine xl started at\n 1645.\n Plan:\n Continue cycle enzymes until trending downward, IVF x1000cc,\n integrillin x 18hrs (d/c at 0500), monitor for further cp, monitor r\n groin and pulses for change, Monitor hemodynamics and response to\n nifedipine. Restart lopressor this pm (pt on metoprolol ER at home),\n increase activity as tolerated.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdoman distended and bloated w/ +bs. Pt c/o nausea prior to cath.\n CT of abd + for gas. +belching and passing flatus. No stool.\n Action:\n Zofran 4mg IV for nausea w/ minimal relief.\n Response:\n Nausea relieved post cath, but continues w/ bloating.\n Plan:\n Hydrox/simethicone prn, increase activity to encourage gi motility,\n bowel meds as necessary.\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668558,
"text": "74 year old male tx from outside hospital where he presented with\n substernal chest pain radiation down both arms and up to his jaw,\n associated w/ diaphoresis and palor. Symptoms also include abdominal\n pain and bloating. EKG revealed st depressions inferiorly and was\n treated with aspirin, plavix, IV NTG, heparin, lopressor and morphine.\n ( tropnin .76 )\n Upon presentation to , he complained of chest pain with no\n ekg changes. Pt. was treated with lopressor, morphine, sl nitro and\n Maalox without relief. Pt also continues to c/o bloating. CT of abd +\n for gas only.\n Chest pain\n Assessment:\n Heart rate 80\ns nsr w/ no vea. BP 150-160/80\ns. Heparin 600units/hr\n and NTG 2mcg/kg/min.\n CPK #2/MB/fraction 586/76/13. Troponin up to 0.4 from 0.2\n Action:\n Heparin increased to 700units/hr for PTT 40. Labetolol 10mg IV\n administered w/ no change in BP. NTG dose decreased to 1mcg/kg/min\n without resolution of pain. Continues w/ pain.\n To cath lab at 1030.\n Response:\n Plan:\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdoman distended and bloated w/ +bs. Pt c/o nausea.\n CT of abd + for gas. +belching and passing flatus. No stool\n Action:\n Zofran 4mg IV for nausea.\n Response:\n No relief from zofran\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Cardiology Fellow Admission Note Addendum",
"row_id": 668455,
"text": "TITLE: Cardiology Fellow Admission Note Addendum\n Pt examined, discussed with housestaff.\n 74 yo M w/ h/o HTN, HL, presumed CAD with reported +inf defect on\n stress test, CVA on aggrenox, who afternoon presented with\n indigestion. Pain radiated from abdomen to shoulders and arms,\n decreased w/ 3 SL NTG at home, recurred within an hour without\n response to 3 more SL NTG. At OSH ED, ECG w/ 1 mm horiz to downsloping\n ST depressions inferiorly and V2-V4, CK flat but TnI 0.23. SBP\n 190. Given GI cocktails, ASA 325, plavix 600, NTG gtt, heparin gtt,\n transferred for further evaluation.\n On arrival here after max NTG/heparin, morphine 8 mg, pt still c/o\n abdominal pain, bloating, feeling need to burp/pass gas, waxing and\n , but has never been pain-free. Reports feels better with\n standing/walking/ bending forward. On exam significant right-sided and\n lower abdominal TTP (no guarding/ rebound), which he reports radiates\n to shoulders. Abd mildly distended appearing, obese. Remainder of exam\n unremarkable.\n Plain ECG and R sided and posterior lead ECGs here in SR, without\n significant ST/T wave changes suggestive of ischemia.\n Imp:\n 1. Abdominal pain, reproducible\n 2. Hypertension\n 3. Borderline Tn elevation\n Etiology of abd pain unclear at this point, with wide ddx. Does not\n seem due to coronary ischemia given reproducible TTP on examination,\n indeterminate Tn at OSH, lack of response to NTG gtt, and lack of\n ischemic appearing ECG. Mild Tn elevation seems secondary to abd\n process.\n Plan:\n 1. R/o aortic dissection/AAA with contrast CT chest/abd/pelvis\n 2. Lower suspicion for PE\n 3. R/o other vascular etiology for abd pain, eg venous thrombosis (pt\n w/ h/o DVTs)\n 4. R/o diverticulitis or other GI cause\n 5. Continue to rx HTN medically\n 6. Cycle cardiac biomarkers, if persistently negative may d/c heparin\n 7. Consider further evaluation of coronary disease as outpt if #6\n negative. No plans for cath currently unless sxs or biomarkers change\n dramatically. (Discussed with Dr. .\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 668457,
"text": "Chief Complaint: Chest pain\n HPI:\n Mr. is 74 with hypertension, hyperlipidemia, coronary disease,\n abnormal nuclear stress test in the past and history of remote stroke\n who is trasfered from OSH after presenting with chest pain.\n His pain was substernal, burning and radiated up to his throat. It was\n in severity. The pain was associated with abdominal bloating, and\n burping. He took calcium carbonate at home and had about 15 minutes of\n relief. When the pain returned, he tried more calciumc arbonate and\n again ahd 15 minutes of relief. When the pain returned again, he took 3\n SL NTG. His pain was relieved for about an hour but returned. When the\n pain recurred, he tried SL NTG again, but this time had no relief, so\n asked his wife to drive him to the hospital.\n He reports that the pain is improved by walking around and by bending\n forward while standing. He feels that it is associated with his\n abdominal bloating. He has never had pain like this before, and it is\n not similar to his anginal pain.\n He has been followed by cardiology every six months over the last year\n and a half. Per notes he has had a nuclear stress in 06,\n suggesting disease involving the right coronary circulation. He's had a\n cath in 96, but the results are not known. He has been having\n intermittent anginal symptoms for which he has been using NTG.\n At OSH his vitals were 97.9 80 190/84 20 98RA. His ECG demonstrated\n inferior ST depressions. His troponin I was noted to be elevated (0.74)\n and he was given ASA, NTG, and clopidrogel. His pain improved with\n these interventions. He was not given IIB/IIIA inhibitors. He was noted\n to have guaiac positive stool. His HCT was 42.8, cre 0.8, tropI 0.23,\n CK 172, MB 5.9. INR 1.1. He denies a history of hematochezia or melena\n in the past. In addition he also received zofran, magic mouthwash, NTG\n drip, pantoprazole, lorazepam, morphine and metoprolol.\n Upon arrival, patient was complaining of pain. ECG here showed no\n evidence of ST depression.\n On review of systems, he denies any prior bleeding, myalgias, joint\n pains, cough, hemoptysis, black stools or red stools. He denies recent\n fevers, chills or rigors. He denies exertional buttock or calf pain.\n All of the other review of systems were negative.\n Cardiac review of systems is notable for absence dyspnea on exertion,\n paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Nitroglycerin - 2.1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:15 AM\n Metoprolol - 12:35 AM\n Other medications:\n Aspirin-dipyridamole\n Oxybutynin 5 mg qhs\n Tamsulosin 0.4 mg qam\n Lisinopril 10 mg qhs\n Esomeprazole 40 mg qd\n nitrostat 0.4 mg prn\n Paroxetine 37.5 daily\n Fluvastatin 80 mg per day\n Nifedipine-XL 90 mg daily\n Nabumetone 500mg \n Carafate 2 mg \n Carbamazepine xr 200 mg\n Metoprolol succinate 50 mg daily\n oxycodone/acetaminophen 5/325\n lumigan 0.03% OU\n patanol 0.15\n tobradex prn\n azopt\n refresh tears\n Past medical history:\n Family history:\n Social History:\n orthopedic surgeries complicated by DVT/PE\n hernia repair\n abnormal nuclear stress test with an inferior defect\n normal LV function\n hypertension\n peripheral sensory stroke\n arthritis\n ? being evaluated for gastric mass\n CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n CARDIAC HISTORY: h/o anginal chest pain\n -CABG:\n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD:\n No family history of early MI, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He does not drink or smoke or do drugs\n Review of systems:\n Flowsheet Data as of 01:52 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 91 (91 - 112) bpm\n BP: 139/86(94) {132/86(94) - 193/106(128)} mmHg\n RR: 15 (14 - 22) insp/min\n SpO2: 96%\n Height: 70 Inch\n Total In:\n 52 mL\n PO:\n TF:\n IVF:\n 52 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -248 mL\n Respiratory\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 8cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, TTP with pain radiating to chest wall, reproduced chest\n pain that patient was experiencing duirng the day. No HSM or\n tenderness. Abd aorta not enlarged by palpation. No abdominial bruits.\n no rebound, no rosvigs no mcmurphys. heme+ stool\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 270\n 314\n 0.6\n 14\n 21\n 100\n 3.5\n 134\n 40.6\n 8.6\n [image002.jpg]\n Other labs: D-dimer:792 ng/mL, Ca++:9, Mg++:1.9, PO4:2.6\n Fluid analysis / Other labs: MB: 12\n LDH 271\n Assessment and Plan\n In brief this is a 74 with hypertension, hyperlipidemia, coronary\n disease, abnormal nuclear stress test in the past and history of remote\n stroke who is trasfered from OSH after presenting with chest pain\n # Chest pain: Initial concern for ACS with NSTEMI/troponin leak at OSH.\n At OSH ST depressions in inferior leads, which is consistent with\n reported history of RCA disease by nuclear stress in 06. The ACS/NSTEMI\n hypothesis is somewhat challenged by the normal ECG at . This may\n represent vasospasm but it is unlikely that it would present at such\n old age. His HCT at OSH was 43 (after 2 lt NS) and this precludes\n demand ischemia. Alternatively, this represents a GI problem.\n Possibilities include GI outlet obstruction, epsecially if his history\n of possible gastric mass is confirmed. Early pancreatitis or billiary\n tract disease may be possible. Alternative etiology includes aortic\n disection, since the pain radiates to the back. Pericarditis is remote\n posibility but no prodromal illness and pressentation would be atypical\n of this. Will trend CE and repeat ECG if chest pain. Will check CT\n torsoe with contrast and add d dimer to eval for possibility of\n dissection. Will check LFTs, lipase, and lactate (but no anion gap).\n Will continue continue management for presumed ACS with clopidrogel,\n heparin ggt, asa, nitro ggt. Will monitor.\n # Sinus tachycardia: Most likely related to pain. Will continue to\n monitor. Will give metoprolol prn for HR<100.\n # HTN: Since he initially was noted to have HTN associated with ECG\n changes when presented to OSH, most likely this represents emergency.\n His ECG changes were not present at but he still has CP. Otherwise\n no renal, retinal or CNS involvement. Nitroglycerin ggt for SBP<150.\n Will continue to monitor. Outpatient BP 140-150/80-100\n # Heme postive stool: Ddx includes upper bleed, such as PUD, gastritis,\n avms or lower gi bleed such as diverticular, hemorrhoids, mass etc. No\n history of IBD and this is remote possibility (may be associated with\n arthritis). Will monitor HCT, VS and stool guaiacs overnight. T/S and\n crossmatch two units. Large bore ivs. HCT>30. If active bleed will hold\n UFH, clopidrogel or aspirin.\n # H/O VTE (post surgical DVT, PE): Presenting symptoms are unlikely to\n be related to PE. consider D Dimer if alternative hypothesis dont\n explain CP. DVT ppx with pneumoboots if active bleed or UFH otherwise.\n # FEN: NPO overnight\n # ACCESS: PIVs\n # PROPHYLAXIS: heparin\n # CODE: Full\n # DISPO: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:15 AM\n 20 Gauge - 12:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668605,
"text": "74 year old male tx from outside hospital where he presented with\n substernal chest pain radiation down both arms and up to his jaw,\n associated w/ diaphoresis and palor. Symptoms also include abdominal\n pain and bloating. EKG revealed st depressions inferiorly and was\n treated with aspirin, plavix, IV NTG, heparin, lopressor and morphine.\n ( tropnin .76 )\n Upon presentation to , he complained of chest pain with no\n ekg changes. Pt. was treated with lopressor, morphine, sl nitro and\n Maalox without relief. Pt also continues to c/o bloating. CT of abd +\n for gas only.\n Chest pain\n Assessment:\n Heart rate 80\ns nsr w/ no vea. BP 150-160/80\ns. Heparin 600units/hr\n and NTG 2mcg/kg/min.\n CPK #2/MB/fraction 586/76/13. Troponin up to 0.4 from 0.2. Heparin\n increased to 700units/hr for PTT 40. Labetolol 10mg IV administered w/\n no change in BP.\n NTG dose decreased to 1mcg/kg/min without resolution of pain.\n Continues w/ pain.\n To cath lab at 1030.\n Action:\n BMS placed to TO ramus. Pt also w/ diag lesion that was not\n interviened on at this time. R groin closed w/ MINX closure device and\n is d/i. Pulses +2/+3. Integrillin 2mcgs/kg/min started in cath lab and\n continues. IV 0.45 NS 100cc/hr started.\n Response:\n Pt tolerated procedure well and is chest pain free post. Pt voiding\n qs.\n HTN continues post procedure however. Nifedipine xl started at 1645.\n Plan:\n Continue cycle enzymes until trending downward, IVF x1000cc,\n integrillin x 18hrs (d/c at 0500), monitor for further cp, monitor r\n groin and pulses for change, Monitor hemodynamics and response to\n nifedipine.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdoman distended and bloated w/ +bs. Pt c/o nausea prior to cath.\n CT of abd + for gas. +belching and passing flatus. No stool.\n Action:\n Zofran 4mg IV for nausea w/ minimal relief.\n Response:\n Nausea relieved post cath, but continues w/ bloating.\n Plan:\n Hydrox/simethicone prn, increase activity to encourage gi motility,\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 668548,
"text": "Chief Complaint: Chest pain\n HPI:\n Mr. is 74 with hypertension, hyperlipidemia, coronary disease,\n abnormal nuclear stress test in the past and history of remote stroke\n who is trasfered from OSH after presenting with chest pain.\n His pain was substernal, burning and radiated up to his throat. It was\n in severity. The pain was associated with abdominal bloating, and\n burping. He took calcium carbonate at home and had about 15 minutes of\n relief. When the pain returned, he tried more calciumc arbonate and\n again ahd 15 minutes of relief. When the pain returned again, he took 3\n SL NTG. His pain was relieved for about an hour but returned. When the\n pain recurred, he tried SL NTG again, but this time had no relief, so\n asked his wife to drive him to the hospital.\n He reports that the pain is improved by walking around and by bending\n forward while standing. He feels that it is associated with his\n abdominal bloating. He has never had pain like this before, and it is\n not similar to his anginal pain.\n He has been followed by cardiology every six months over the last year\n and a half. Per notes he has had a nuclear stress in 06,\n suggesting disease involving the right coronary circulation. He's had a\n cath in 96, but the results are not known. He has been having\n intermittent anginal symptoms for which he has been using NTG.\n At OSH his vitals were 97.9 80 190/84 20 98RA. His ECG demonstrated\n inferior ST depressions. His troponin I was noted to be elevated (0.74)\n and he was given ASA, NTG, and clopidrogel. His pain improved with\n these interventions. He was not given IIB/IIIA inhibitors. He was noted\n to have guaiac positive stool. His HCT was 42.8, cre 0.8, tropI 0.23,\n CK 172, MB 5.9. INR 1.1. He denies a history of hematochezia or melena\n in the past. In addition he also received zofran, magic mouthwash, NTG\n drip, pantoprazole, lorazepam, morphine and metoprolol.\n Upon arrival, patient was complaining of pain. ECG here showed no\n evidence of ST depression.\n On review of systems, he denies any prior bleeding, myalgias, joint\n pains, cough, hemoptysis, black stools or red stools. He denies recent\n fevers, chills or rigors. He denies exertional buttock or calf pain.\n All of the other review of systems were negative.\n Cardiac review of systems is notable for absence dyspnea on exertion,\n paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,000 units/hour\n Nitroglycerin - 2.1 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 12:15 AM\n Metoprolol - 12:35 AM\n Other medications:\n Aspirin-dipyridamole\n Oxybutynin 5 mg qhs\n Tamsulosin 0.4 mg qam\n Lisinopril 10 mg qhs\n Esomeprazole 40 mg qd\n nitrostat 0.4 mg prn\n Paroxetine 37.5 daily\n Fluvastatin 80 mg per day\n Nifedipine-XL 90 mg daily\n Nabumetone 500mg \n Carafate 2 mg \n Carbamazepine xr 200 mg\n Metoprolol succinate 50 mg daily\n oxycodone/acetaminophen 5/325\n lumigan 0.03% OU\n patanol 0.15\n tobradex prn\n azopt\n refresh tears\n Past medical history:\n Family history:\n Social History:\n orthopedic surgeries complicated by DVT/PE\n hernia repair\n abnormal nuclear stress test with an inferior defect\n normal LV function\n hypertension\n peripheral sensory stroke\n arthritis\n ? being evaluated for gastric mass\n CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension\n CARDIAC HISTORY: h/o anginal chest pain\n -CABG:\n -PERCUTANEOUS CORONARY INTERVENTIONS:\n -PACING/ICD:\n No family history of early MI, otherwise non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He does not drink or smoke or do drugs\n Review of systems:\n Flowsheet Data as of 01:52 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 91 (91 - 112) bpm\n BP: 139/86(94) {132/86(94) - 193/106(128)} mmHg\n RR: 15 (14 - 22) insp/min\n SpO2: 96%\n Height: 70 Inch\n Total In:\n 52 mL\n PO:\n TF:\n IVF:\n 52 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -248 mL\n Respiratory\n SpO2: 96%\n ABG: ///21/\n Physical Examination\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 8cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, TTP with pain radiating to chest wall, reproduced chest\n pain that patient was experiencing duirng the day. No HSM or\n tenderness. Abd aorta not enlarged by palpation. No abdominial bruits.\n no rebound, no rosvigs no mcmurphys. heme+ stool\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 270\n 314\n 0.6\n 14\n 21\n 100\n 3.5\n 134\n 40.6\n 8.6\n [image002.jpg]\n Other labs: D-dimer:792 ng/mL, Ca++:9, Mg++:1.9, PO4:2.6\n Fluid analysis / Other labs: MB: 12\n LDH 271\n Assessment and Plan\n In brief this is a 74 with hypertension, hyperlipidemia, coronary\n disease, abnormal nuclear stress test in the past and history of remote\n stroke who is trasfered from OSH after presenting with chest pain\n # Chest pain: Initial concern for ACS with NSTEMI/troponin leak at OSH.\n At OSH ST depressions in inferior leads, which is consistent with\n reported history of RCA disease by nuclear stress in 06. The ACS/NSTEMI\n hypothesis is somewhat challenged by the normal ECG at . This may\n represent vasospasm but it is unlikely that it would present at such\n old age. His HCT at OSH was 43 (after 2 lt NS) and this precludes\n demand ischemia. Alternatively, this represents a GI problem.\n Possibilities include GI outlet obstruction, epsecially if his history\n of possible gastric mass is confirmed. Early pancreatitis or billiary\n tract disease may be possible. Alternative etiology includes aortic\n disection, since the pain radiates to the back. Pericarditis is remote\n posibility but no prodromal illness and pressentation would be atypical\n of this. Will trend CE and repeat ECG if chest pain. Will check CT\n torsoe with contrast and add d dimer to eval for possibility of\n dissection. Will check LFTs, lipase, and lactate (but no anion gap).\n Will continue continue management for presumed ACS with clopidrogel,\n heparin ggt, asa, nitro ggt. Will monitor.\n # Sinus tachycardia: Most likely related to pain. Will continue to\n monitor. Will give metoprolol prn for HR<100.\n # HTN: Since he initially was noted to have HTN associated with ECG\n changes when presented to OSH, most likely this represents emergency.\n His ECG changes were not present at but he still has CP. Otherwise\n no renal, retinal or CNS involvement. Nitroglycerin ggt for SBP<150.\n Will continue to monitor. Outpatient BP 140-150/80-100\n # Heme postive stool: Ddx includes upper bleed, such as PUD, gastritis,\n avms or lower gi bleed such as diverticular, hemorrhoids, mass etc. No\n history of IBD and this is remote possibility (may be associated with\n arthritis). Will monitor HCT, VS and stool guaiacs overnight. T/S and\n crossmatch two units. Large bore ivs. HCT>30. If active bleed will hold\n UFH, clopidrogel or aspirin.\n # H/O VTE (post surgical DVT, PE): Presenting symptoms are unlikely to\n be related to PE. consider D Dimer if alternative hypothesis dont\n explain CP. DVT ppx with pneumoboots if active bleed or UFH otherwise.\n # FEN: NPO overnight\n # ACCESS: PIVs\n # PROPHYLAXIS: heparin\n # CODE: Full\n # DISPO: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:15 AM\n 20 Gauge - 12:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I reviewed his admission and tests.examined Pt.\n Agree with Dr. notes.\n Agree with plan of treatment.\n Spent 45 mins over case.\n \n ------ Protected Section Addendum Entered By: \n on: 11:04 ------\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668479,
"text": "Received this 74 year old male from an outside hospital where he\n presented with substernal chest pain with radiation down both arms and\n up to his jaw. He was diaphoretic and pale, with accompanying\n abdominal pain and bloating. EKG revealed st depressions inferiorly\n and was treated with aspirin, plavix, nitro and heparin lopressor and\n morphine. ( tropnin .76 ) Upon presentation to , he complained\n of chest pain with no ekg changes . He was treated with lopressor,\n morphine sl nitro and Maalox.\n Chest pain\n Assessment:\n Heart rate 100-110 sinus tach . SBP 190/100. Chest pain \n Action:\n Lopressor 10mg, morphine 2 mg, Maalox and titration of iv nitro to 3.5\n mcgs/kg EKG non-ischemic\n Response:\n Painfree\n Plan:\n Cycle cardiac enzymes and monitor for further chest pain\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abdoman distended and bloated. Patient unable to fasten pants.\n Positive belching. Patient reports normal bowel movement on \n Action:\n Baricat prep in progress\n Response:\n Tolerating prep\n Plan:\n Abd/Chest ct to rule out ischemic bowel/AAA\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 668764,
"text": "74 yo M w/ h/o HTN, HL, presumed CAD with reported +inf defect on\n stress test, CVA on aggrenox, who afternoon presented with\n indigestion. Pain radiated from abdomen to shoulders and arms,\n decreased first with antacids, then recurred and pt. took 3 SL NTG at\n home. At OSH ED, ECG w/ 1 mm horiz to downsloping ST depressions\n inferiorly and V2-V4, CK flat but TnI 0.23. SBP 190. Given GI\n cocktails, ASA 325, plavix 600, NTG gtt, heparin gtt, transferred for\n further evaluation.\n On arrival here after max NTG/heparin, morphine 8 mg, pt still c/o\n abdominal pain, bloating, feeling need to burp/pass gas, waxing and\n , but was never pain-free. Pt. reported feeling better with\n standing/walking/ bending forward. Abd. exam was significant for\n distention/bloating. CT was essentially negative, revealing only\ngas.\n Plain ECG and R sided and posterior lead ECGs here in SR, without\n significant ST/T wave changes suggestive of ischemia.\n Pt. to cath lab - BMS placed to TO ramus. Pt also w/ diag lesion\n that was not interviened on at this time. R groin closed w/ MINX\n closure device and is d/i. Pulses +2/+3. Integrillin 2mcgs/kg/min\n started in cath lab and d/c\nd this early a.m. CK\ns trending downwards\n this a.m.\n Non STEMI\n Assessment:\n VSS\n HR 70-90 SR no ectopy. SBP 110\ns. Skin warm, dry. Right groin\n PCI site wnl, dsd intact, distal circulation adequate. No complaints.\n LS dim bibasilar. Abd. remains distended, but pt. had guiaic negative\n loose BM this a.m.\n Action:\n MI packet given. Pt. weaned to RA. OOB to chair. Pt. presently on\n bowel regimen.\n Response:\n Pt. remains stable. Verbalizes understanding of packet information.\n Abd. remains distended, but pt. only complains of mild\nbloating.\n Plan:\n Continue education. To 3 this afternoon. Possible d/c tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 668774,
"text": "74 yo M w/ h/o HTN, HL, presumed CAD with reported +inf defect on\n stress test, CVA on aggrenox, who afternoon presented with\n indigestion. Pain radiated from abdomen to shoulders and arms,\n decreased first with antacids, then recurred and pt. took 3 SL NTG at\n home. At OSH ED, ECG w/ 1 mm horiz to downsloping ST depressions\n inferiorly and V2-V4, CK flat but TnI 0.23. SBP 190. Given GI\n cocktails, ASA 325, plavix 600, NTG gtt, heparin gtt, transferred for\n further evaluation.\n On arrival here after max NTG/heparin, morphine 8 mg, pt still c/o\n abdominal pain, bloating, feeling need to burp/pass gas, waxing and\n , but was never pain-free. Pt. reported feeling better with\n standing/walking/ bending forward. Abd. exam was significant for\n distention/bloating. CT was essentially negative, revealing only\ngas.\n Plain ECG and R sided and posterior lead ECGs here in SR, without\n significant ST/T wave changes suggestive of ischemia.\n Pt. to cath lab - BMS placed to TO ramus. Pt also w/ diag lesion\n that was not interviened on at this time. R groin closed w/ MINX\n closure device and is d/i. Pulses +2/+3. Integrillin 2mcgs/kg/min\n started in cath lab and d/c\nd this early a.m. CK\ns trending downwards\n this a.m.\n Non STEMI\n Assessment:\n VSS\n HR 70-90 SR no ectopy. SBP 110\ns. Skin warm, dry. Right groin\n PCI site wnl, dsd intact, distal circulation adequate. No complaints.\n LS dim bibasilar. Abd. remains distended, but pt. had guiaic negative\n loose BM this a.m.\n Action:\n MI packet given. Pt. weaned to RA. OOB to chair. Pt. presently on\n bowel regimen.\n Response:\n Pt. remains stable. Tolerating chair. Verbalizes understanding of\n packet information. Abd. remains distended, but pt. only complains of\n mild\nbloating.\n Pt. had second BM this afternoon.\n Plan:\n Continue education. To 3 this afternoon. Possible d/c tomorrow.\n Demographics\n Attending MD:\n I.\n Admit diagnosis:\n MYOCARDIAL INFARCT\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 76 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown;\n Aspirin\n gi upset;\n Precautions:\n PMH: Seizures\n CV-PMH: CAD, CVA, Hypertension\n Additional history: orthopedic surgeries complicated by DVT/PE\n hernia repair\n abnormal stress testwith an inferior defect..normal LV function\n hypertension\n peripheral sensory stroke\n Le arthritis\n Surgery / Procedure and date: CATH \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:104\n D:60\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 301 mL\n 24h total out:\n 850 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:07 AM\n Potassium:\n 4.1 mEq/L\n 05:07 AM\n Chloride:\n 102 mEq/L\n 05:07 AM\n CO2:\n 28 mEq/L\n 05:07 AM\n BUN:\n 15 mg/dL\n 05:07 AM\n Creatinine:\n 0.8 mg/dL\n 05:07 AM\n Glucose:\n 113 mg/dL\n 05:07 AM\n Hematocrit:\n 37.0 %\n 05:07 AM\n Finger Stick Glucose:\n 135\n 10:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Lower )\n Other valuables: robe, toiletries\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: watch, wedding band, medical bracelet - pt. wearing all\n Transferred from: CCU 619\n Transferred to: 320\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 668702,
"text": "Mr. is 74 with hypertension, hyperlipidemia, coronary disease,\n abnormal nuclear stress test in the past and history of remote stroke\n who is trasfered from OSH after presenting with chest pain.\n At OSH his vitals were 97.9 80 190/84 20 98RA. His ECG demonstrated\n inferior ST depressions. His troponin I was noted to be elevated (0.74)\n and he was given ASA, NTG, and clopidrogel\n Trop was elevated to .4 on AM of and pt. went to cath lab at\n 1030.\n BMS placed to TO ramus. Pt also w/ diag lesion that was not\n interviened on at this time. R groin closed w/ MINX closure device\n Nifedipine was restarted as was lopressor po post cath.\n Chest pain\n Assessment:\n Overnight, no c/o CP, SOB. HR 80\ns-90\ns, SR higher when awake. BP\n 120\ns-140\ns/. LS clear. Sats 99% on NC.\n Right fem. Site d/i. pulses palp.\n Action:\n Lopressor 12.5mg at . also contin. on nifedipine SR daily.\n Integrillin d/c\nd at 0500 per order. Post cath fluids d/c\nd at 0100.\n Response:\n Slept well through night. Wakes easily and w/o CP or other c/o.\n Plan:\n OOB in AM . labs pnd. Follow CK as it was trending up post cath.\n .H/O abdominal pain (including abdominal tenderness)\n Assessment:\n Abd soft/distended. Pos. BS. Denies nausea/pain. CT positive for\n gas.\n Action:\n Colace and MOM given. also ordered. Simethicone prn.\n Response:\n No stool. Slept comfortably and states abd feels better.\n Plan:\n OOB, colace, senna, MOM prn.\n"
},
{
"category": "Echo",
"chartdate": "2196-05-18 00:00:00.000",
"description": "Report",
"row_id": 86208,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease. Hypertension. Left ventricular function. Right ventricular function.\nHeight: (in) 67\nWeight (lb): 158\nBSA (m2): 1.83 m2\nBP (mm Hg): 139/86\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. Diastolic function could not be assessed. No resting\nLVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanterolateral - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is mild regional left ventricular\nsystolic dysfunction with mid to distal lateral segments. Diastolic function\ncould not be assessed. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. No mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Mild symmetric LVH. Mild focal LV hypokinesis consistent with\nischemia/infarction. Trace aortic regurgitation. Mild pulmonary artery\nsystolic hypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Report",
"row_id": 217223,
"text": "Sinus rhythm\nBorderline left axis deviation\nDelayed R wave progression suggests prior septal myocardial infarction\nST-T wave abnormalities raises the consideration of lateral ischemia injury\nClinical correlation is suggested\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Report",
"row_id": 217224,
"text": "Sinus rhythm\nBorderline left axis deviation\nDelayed R wave progression suggests prior septal myocardial infarction\nST-T wave abnormalities raises the consideration of lateral ischemia injury\nClinical correlation is suggested\nSince previous tracing of the same date, probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Report",
"row_id": 216993,
"text": "Sinus rhythm\nBorderline left axis deviation\nDelayed R wave progression suggests prior septal myocardial infarction\nST-T wave abnormalities raises the consideration of lateral ischemia injury\nClinical correlation is suggested\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2196-05-16 00:00:00.000",
"description": "Report",
"row_id": 217225,
"text": "Artifact is present. Sinus rhythm. There are Q waves in the anterior leads\nconsistent with possible prior anterior myocardial infarction. Non-specific\nST-T wave changes. Compared to the previous tracing there is no significant\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2196-05-15 00:00:00.000",
"description": "Report",
"row_id": 217226,
"text": "Sinus rhythm. There are tiny R waves in the anterior leads consistent with\npossible prior myocardial infarction. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-05-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1072895,
"text": " 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT PELVIS W&W/O C\n Reason: please evaluate for aneurismal disease\n Admitting Diagnosis: MYOCARDIAL INFARCT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with chest pain and abdominal pain radiating to shoulders.\n REASON FOR THIS EXAMINATION:\n please evaluate for aneurismal disease\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLKb MON 12:20 PM\n No aortic dissection. Aorta is normal in size. Left kidney is smaller than\n right. Celiac artery is narrowed at origin, with post stenotic dilatation..\n Coronary artery calcifications.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old male with chest pain and abdominal pain which radiates\n to shoulders. Please evaluate for aneurysmal disease.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT of the chest, abdomen and pelvis was obtained before and\n after administration of intravenous contrast. Images were reformatted in the\n axial, sagittal and coronal planes.\n\n FINDINGS:\n\n CT OF THE CHEST: Thoracic aorta is normal in size, with ascending aorta\n measuring 31 mm at the level of the right main pulmonary artery. At the same\n level the descending aorta measures 26 mm. Presence of coronary artery\n calcifications.\n\n There is no evidence of aortic dissection. No evidence of pulmonary embolism.\n Please note that there are two areas with apparent filling defect (3:56, 60)\n that correspond to partial volumes from branching, confirmed in the sagittal\n and coronal views. Presence of linear atelectasis in lung bases. Heart size\n is within normal limits. There is no pericardial or pleural effusion. No\n pathologically enlarged mediastinal or hilar lymph nodes. Visualized portions\n of the airways are patent to the subsegmental levels bilaterally.\n\n CT ABDOMEN AND PELVIS: Abdominal aorta is normal in size, present with\n minimal atherosclerotic calcifications and mural plaques. The origin of the\n celiac trunk is narrowed, presenting with a post-stenotic dilatation. The\n renal arteries, superior and inferior mesenteric arteries are widely patent.\n\n The liver, gallbladder, spleen, pancreas, adrenal glands are unremarkable. The\n kidneys enhance and excrete contrast symmetrically. The left kidney is\n smaller than the right (left kidney measures up to 87 mm and the right kidney\n measures up to 125 mm in the sagittal view). Normal-sized bowel loops with\n oral contrast in its interior. Urinary bladder is unremarkable. Prostate gland\n measures 54 x 46 mm and presents with gross calcifications. Visualized\n (Over)\n\n 7:15 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CTA ABD W&W/O C & RECONSClip # \n CT PELVIS W&W/O C\n Reason: please evaluate for aneurismal disease\n Admitting Diagnosis: MYOCARDIAL INFARCT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n portions of the iliac arteries are widely patent.\n\n There is no free fluid. No pathologically enlarged mediastinal or\n retroperitoneal lymph nodes.\n\n BONE WINDOWS: Degenerative changes and Schmorl's nodes are noted in the\n spine. A 6-mm air containing lesion noted in the left sacrum adjacent to the\n left sacroiliac joint, corresponds to an intraosseous pneumtocyst, and does\n not have clinical significance.\n\n IMPRESSION:\n 1. Normal-sized aorta. Minimal atherosclerotic disease in the normal-sized\n aorta. Narrowing calcification at the origin of the celiac trunk causing\n narrowing and post-stenotic dilatation.\n 2. Coronary artery calcifications.\n\n\n\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 668727,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - Cath: Pt had TO of Ramus BMS placed.\n - Wrote for home nifedipine, will start metoprolol if blood pressures\n do not come down appropriately\n - CK increased to 1400\n Allergies:\n Penicillins\n Unknown;\n Aspirin\n gi upset;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:06 AM\n Labetalol - 09:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 80 (74 - 105) bpm\n BP: 118/66(78) {92/64(73) - 165/124(131)} mmHg\n RR: 11 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,974 mL\n 61 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 1,474 mL\n 61 mL\n Blood products:\n Total out:\n 3,475 mL\n 500 mL\n Urine:\n 3,475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -501 mL\n -439 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 8cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, TTP with pain radiating to chest wall, reproduced chest\n pain that patient was experiencing duirng the day. No HSM or\n tenderness. Abd aorta not enlarged by palpation. No abdominial bruits.\n no rebound, no rosvigs no mcmurphys. heme+ stool\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 238 K/uL\n 13.2 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.2 %\n 11.6 K/uL\n [image002.jpg]\n 09:00 AM\n 05:14 PM\n WBC\n 11.6\n Hct\n 37.2\n Plt\n 269\n 238\n Cr\n 0.7\n TropT\n 0.40\n Glucose\n 138\n Other labs: PT / PTT / INR:13.4/40.0/1.1, CK / CKMB /\n Troponin-T:1465/179/0.40, D-dimer:792 ng/mL, Lactic Acid:1.7 mmol/L,\n Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n In brief this is a 74 with hypertension, hyperlipidemia, coronary\n disease, abnormal nuclear stress test in the past and history of remote\n stroke who is trasfered from OSH after presenting with chest pain\n # Chest pain: ACS with chath + for 70% LAD and total occlusion of\n ramus. CK at 1400. BMS at ramus with improvement in symptoms and CK\n trending down. On asa, clopidrogel, heparin, atorvastatin,\n eptifibatide. Consider starting home ace/bb if pressure tolerates. Off\n nitro ggt. Consider ECHO to eval for wall motion abnormalities and EF.\n # HTN: Better control during the day yesterday.\n # Heme postive stool: no evidence of bleeding. Hct stable.\n # H/O VTE (post surgical DVT, PE): on heparin ggt\n # FEN: NPO overnight\n # ACCESS: PIVs\n # PROPHYLAXIS: heparin\n # CODE: Full\n # DISPO: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:15 AM\n 20 Gauge - 12:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2196-05-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 668745,
"text": "Chief Complaint:\n 24 Hour Events:\n :\n - Cath: Pt had TO of Ramus BMS placed.\n - Wrote for home nifedipine, will start metoprolol if blood pressures\n do not come down appropriately\n - CK increased to 1400\n Allergies:\n Penicillins\n Unknown;\n Aspirin\n gi upset;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:06 AM\n Labetalol - 09:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.3\n HR: 80 (74 - 105) bpm\n BP: 118/66(78) {92/64(73) - 165/124(131)} mmHg\n RR: 11 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,974 mL\n 61 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 1,474 mL\n 61 mL\n Blood products:\n Total out:\n 3,475 mL\n 500 mL\n Urine:\n 3,475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n -501 mL\n -439 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 8cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n rhonchi.\n ABDOMEN: Soft, TTP with pain radiating to chest wall, reproduced chest\n pain that patient was experiencing duirng the day. No HSM or\n tenderness. Abd aorta not enlarged by palpation. No abdominial bruits.\n no rebound, no rosvigs no mcmurphys. heme+ stool\n EXTREMITIES: No c/c/e. No femoral bruits.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 238 K/uL\n 13.2 g/dL\n 138 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 12 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.2 %\n 11.6 K/uL\n [image002.jpg]\n 09:00 AM\n 05:14 PM\n WBC\n 11.6\n Hct\n 37.2\n Plt\n 269\n 238\n Cr\n 0.7\n TropT\n 0.40\n Glucose\n 138\n Other labs: PT / PTT / INR:13.4/40.0/1.1, CK / CKMB /\n Troponin-T:1465/179/0.40, D-dimer:792 ng/mL, Lactic Acid:1.7 mmol/L,\n Ca++:9.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n In brief this is a 74 with hypertension, hyperlipidemia, coronary\n disease, abnormal nuclear stress test in the past and history of remote\n stroke who is trasfered from OSH after presenting with chest pain\n # Chest pain: ACS with chath + for 70% LAD and total occlusion of\n ramus. CK at 1400. BMS at ramus with improvement in symptoms and CK\n trending down. On asa, clopidrogel (x9mo for noted MI), atorvastatin,\n eptifibatide. Consider starting home ace/bb if pressure tolerates. Off\n nitro ggt. Consider ECHO to eval for wall motion abnormalities and EF.\n # HTN: Better control during the day yesterday. Nifedipine, metoprolol.\n # Heme postive stool: no evidence of bleeding. Hct stable.\n # H/O VTE (post surgical DVT, PE): on heparin ggt\n # FEN: NPO overnight\n # ACCESS: PIVs\n # PROPHYLAXIS: heparin\n # CODE: Full\n # DISPO: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:15 AM\n 20 Gauge - 12:15 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
}
] |
9,710 | 185,394 | 1. Foot Ulcers She was initially admitted to the podiatry service on for debridement of left foot wound. She was evaluated by vascular surgery who performed right side angiography, revealing significant SFA and popliteal disease which was not intervened upon. She was covered with cipro/flagyl/vanco (Day 1 = ), and remained afebrile without leukocytosis throughout her hospital course. She was then transitioned to bactrim to complete a 2 week course of outpatient therapy, last day . She will be following up in 1 week with Dr. . She will have home VNA for assistance with daily dressing changes. 2. Seizures She was to be discharged to home with TMP/SMX and then follow-up with podiatry in one week. On the morning of likely discharge while eating breakfast, she asked to be transferred to the comode to pass a BM. On the comode she describes acute onset of nausea and weakness. She then was witnessed to have multiple, recurrent brief episodes of "staring spells" during which she was unresponsive. In between these episodes she responded appropriately to voice. Based on concern for seizures, she was given ativan 1mg x 2 without response. Neurology consult was obtained who described persistant complex partial status, and recommended ativan 2mg x 1 with subsequent dilantin loading. The pt remained in status for ~30-45 min. By report, during the episode, her O2 sats dropped to 79%RA, but BP was stable. Post event, transfer note indicates VS 98.8 109/68 92 14 98%3L. Immediately after her the seizures, pt was with the above vital signs, sitting up in bed, somnolent, responsive to voice. Her somnolence intermittently resolved, notably upon the arrival of her PCP whom she recognized and spoke with. MICU transfer was requested in the setting of persistent complex partial status for closer airway monitoring and for evaluation of potential contribution by patient's multiple medical conditions. Etiology of her seizures was thought likely related to poorly controlled seizures, further triggered by infection and decreased seizure threshold in the setting of quinolone therapy. On the floor, she remained seizure free. She refused EEG as recommended by Neuro. She was started on Zonegram per Neuro in addition to her home Carbamazepine. IV Dilantin was discontinued. CT Head was negative for bleed. She was resumed on her home coumadin. Pt has an appt scheduled with neuro for follow-up with Dr. , given limited availability of appts with Dr. . She was given the number to call to check for cancellations with Dr. . . #. h/o DVT Pt had been transitioned off coumadin in anticipation of wound debridgement/surgical intervention. She was resumed on Coumadin with Lovenox bridge after CT Head negative for bleed. She was discharged home on her home coumadin dose (no Lovenox bridge, with hx of remote and fully treated DVT), with INR to be checked and followed by the clinic. . # Transaminitis. New on AM labs (but no LFTs done prior in admission). Etiology unclear - ?new drug effect. Seems soon for dilantin (within ~1 hour). Cipro a rare cause; should not be flagyl or vanco related. No rash or other evidence of drug reaction. Could also possibly be related to anesthesia meds during angiography. Atorvastatin was held and will be re-evaluated for resumption as outpatient. On day of discharge transaminitis had resolved. Further etiology will be evaluated as outpatient. . # Elevated lipase: unclear etiology. Appears to have remained chronically elevated over past few years. Pt otherwise asymptomatic. Will be followed up further as outpatient. . # Deconditioning: pt with difficulty transferring from bed to commode/wheelchair, which improved during her stay. | Neurology consult was obtained who described persistant complex partial status, and recommended ativan 2mg x 1 with subsequent dilantin loading. Neurology consult was obtained who described persistant complex partial status, and recommended ativan 2mg x 1 with subsequent dilantin loading. Neurology consult was obtained who described persistent complex partial status, and recommended ativan 2mg x 1 with subsequent Dilantin loading. Neurology consult was obtained who described persistent complex partial status, and recommended ativan 2mg x 1 with subsequent Dilantin loading. - continue lovenox - transition to coumadin once head CT performed . - continue lovenox - transition to coumadin once head CT performed . Stroke and recurrent TIAs, on Plavix 11. Stroke and recurrent TIAs, on Plavix 11. Sinus rhythm with borderline 1st degree A-V blockPossible left anterior fascicular blockNonspecific intraventricular conduction delayPoor R wave progressionSince previous tracing of , sinus tachycardia absent Trazodone 25mg PO qhs prn insomnia 16. Trazodone 25mg PO qhs prn insomnia 16. 2+edema, stasis changes. Sarcoidosis - diagnosed on hilar node biopsy in ; quiescent in recent past 3. ? Sarcoidosis - diagnosed on hilar node biopsy in ; quiescent in recent past 3. ? Albuterol nebs prn 2. Albuterol nebs prn 2. Post event, transfer note indicates VS 98.8 109/68 92 14 98%3L. Post event, transfer note indicates VS 98.8 109/68 92 14 98%3L. Seizure, with status epilepticus Assessment: From following multiple brief episodes of absence seizures, post 4mg ativan, 1000mg Dilantin load. Seizure, with status epilepticus Assessment: From following multiple brief episodes of absence seizures, post 4mg ativan, 1000mg Dilantin load. - start bactrim - appreciate podiatry recs - outpatient podiatry follow-up . - start bactrim - appreciate podiatry recs - outpatient podiatry follow-up . Head CT ordered. Head CT ordered. Fluticasone 4400mcg puffs 7. Fluticasone 4400mcg puffs 7. BLE dressings c/d/i. DVT/PE - , completed course of anticoagulation 8. DVT/PE - , completed course of anticoagulation 8. Carbamazepine 200mg PO qid 4. Carbamazepine 200mg PO qid 4. Exam notable for Tm 97.9 BP 130/70 HR 80 RR 18 with sat 97 on RA. Will continue lovenox for DVT/PE. - continue beta blocker, ACEI, plavix - restart atorvastatin - continue nitrate for further afterload reduction ICU Care Nutrition: diabetic diet Glycemic Control: Lines: 22 Gauge - 12:20 PM 18 Gauge - 03:00 PM Prophylaxis: DVT: anticoagulated on lovenox Stress ulcer: not indicated VAP: not indicated Comments: Communication: Comments: Patient, Daughter status: FULL CODE Disposition: ICU for now ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. Surgery / Procedure and date: remote hx c-section. On the floor, pt is intermittently somnolent consistent with post-ictal state. On the floor, pt is intermittently somnolent consistent with post-ictal state. Phenytoin 100mg IV q8h . Phenytoin 100mg IV q8h . Vicodin prn 10. Vicodin prn 10. Diphenhydramine 25mg PO q6h prn itch 18. Diphenhydramine 25mg PO q6h prn itch 18. Vancomycin 1250mg IV q12h 21. Vancomycin 1250mg IV q12h 21. Based on concern for seizures, she was given ativan 1mg x 2 without response. Based on concern for seizures, she was given ativan 1mg x 2 without response. Based on concern for seizures, she was given ativan 1mg x 2 without response. Based on concern for seizures, she was given ativan 1mg x 2 without response. The only documented vitals prior to the event were at 0800 98.8 156/75 87 20 97%RA. The only documented vitals prior to the event were at 0800 98.8 156/75 87 20 97%RA. - continue beta blocker, ACEI, plavix - restart atorvastatin - continue nitrate for further afterload reduction ICU Care Nutrition: diabetic diet Glycemic Control: Lines: 22 Gauge - 12:20 PM 18 Gauge - 03:00 PM Prophylaxis: DVT: anticoagulated on lovenox Stress ulcer: not indicated VAP: not indicated Comments: Communication: Comments: Patient, Daughter status: FULL CODE Disposition: ICU for now Will initiate bactrim for LE infection / ulcers; cipro may well have lowered her seizure threshold during this admission. multiple sclerosis, s/p several laminectomies 2. multiple sclerosis, s/p several laminectomies 2. NPH 70 units q AM / 40 units q PM Allergies: Aspirin upset stomach w Reglan (Oral) (Metoclopramide Hcl) facial swelling Quinine Sulfate Hives; Codeine Unknown; Augmentin (Oral) (Amox Tr/Potassium Clavulanate) Nausea/Vomiting Clindamycin Nausea/Vomiting Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: TRANSFER MEDICATIONS: 1. | 10 | [
{
"category": "Physician ",
"chartdate": "2167-07-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 376996,
"text": "Chief Complaint: status epilepticus\n HPI:\n 61yo female with history of partial complex seizures, multiple\n sclerosis, and quadraparesis of unclear etiology was admitted to the\n MICU for evaluation of status epilepticus in the setting of hospital\n admission for nonhealing ulcers.\n .\n She was initially admitted to the podiatry service on for\n debridement of left foot wound. She was evaluated by vascular surgery\n who performed right side angiography, revealing significant SFA and\n popliteal disease which was not intervened upon. She was covered with\n cipro/flagyl/vanco (Day 1 = ), and remained afebrile without\n leukocytosis throughout her hospital course.\n .\n On the morning of transfer, she was to be discharged to home with\n TMP/SMX and then follow-up with podiatry in one week. On the morning of\n transfer at ~8:45 while eating breakfast, she asked to be transferred\n to the comode to pass a BM. On the comode she describes acute onset of\n nausea and weakness. She then was witnessed to have multiple,\n recurrent brief episodes of \"staring spells\" during which she was\n unresponsive. In between these episodes she responded appropriately to\n voice. Based on concern for seizures, she was given ativan 1mg x 2\n without response. Neurology consult was obtained who described\n persistant complex partial status, and recommended ativan 2mg x 1 with\n subsequent dilantin loading. The pt remained in status for ~30-45 min.\n .\n The only documented vitals prior to the event were at 0800 98.8 156/75\n 87 20 97%RA. By report, during the episode, her O2 sats dropped to\n 79%RA, but BP was stable. Post event, transfer note indicates VS 98.8\n 109/68 92 14 98%3L. Immediately after her the seizures, pt was with\n the above vital signs, sitting up in bed, somnolent, responsive to\n voice. Her somnolence intermittently resolved, notably upon the\n arrival of her PCP whom she recognized and spoke with. MICU transfer\n was requested in the setting of persistent complex partial status for\n closer airway monitoring and for evaluation of potential contribution\n by patient's multiple medical conditions.\n .\n On the floor, pt is intermittently somnolent consistent with post-ictal\n state. At other times she is easily arousable, and A&Ox3. She denies\n chest pain, dyspnea, n/v, abdominal pain, fevers, shaking chills, night\n sweats, cough, sputum production.\n HOME MEDICATIONS:\n 1. Albuterol nebs prn\n 2. Atorvastatin 80mg PO daily\n 3. Carbamazepine 200mg PO qid\n 4. Cephalexin 500mg PO qid (Day 1 - , 10 day course)\n 5. Clopidogrel 75mg PO bid\n 6. Fluticasone 4400mcg puffs \n 7. Vicodon tab qid\n 8. Imdur 90mg PO daily\n 9. Lisinopril 5mg PO daily\n 10. Metoprolol Succinate 200mg PO daily\n 11. Nitroglycerin prn\n 12. Ranitidine 150mg daily\n 13. Tramadol 50mg PO qid\n 14. Warfarin 5mg PO daily\n 15. Acetaminophen 650mg PO q6-8h prn headache\n 16. Regular insulin 15 units q AM / 10 units q PM\n 17. NPH 70 units q AM / 40 units q PM\n Allergies:\n Aspirin\n upset stomach w\n Reglan (Oral) (Metoclopramide Hcl)\n facial swelling\n Quinine Sulfate\n Hives;\n Codeine\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Clindamycin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDICATIONS:\n 1. Acetaminophen 325-650mg PO q6h prn fever\n 2. Lisinopril 5mg PO daily\n 3. Metoprolol Succinate 200mg PO daily\n 4. Clopidogrel 75mg PO daily\n 5. Isosorbide Mononitrate 90mg PO daily\n 6. Tramadol 50mg PO qid\n 7. Carbamazepine 200mg PO qid\n 8. Ranitidine 150mg PO daily\n 9. Vicodin prn\n 10. Senna 1 tab PO bid\n 11. Docusate 100mg PO bid\n 12. Metronidazole 500mg PO q8h\n 13. Ciprofloxacin 750mg PO q12h\n 14. Bisacodyl 10mg daily\n 15. Trazodone 25mg PO qhs prn insomnia\n 16. Zofran 4mg IV q8h prn nausea / vomiting\n 17. Diphenhydramine 25mg PO q6h prn itch\n 18. Insulin\n 19. Lovenox 130mg SC q12h\n 20. Vancomycin 1250mg IV q12h\n 21. Coumadin\n 22. Phenytoin 100mg IV q8h\n .\n Past medical history:\n Family history:\n Social History:\n 1. Quadriparesis\n - worse legs than arms, related to multiple level degenerative spine\n disease with spinal stenosis and ? multiple sclerosis, s/p several\n laminectomies\n 2. Sarcoidosis\n - diagnosed on hilar node biopsy in ; quiescent in recent past\n 3. ? Multiple sclerosis\n - repeated MRIs showing small atypical lesions, sometimes read as\n small vessel disease vs demyelinating process\n 4. Diabetes Mellitus\n 5. Reactive airways disease\n 6. Hypertension, in good control\n 7. DVT/PE\n - , completed course of anticoagulation\n 8. Recurrent cutaneous infections related to DM and\n lack of sensation distally, bacteremic with buttock abscess in\n \n 9. Neuropathic pain\n 10. Stroke and recurrent TIAs, on Plavix\n 11. Seizure disorder\n - followed by Dr. , on carbamazepine\n 12. Endometrial carcinoma s/p TAH/BSO\n 13. Several laminectomies, abscess I & D without anesthetic\n complications.\n 14. Hand surgery .\n 15. Coronary Artery Disease\n - s/p cardiac catheterization and RCA stent placement in \n noncontributory\n Occupation: retired nurse\n Drugs: denies\n Tobacco: 70 PPY history\n Alcohol: denies, history of alcohol abuse\n Other: Home: lives with daughter in \n Review of systems:\n Flowsheet Data as of 05:58 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 82 (76 - 85) bpm\n BP: 116/49(66) {102/46(61) - 127/61(75)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 357 mL\n PO:\n TF:\n IVF:\n 357 mL\n Blood products:\n Total out:\n 0 mL\n 1,045 mL\n Urine:\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -688 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General: Alert, oriented X 3, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: obese, soft, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly\n Ext: bilaterally feet are wrapped\n Labs / Radiology\n Fluid analysis / Other labs: \n Na 136 / K 4.1 / Cl 99 / CO22 6 / BUN 19 / Cr 1 / BG 150\n Ca 8.7 / Phos 3.9\n ALT 49 / AST 76 / Lipase 81 / Alk Phos 50 / TB .3\n TSH pending\n Vanco level pending\n Imaging: STUDIES:\n - CXR - Bibasilar atelectasis. No acute cardiopulmonary\n abnormality\n - Right UE US - Limited study. No evidence of deep venous\n thrombosis in the right common femoral vein, proximal superficial\n femoral vein, popliteal or calf veins. Evaluation of the right mid and\n distal superficial femoral vein was limited,\n and deep venous thrombosis cannot be excluded secondary to limitations.\n - CXR - Unchanged bibasilar atelectasis.\n Microbiology: Blood Cx pending\n Urine Cx pending\n Assessment and Plan\n 61yo female with a complicated medical history including complex\n partial seizures and bilateral nonhealing foot ulcers was transferred\n to the MICU with status epilepticus.\n .\n 1. Seizures\n Patient has a complex prior neurologic history including complex\n partial seizures. Etiology of her status epilepticus is unclear,\n differential diagnosis includes most likely poorly controlled primary\n seizure disorder given her history, although additional toxic-metabolic\n causes of seizures should be evaluated. Infectious source includes her\n foot ulcers, although these were recently debrided and reportedly have\n no additional evidence of infection. Urine or blood infections are\n possible, although patient otherwise has no symptoms. Pulmonary\n infection is also possible, although appears less likely given that she\n has no pulmonary symptoms and CXR was unremarkable. Etiology of her\n desaturation during her seizure this morning prior to transfer is\n unclear as patient has been stable on room air since transfer to the\n MICU. CNS bleed is also possible given that she is anticoagulated.\n - appreciate neurology recs\n - dilantin load and start dilantin 100mg tid\n - follow-up urine and blood cultures\n - CT Head to evaluate for CNS bleed as a precipitant\n - EEG today.\n - appreciate neurology recs\n - seizure precautions.\n - NPO until mental status improves.\n .\n 2. Foot Wound\n Patient was on podiatry service for evaluation of nonhealing foot\n ulcer. Plan per podiatry was to discharge on bactrim.\n - start bactrim\n - appreciate podiatry recs\n - outpatient podiatry follow-up\n .\n 3. h/o DVT\n Pt had been transitioned off coumadin in anticipation of wound\n debridgement/surgical intervention.\n - continue lovenox\n - transition to coumadin once head CT performed\n .\n 4. DM\n Stable\n - continue SSI.\n .\n 5. Coronary Artery Disease\n Patient has a history of CAD and is chest pain free.\n - continue beta blocker, ACEI, plavix\n - restart atorvastatin\n - continue nitrate for further afterload reduction\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control:\n Lines:\n 22 Gauge - 12:20 PM\n 18 Gauge - 03:00 PM\n Prophylaxis:\n DVT: anticoagulated on lovenox\n Stress ulcer: not indicated\n VAP: not indicated\n Comments:\n Communication: Comments: Patient, Daughter\n status: FULL CODE\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2167-07-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 377000,
"text": "61yo female with history of partial complex seizures, multiple\n sclerosis, and paraplegia of unclear etiology was admitted to the MICU\n for evaluation of status epilepticus in the setting of hospital\n admission for nonhealing ulcers.\n .\n She was initially admitted to the podiatry service on for\n debridement of left foot wound. She was evaluated by vascular surgery\n who performed right side angiography, revealing significant SFA and\n popliteal disease which was not intervened upon. She was covered with\n cipro/flagyl/vanco (Day 1 = ), and remained afebrile without\n leukocytosis throughout her hospital course.\n .\n On the morning of transfer, she was to be discharged to home with\n TMP/SMX and then follow-up with podiatry in one week. On the morning of\n transfer at ~8:45 while eating breakfast, she asked to be transferred\n to the commode to pass a BM. On the commode she describes acute onset\n of nausea and weakness. She then was witnessed to have multiple,\n recurrent brief episodes of \"staring spells\" during which she was\n unresponsive. In between these episodes she responded appropriately to\n voice. Based on concern for seizures, she was given ativan 1mg x 2\n without response. Neurology consult was obtained who described\n persistent complex partial status, and recommended ativan 2mg x 1 with\n subsequent Dilantin loading. The pt remained in status for ~30-45 min.\n Impaired Physical Mobility\n Assessment:\n Patient has hx of MS, sarcoidosis, and spinal cord compression, and\n paraplegia. She is wheelchair bound at home where she lives with her\n daughter, although able to transfer herself with slide board and is\n independent with ADL\ns. She experiences discomfort when HOB is lowered\n for turns, care.\n Action:\n Scheduled Ultram, PRN Vicodin for pain control. HOB kept >45 degrees.\n Response:\n Patient is comfortable at rest.\n Plan:\n Pain medications as needed for comfort.\n Seizure, with status epilepticus\n Assessment:\n From following multiple brief episodes of absence seizures, post\n 4mg ativan, 1000mg Dilantin load. No further seizure activity noted\n since arrival to unit. A&Ox3, conversing normally. Demanding to go\n home. (Was being D/C\nd to home this morning when she seized?)\n Action:\n EEG at bedside. Head CT ordered. Second 1000mg dilantin load ordered.\n Seizure pads on side rails, 4 rails up for safety. Patient NPO for\n diet.\n Response:\n Patient back to baseline, states she has seizures a week at home,\n and that MD\ns have\noverreacted\n and that she is going home. Patient\n has removed all her monitor equipment, refusing monitoring, EEG, and\n CT. Patient remains very pleasant and appropriate with staff but\n adamant she is leaving. Pt c/o hunger, thirst. FBG=83, patient given\n juice and crackers (ok with MD). Patient received\n of second\n Dilantin load, and then demanded RN D/C drip due to burning pain at IV\n site. (Tried new PIV, slowing med, not effective, so med stopped).\n Plan:\n Resident to bedside to speak with patient calls out to neuro and PCP to\n inform them of patient\ns wish to leave. PCP is to come in to se patient\n after his rounds this evening. Per neuro, OK to discontinue EEG and\n remove EEG leads.\n"
},
{
"category": "Nursing",
"chartdate": "2167-07-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 377001,
"text": "61yo female with history of partial complex seizures, multiple\n sclerosis, and paraplegia of unclear etiology was admitted to the MICU\n for evaluation of status epilepticus in the setting of hospital\n admission for nonhealing ulcers.\n .\n She was initially admitted to the podiatry service on for\n debridement of left foot wound. She was evaluated by vascular surgery\n who performed right side angiography, revealing significant SFA and\n popliteal disease which was not intervened upon. She was covered with\n cipro/flagyl/vanco (Day 1 = ), and remained afebrile without\n leukocytosis throughout her hospital course.\n .\n On the morning of transfer, she was to be discharged to home with\n TMP/SMX and then follow-up with podiatry in one week. On the morning of\n transfer at ~8:45 while eating breakfast, she asked to be transferred\n to the commode to pass a BM. On the commode she describes acute onset\n of nausea and weakness. She then was witnessed to have multiple,\n recurrent brief episodes of \"staring spells\" during which she was\n unresponsive. In between these episodes she responded appropriately to\n voice. Based on concern for seizures, she was given ativan 1mg x 2\n without response. Neurology consult was obtained who described\n persistent complex partial status, and recommended ativan 2mg x 1 with\n subsequent Dilantin loading. The pt remained in status for ~30-45 min.\n Impaired Physical Mobility\n Assessment:\n Patient has hx of MS, sarcoidosis, and spinal cord compression, and\n paraplegia. She is wheelchair bound at home where she lives with her\n daughter, although able to transfer herself with slide board and is\n independent with ADL\ns. She experiences discomfort when HOB is lowered\n for turns, care.\n Action:\n Scheduled Ultram, PRN Vicodin for pain control. HOB kept >45 degrees.\n Response:\n Patient is comfortable at rest.\n Plan:\n Pain medications as needed for comfort.\n Seizure, with status epilepticus\n Assessment:\n From following multiple brief episodes of absence seizures, post\n 4mg ativan, 1000mg Dilantin load. No further seizure activity noted\n since arrival to unit. A&Ox3, conversing normally. Demanding to go\n home. (Was being D/C\nd to home this morning when she seized?)\n Action:\n EEG at bedside. Head CT ordered. Second 1000mg dilantin load ordered.\n Seizure pads on side rails, 4 rails up for safety. Patient NPO for\n diet.\n Response:\n Patient back to baseline, states she has seizures a week at home,\n and that MD\ns have\noverreacted\n and that she is going home. Patient\n has removed all her monitor equipment, refusing monitoring, EEG, and\n CT. Patient remains very pleasant and appropriate with staff but\n adamant she is leaving. Pt c/o hunger, thirst. FBG=83, patient given\n juice and crackers (ok with MD). Patient received\n of second\n Dilantin load, and then demanded RN D/C drip due to burning pain at IV\n site. (Tried new PIV, slowing med, not effective, so med stopped).\n Plan:\n Resident to bedside to speak with patient calls out to neuro and PCP to\n inform them of patient\ns wish to leave. PCP is to come in to se patient\n after his rounds this evening. Per neuro, OK to discontinue EEG and\n remove EEG leads.\n"
},
{
"category": "Physician ",
"chartdate": "2167-07-15 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 377015,
"text": "Chief Complaint: status epilepticus\n HPI:\n 61yo female with history of partial complex seizures, multiple\n sclerosis, and quadraparesis of unclear etiology was admitted to the\n MICU for evaluation of status epilepticus in the setting of hospital\n admission for nonhealing ulcers.\n .\n She was initially admitted to the podiatry service on for\n debridement of left foot wound. She was evaluated by vascular surgery\n who performed right side angiography, revealing significant SFA and\n popliteal disease which was not intervened upon. She was covered with\n cipro/flagyl/vanco (Day 1 = ), and remained afebrile without\n leukocytosis throughout her hospital course.\n .\n On the morning of transfer, she was to be discharged to home with\n TMP/SMX and then follow-up with podiatry in one week. On the morning of\n transfer at ~8:45 while eating breakfast, she asked to be transferred\n to the comode to pass a BM. On the comode she describes acute onset of\n nausea and weakness. She then was witnessed to have multiple,\n recurrent brief episodes of \"staring spells\" during which she was\n unresponsive. In between these episodes she responded appropriately to\n voice. Based on concern for seizures, she was given ativan 1mg x 2\n without response. Neurology consult was obtained who described\n persistant complex partial status, and recommended ativan 2mg x 1 with\n subsequent dilantin loading. The pt remained in status for ~30-45 min.\n .\n The only documented vitals prior to the event were at 0800 98.8 156/75\n 87 20 97%RA. By report, during the episode, her O2 sats dropped to\n 79%RA, but BP was stable. Post event, transfer note indicates VS 98.8\n 109/68 92 14 98%3L. Immediately after her the seizures, pt was with\n the above vital signs, sitting up in bed, somnolent, responsive to\n voice. Her somnolence intermittently resolved, notably upon the\n arrival of her PCP whom she recognized and spoke with. MICU transfer\n was requested in the setting of persistent complex partial status for\n closer airway monitoring and for evaluation of potential contribution\n by patient's multiple medical conditions.\n .\n On the floor, pt is intermittently somnolent consistent with post-ictal\n state. At other times she is easily arousable, and A&Ox3. She denies\n chest pain, dyspnea, n/v, abdominal pain, fevers, shaking chills, night\n sweats, cough, sputum production.\n HOME MEDICATIONS:\n 1. Albuterol nebs prn\n 2. Atorvastatin 80mg PO daily\n 3. Carbamazepine 200mg PO qid\n 4. Cephalexin 500mg PO qid (Day 1 - , 10 day course)\n 5. Clopidogrel 75mg PO bid\n 6. Fluticasone 4400mcg puffs \n 7. Vicodon tab qid\n 8. Imdur 90mg PO daily\n 9. Lisinopril 5mg PO daily\n 10. Metoprolol Succinate 200mg PO daily\n 11. Nitroglycerin prn\n 12. Ranitidine 150mg daily\n 13. Tramadol 50mg PO qid\n 14. Warfarin 5mg PO daily\n 15. Acetaminophen 650mg PO q6-8h prn headache\n 16. Regular insulin 15 units q AM / 10 units q PM\n 17. NPH 70 units q AM / 40 units q PM\n Allergies:\n Aspirin\n upset stomach w\n Reglan (Oral) (Metoclopramide Hcl)\n facial swelling\n Quinine Sulfate\n Hives;\n Codeine\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Clindamycin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n TRANSFER MEDICATIONS:\n 1. Acetaminophen 325-650mg PO q6h prn fever\n 2. Lisinopril 5mg PO daily\n 3. Metoprolol Succinate 200mg PO daily\n 4. Clopidogrel 75mg PO daily\n 5. Isosorbide Mononitrate 90mg PO daily\n 6. Tramadol 50mg PO qid\n 7. Carbamazepine 200mg PO qid\n 8. Ranitidine 150mg PO daily\n 9. Vicodin prn\n 10. Senna 1 tab PO bid\n 11. Docusate 100mg PO bid\n 12. Metronidazole 500mg PO q8h\n 13. Ciprofloxacin 750mg PO q12h\n 14. Bisacodyl 10mg daily\n 15. Trazodone 25mg PO qhs prn insomnia\n 16. Zofran 4mg IV q8h prn nausea / vomiting\n 17. Diphenhydramine 25mg PO q6h prn itch\n 18. Insulin\n 19. Lovenox 130mg SC q12h\n 20. Vancomycin 1250mg IV q12h\n 21. Coumadin\n 22. Phenytoin 100mg IV q8h\n .\n Past medical history:\n Family history:\n Social History:\n 1. Quadriparesis\n - worse legs than arms, related to multiple level degenerative spine\n disease with spinal stenosis and ? multiple sclerosis, s/p several\n laminectomies\n 2. Sarcoidosis\n - diagnosed on hilar node biopsy in ; quiescent in recent past\n 3. ? Multiple sclerosis\n - repeated MRIs showing small atypical lesions, sometimes read as\n small vessel disease vs demyelinating process\n 4. Diabetes Mellitus\n 5. Reactive airways disease\n 6. Hypertension, in good control\n 7. DVT/PE\n - , completed course of anticoagulation\n 8. Recurrent cutaneous infections related to DM and\n lack of sensation distally, bacteremic with buttock abscess in\n \n 9. Neuropathic pain\n 10. Stroke and recurrent TIAs, on Plavix\n 11. Seizure disorder\n - followed by Dr. , on carbamazepine\n 12. Endometrial carcinoma s/p TAH/BSO\n 13. Several laminectomies, abscess I & D without anesthetic\n complications.\n 14. Hand surgery .\n 15. Coronary Artery Disease\n - s/p cardiac catheterization and RCA stent placement in \n noncontributory\n Occupation: retired nurse\n Drugs: denies\n Tobacco: 70 PPY history\n Alcohol: denies, history of alcohol abuse\n Other: Home: lives with daughter in \n Review of systems:\n Flowsheet Data as of 05:58 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 37.1\nC (98.7\n HR: 82 (76 - 85) bpm\n BP: 116/49(66) {102/46(61) - 127/61(75)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 357 mL\n PO:\n TF:\n IVF:\n 357 mL\n Blood products:\n Total out:\n 0 mL\n 1,045 mL\n Urine:\n 1,045 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -688 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n General: Alert, oriented X 3, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: obese, soft, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding, no organomegaly\n Ext: bilaterally feet are wrapped\n Labs / Radiology\n Fluid analysis / Other labs: \n Na 136 / K 4.1 / Cl 99 / CO22 6 / BUN 19 / Cr 1 / BG 150\n Ca 8.7 / Phos 3.9\n ALT 49 / AST 76 / Lipase 81 / Alk Phos 50 / TB .3\n TSH pending\n Vanco level pending\n Imaging: STUDIES:\n - CXR - Bibasilar atelectasis. No acute cardiopulmonary\n abnormality\n - Right UE US - Limited study. No evidence of deep venous\n thrombosis in the right common femoral vein, proximal superficial\n femoral vein, popliteal or calf veins. Evaluation of the right mid and\n distal superficial femoral vein was limited,\n and deep venous thrombosis cannot be excluded secondary to limitations.\n - CXR - Unchanged bibasilar atelectasis.\n Microbiology: Blood Cx pending\n Urine Cx pending\n Assessment and Plan\n 61yo female with a complicated medical history including complex\n partial seizures and bilateral nonhealing foot ulcers was transferred\n to the MICU with status epilepticus.\n .\n 1. Seizures\n Patient has a complex prior neurologic history including complex\n partial seizures. Etiology of her status epilepticus is unclear,\n differential diagnosis includes most likely poorly controlled primary\n seizure disorder given her history, although additional toxic-metabolic\n causes of seizures should be evaluated. Infectious source includes her\n foot ulcers, although these were recently debrided and reportedly have\n no additional evidence of infection. Urine or blood infections are\n possible, although patient otherwise has no symptoms. Pulmonary\n infection is also possible, although appears less likely given that she\n has no pulmonary symptoms and CXR was unremarkable. Etiology of her\n desaturation during her seizure this morning prior to transfer is\n unclear as patient has been stable on room air since transfer to the\n MICU. CNS bleed is also possible given that she is anticoagulated.\n - appreciate neurology recs\n - dilantin load and start dilantin 100mg tid\n - follow-up urine and blood cultures\n - CT Head to evaluate for CNS bleed as a precipitant\n - EEG today.\n - appreciate neurology recs\n - seizure precautions.\n - NPO until mental status improves.\n .\n 2. Foot Wound\n Patient was on podiatry service for evaluation of nonhealing foot\n ulcer. Plan per podiatry was to discharge on bactrim.\n - start bactrim\n - appreciate podiatry recs\n - outpatient podiatry follow-up\n .\n 3. h/o DVT\n Pt had been transitioned off coumadin in anticipation of wound\n debridgement/surgical intervention.\n - continue lovenox\n - transition to coumadin once head CT performed\n .\n 4. DM\n Stable\n - continue SSI.\n .\n 5. Coronary Artery Disease\n Patient has a history of CAD and is chest pain free.\n - continue beta blocker, ACEI, plavix\n - restart atorvastatin\n - continue nitrate for further afterload reduction\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control:\n Lines:\n 22 Gauge - 12:20 PM\n 18 Gauge - 03:00 PM\n Prophylaxis:\n DVT: anticoagulated on lovenox\n Stress ulcer: not indicated\n VAP: not indicated\n Comments:\n Communication: Comments: Patient, Daughter\n status: FULL CODE\n Disposition: ICU for now\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 61F complex PMH including seizure d/o,\n multiple sclerosis, PVD c/b LE ulceration and infection, sarcoidosis,\n DM, HTN p/w refractory seizures on the podiatry service.\n Exam notable for Tm 97.9 BP 130/70 HR 80 RR 18 with sat 97 on RA. WD\n woman, pleasant, wants to leave AMA. JVD 6cm. CTA B. RRR s1s2. Soft\n +BS. 2+edema, stasis changes. BLE dressings c/d/i. Labs notable for WBC\n 8K, HCT 33, K+ 4.1, Cr 1.0.\n Agree with plan to manage seizures with IV dilantin load; will check\n head CT and EEG now. Neuro team following; will collaborate re any\n change in AEDs given reports of ongoing seizures at home. Will initiate\n bactrim for LE infection / ulcers; cipro may well have lowered her\n seizure threshold during this admission. Remainder of wound care per\n podiatry team. No further plans for vascular interventions. Will\n continue lovenox for DVT/PE. PCP ( ) to come by this PM and\n discuss with patient the value of staying in the hospital at least\n overnight. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 09:09 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2167-07-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 377027,
"text": "Events: Pt PCP visiting pt and pt agreed to stay for CT in AM- no EEG-\n CT to call 5 at 7AM to plan for time of scan. pain\n managed with getting pt OOB to chair. PT will be leaving with likely\n VNA and needs setup in AM. Requests Eastcare ambulance to take her\n home.\n Impaired Physical Mobility\n Assessment:\n Pt had MS loss of sensation in bilat legs, upper body\n strength intact,\n Action:\n to chair\n Response:\n Tolerating chair, requesting to remain overnight in chair\n Plan:\n Needs assistance with ADL\n Seizure, with status epilepticus\n Assessment:\n No seizures noted, per pt\nve had lots of then over the past years,\n its not new to me\n Action:\n IV Dilantin given\n Response:\n No seizures noted\n Plan:\n Cont IV Dilantin ? changing to PO for anticipated D/C in AM\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LEFT FOOT INFECTION\n Code status:\n Height:\n Admission weight:\n 133.4 kg\n Daily weight:\n Allergies/Reactions:\n Aspirin\n upset stomach w\n Reglan (Oral) (Metoclopramide Hcl)\n facial swelling\n Quinine Sulfate\n Hives;\n Codeine\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Clindamycin\n Nausea/Vomiting\n Precautions:\n PMH: Anemia, COPD, Diabetes - Insulin, Seizures\n CV-PMH: CAD, CVA, Hypertension, PVD\n Additional history: Saarcoidosis, multilpe Sclerosis, paraplegic, CAD,\n s/p multiple recurrent DVT's, CVA, spinal cord compression, , seizure\n disorder, HTN, DM type II, hyperlipidemia, uterine/cervical CA, asthma,\n COPD, OSA, cardiac arrest.\n Surgery / Procedure and date: remote hx c-section.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:146\n D:70\n Temperature:\n 99.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 92% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 89 mL\n 24h total out:\n 370 mL\n Pertinent Lab Results:\n Finger Stick Glucose:\n 168\n 11:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\n Other valuables: pt states wallet in safe on 5\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 511\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2167-07-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 377025,
"text": "Events: Pt PCP visiting pt and pt agreed to stay for CT in AM- no EEG.\n pain managed with getting pt OOB to chair. PT will be leaving\n with likely VNA and needs setup in AM. Requests Eastcare ambulance to\n take her home.\n Impaired Physical Mobility\n Assessment:\n Pt had MS loss of sensation in bilat legs, upper body\n strength intact,\n Action:\n to chair\n Response:\n Tolerating chair, requesting to remain overnight in chair\n Plan:\n Needs assistance with ADL\n Seizure, with status epilepticus\n Assessment:\n No seizures noted, per pt\nve had lots of then over the past years,\n its not new to me\n Action:\n IV Dilantin given\n Response:\n No seizures noted\n Plan:\n Cont IV Dilantin ? changing to PO for anticipated D/C in AM\n"
},
{
"category": "Nursing",
"chartdate": "2167-07-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 377026,
"text": "Events: Pt PCP visiting pt and pt agreed to stay for CT in AM- no EEG-\n CT to call 5 at 7AM to plan for time of scan. pain\n managed with getting pt OOB to chair. PT will be leaving with likely\n VNA and needs setup in AM. Requests Eastcare ambulance to take her\n home.\n Impaired Physical Mobility\n Assessment:\n Pt had MS loss of sensation in bilat legs, upper body\n strength intact,\n Action:\n to chair\n Response:\n Tolerating chair, requesting to remain overnight in chair\n Plan:\n Needs assistance with ADL\n Seizure, with status epilepticus\n Assessment:\n No seizures noted, per pt\nve had lots of then over the past years,\n its not new to me\n Action:\n IV Dilantin given\n Response:\n No seizures noted\n Plan:\n Cont IV Dilantin ? changing to PO for anticipated D/C in AM\n"
},
{
"category": "ECG",
"chartdate": "2167-07-18 00:00:00.000",
"description": "Report",
"row_id": 278348,
"text": "Sinus rhythm\nLeftward axis\nSince previous tracing of , axis is less leftward\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-17 00:00:00.000",
"description": "Report",
"row_id": 278349,
"text": "Sinus rhythm. Left anterior fascicular block. Late R wave progression,\nprobably related to axis. Since the previous tracing of no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2167-07-10 00:00:00.000",
"description": "Report",
"row_id": 278350,
"text": "Sinus rhythm with borderline 1st degree A-V block\nPossible left anterior fascicular block\nNonspecific intraventricular conduction delay\nPoor R wave progression\nSince previous tracing of , sinus tachycardia absent\n\n"
}
] |
79,564 | 111,848 | This is a 56-year-old woman with metastatic breast cancer to bone, lung and brain, presenting with worsening lower extremity edema, found to be hypoxic and with new large right pleural effusion. | HYPERTENSION: As above, likely cause of SAH. HEENT: Normocephalic, atraumatic. Action: Pt is on levofloxcin, xrays were taken of the right lower ext, Response: Still unclear what type of rash/cellulitis this is. ECG: Sinus rhythm with 1st degree AV block, inferior Q waves and 1-2mm lateral ST depressions. URINARY TRACT INFECTION: Levaquin for now. ECG CHANGES: In setting of acute stress event, likely represent mild demand ischemia in setting of known completely obstructed RCA with left filling and likely steal -- ROMI -- ECG in am . Sarcoidosis diagnosed in . Respiratory failure, acute (not ARDS/) Assessment: Received pt on 4LNC. Respiratory failure, acute (not ARDS/) Assessment: Received pt on 4LNC. Respiratory failure, acute (not ARDS/) Assessment: Received pt on 4LNC. Respiratory failure, acute (not ARDS/) Assessment: Received pt on 4LNC. ECG: CARDIAC CATH: FINAL DIAGNOSIS: 1. -- CT Head non contrast ordered -- Hold aspirin -- Hold plavix -- Seizure management per neurology . Likely hct drop is dilutional, check serial CBCx. -- F/U Final read of LENI -- Consider imaging of abd/pelvis -- Elevation of LE -- Consider ECHO . Lower extremity ultrasound was obtained to evaluate for DVT, CTA of the chest ordered to rule out PE. Lower extremity ultrasound was obtained to evaluate for DVT, CTA of the chest ordered to rule out PE. Respiratory failure, acute (not ARDS/) Assessment: Received pt on 5LNC. Respiratory failure, acute (not ARDS/) Assessment: Received pt on 5LNC. F/u studies though likely a malignant pleural effusion. F/u studies though likely a malignant pleural effusion. There are diffuse patchy opacities bilaterally consistent with known pulmonary masses. Mild symmetric left ventricularhypertrophy with normal cavity sizes and global biventricular systolicfunction. Unchanged small hyperdense foci in the right cerebellar hemisphere within a known metastasis. Diffuse patchy opacity consistent with known pulmonary masses. FINAL REPORT PORTABLE CHEST INDICATION: Right thoracentesis. HISTORY: Bilateral lower extremity swelling. Left pleural effusion. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. There is mild pulmonaryartery systolic hypertension. There is a trace left pleural effusion and a large right pleural effusion identified. Possible prior inferiormyocardial infarction. Consider prior anteroseptalmyocardial infarction. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. LOWER EXTREMITY EDEMA: Concerning for venous obstruction. LOWER EXTREMITY EDEMA: Concerning for venous obstruction. Left atrial abnormality. No PS.Physiologic PR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor apical views.Conclusions:The left atrium and right atrium are normal in cavity size. REASON FOR THIS EXAMINATION: please assess for re-accumulation of right sided pleural effusions PFI REPORT Re-accumulation of right pleural effusion, now in small amount, with costophrenic angle still visible. Large left pleural effusion and small right pleural effusion. Large left pleural effusion and small right pleural effusion. Large left pleural effusion and small right pleural effusion. COMPARISON: Head MRI dated ; noncontrast head CT dated . There is probable mild superimposed congestive failure. Mild aortic valve sclerosis. Probable small left pleural effusion. Retrocardiac atelectasis. Shortness of breath.Height: (in) 67Weight (lb): 148BSA (m2): 1.78 m2BP (mm Hg): 130/84HR (bpm): 92Status: OutpatientDate/Time: at 09:44Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%decrease during respiration (estimated RA pressure (0-5mmHg).LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolicfunction (LVEF>55%). HYPERTENSION: As above, likely cause of SAH. In ER hypoxemia. HEENT: Normocephalic, atraumatic. ECG: Sinus rhythm with 1st degree AV block, inferior Q waves and 1-2mm lateral ST depressions. URINARY TRACT INFECTION: Levaquin for now. ECG: CARDIAC CATH: FINAL DIAGNOSIS: 1. Please assess for reaccumulation of right-sided pleural effusion. -- CT Head non contrast ordered -- Hold aspirin -- Hold plavix -- Seizure management per neurology . ECG CHANGES: In setting of acute stress event, likely represent mild demand ischemia in setting of known completely obstructed RCA with left filling and likely steal -- ROMI -- ECG in am . Reaccumulation of right pleural effusion, now in a small amount. PA AND LATERAL CHEST RADIOGRAPHS: There is reaccumulation of right pleural effusion, in small amount, but with still visible costophrenic sinus. -- F/U Final read of LENI -- Consider imaging of abd/pelvis -- Elevation of LE -- Consider ECHO #. -- F/U Final read of LENI -- Consider imaging of abd/pelvis -- Elevation of LE -- Consider ECHO #. REASON FOR THIS EXAMINATION: please assess for re-accumulation of right sided pleural effusions PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 2:22 PM Re-accumulation of right pleural effusion, now in small amount, with costophrenic angle still visible. Chest CT: Known metastatic disease to lungs. Chest CT: Known metastatic disease to lungs. Retrocardiac atelectasis. plan for therapeutic thoracentesis in a.m , ? plan for therapeutic thoracentesis in a.m , ? Large inguinal hernia, partially reducible, non tender or discolored. Needs thoracentesis, treat with emperic antibiotics, obtain old records and films LE edema - no DVT though may be more proximal ? | 41 | [
{
"category": "Nursing",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664838,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 4LNC. Pt denies SOB but does have DOE. LS are noted for\n crackles throughout.\n Action:\n Thoracentesis done on right side yesterday. 1200ml of serous fluid\n removed. Given Morphine 2mg IV x 1 for pain with good effect.\n Response:\n Pt appeared much more comfortable after procedure. Pt slept throughout\n shift. Sats 98-100% and RR low 20\ns. Pt states that she feels better.\n Pt appears very comfortable.\n Plan:\n Continue to monitor resp status and pain.\n Rash\n Assessment:\n Lower extremities remain edematous at about 8mm. Pulses palpable\n bilaterally. Left foot cool however has good pulse. Right foot very\n warm and painful to touch.\n Action:\n Pt is on levofloxcin, xrays were taken of the right lower ext,\n Response:\n Still unclear what type of rash/cellulitis this is. Pt has remained\n afebrile, and is receiving heparin q 8 hrs.\n Plan:\n Cont to monitor, f/u with xrays.\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 664734,
"text": "Chief Complaint: Lower extremity edema\n HPI:\n Ms is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema since\n starting dexamethasone as part of her chemotherapy, as was noted in her\n neuro-oncology visit note. Patient reports she began having pain in her\n right leg that was worse with walking. She also reports having \"cold\n like symptoms\" with a cough and some runny nose, denies any fevers or\n chills. Patient decided to come into the ED after her symptoms were not\n improved with tylenol.\n .\n In the emergency department patient 97 114 127/103 93% on 4L. Lower\n extremity ultrasound was obtained to evaluate for DVT, CTA of the chest\n ordered to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia. Patient also given 500ml bolus.\n Patient noted to have transient desaturations to mid 80's with\n movement. Given tenuous stauts, patient admitted to for close\n monitoring.\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n ONCOLOGICAL HISTORY:\n Breast cancer with metastases to cerebellum\n - Right breast mass found , s/p righ breast mass lumpectomy\n (T1N0M0), s/p chest XRT and CMF (cyclophosphamide, methotrexate, and\n 5-FU), adjuvant chemotherapy, followed by tamoxifen\n - with left breast mass, s/p left lumpectomy, chest XRT followed\n by tamoxifen, stopped in .\n - , recurrent disease in the left breast. Metastatic work up with\n metastases in lungs and bone, s/p Adriamycin and cyclophosphamide x 4\n cycles, also taxol from which she developed an anaphylactic reaction.\n -completed whole brain cranial irradiation on , adjuvant\n Herceptin and navelbine, followed by recent Herceptin and Xeloda\n -s/p a third ventriculostomy by , M.D. on ,\n -s/p Cyberknife radiosurgery on to a left cerebellar\n metastasis to 1,800 cGy at 82% isodose line and to a right\n cerebellar metastasis to 1,600 cGy at 73% isodose line on\n , and\n -has been getting lapatinib and carboplatin every 3 weeks\n since for her progressive disease; delayed because\n of her surgeries.\n -s/p second third ventriculostomy procedure by ,\n M.D. on .\n - she was scheduled to receive Doxil on but did not go.\n - She has started bevacizumab alone in .\n OTHER PAST MEDICAL HISTORY:\n h/o Factor VIII deficiency\n Suspected anti-cardiolipin antibody\n Hypertension\n Sarcoidosis\n s/p Lung biopsy \n Mother died of breast cancer. An aunt from the maternal side has breast\n cancer. She has 2 uncles, one died of smoking-related lung cancer while\n another is alive with non-smoking-related cancer. There are other\n members of her family with diabetes.\n Occupation:\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (118 - 118) bpm\n BP: 142/88(101) {142/88(101) - 142/88(101)} mmHg\n RR: 7 (7 - 7) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -80 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n Physical Examination\n GENERAL: Pleasant, well appearing woman with cushinoid features.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. obese neck.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or gallops\n LUNGS: Decreased breath sounds at right base, (+) Egophony. Anterior\n rhonchi on right.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: Massive lower extremity edema to the thigh. 2+ pulses\n throughout\n SKIN: Rash along posterior surface of right leg.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 134\n 133\n 0.7\n 21\n 22\n 105\n 3.2\n 140\n 33.6\n 8.7\n [image002.jpg]\n Other labs: Ca++:8.9, Mg++:1.7, PO4:2.5\n Imaging: .\n Bilat Lower Ext Veins: No DVT\n 10:37p\n Cta Chest W&W/O C&Recons, Non-Coronary -- Preliminary Result: no\n definate pe. large right pleural effusion. extensive lung masses\n increased with ground glass opacities.\n 10:37p\n CT Head W/O Contrast -- Preliminary Result: no sig change\n ECG: Sinus tachycardia, non specific ST changes.\n Assessment and Plan\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n .\n #. RESPIRATORY DISTRESS: Multifactorial in this woman with lung\n metastasis, history of sarcoidosis, s/p XRT to both sides of the chest\n and now with likely obstructing lesions and pneumonia as well as large\n effusion. Suspect effusion is most likely secondary to malignancy.\n -- Vanc and levaquin for post obstructive pneumonia\n -- F/U Final chest CTA read given high risk of PE, especially in light\n of bevacizumab therapy\n -- Would strongly consider therapeutic thoracentesis in AM\n -- Supplemental oxygen, avoid hypoxia and resulting pulmonary\n vasoconstriction.\n .\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction. Alghough\n no LE DVE was seen on US and chest clear for PE, given malignancy,\n history of pro-coagulable disorder and bevacizumab therapy, would still\n strongly consider -occlusive event, specifically of the IVC. Would\n also consider extrinsic compression of IVC, as well as massive fluid\n retention from corticosteroids and right sided heart failure (as\n evidenced by increased BNP). This however could be secondary to\n increased pulmonary pressures from large effusion.\n -- F/U Final read of LENI\n -- Consider imaging of abd/pelvis\n -- Elevation of LE\n -- Consider ECHO\n .\n #. BREAST CANCER: No plans for inpatient therapy\n .\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n .\n #. URINARY TRACT INFECTION: Adequately convered on above antibiotic\n regimen.\n -- F/U Culture\n .\n FEN: Regular diet\n .\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n .\n ACCESS: PIV's\n .\n CODE STATUS: full\n .\n .\n DISPOSITION: ICU overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664817,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 4LNC. Appeared comfortable however pt stated that she\n was having some difficulty with breathing. Sats 92-96%. LS diminished\n at bases with some diffuse crackles. Lower extremities remain\n edematous at about 8mm. Pulses dopplerable. Left foot cool however\n has good pulse. Right foot very painful with touch.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664819,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 4LNC. Appeared comfortable however pt stated that she\n was having some difficulty with breathing. Sats 92-96%. LS diminished\n at bases with some diffuse crackles. Lower extremities remain\n edematous at about 8mm. Pulses dopplerable. Left foot cool however\n has good pulse. Right foot very painful with touch.\n Action:\n Thoracentesis done on right side today. 1200ml of serous fluid\n removed. Given Morphine 2mg IV x 1 for pain with good effect.\n Response:\n Pt appeared much more comfortable after procedure. Sats 98-100% and RR\n low 20\ns. Pt states that she feels better.\n Plan:\n Continue to monitor resp status and pain.\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664824,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 4LNC. Appeared comfortable however pt stated that she\n was having some difficulty with breathing. Sats 92-96%. LS diminished\n at bases with some diffuse crackles. Lower extremities remain\n edematous at about 8mm. Pulses dopplerable. Left foot cool however\n has good pulse. Right foot very painful with touch.\n Action:\n Thoracentesis done on right side today. 1200ml of serous fluid\n removed. Given Morphine 2mg IV x 1 for pain with good effect.\n Response:\n Pt appeared much more comfortable after procedure. Sats 98-100% and RR\n low 20\ns. Pt states that she feels better.\n Plan:\n Continue to monitor resp status and pain.\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 664893,
"text": "Demographics\n Attending MD:\n \n Admit diagnosis:\n METASTATIC CANCER;HYPOXIA\n Code status:\n Full code\n Height:\n Admission weight:\n 65.2 kg\n Daily weight:\n Allergies/Reactions:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: mestastatic breast cancer, liver and lung lesions,\n brain metastases. Sarcoidosis diagnosed in .\n Surgery / Procedure and date: R lumpectomy followed by radiation and\n CMF chemotherapy in .\n underwent lumpectomy for a left-sided breast cancer followed by\n radiation therapy..\n mastectomy with reconstruction and four cycles of chemotherapy.\n , mastectomy for a second right breast cancer.\n , ventriculostomy followed by Cyberknife stereotactic\n radiotherapy for two cerebellar metastases.\n , second ventriculostomy .\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:142\n D:90\n Temperature:\n 96.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 105 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 342 mL\n 24h total out:\n 391 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 05:02 AM\n Potassium:\n 4.1 mEq/L\n 05:02 AM\n Chloride:\n 106 mEq/L\n 05:02 AM\n CO2:\n 24 mEq/L\n 05:02 AM\n BUN:\n 17 mg/dL\n 05:02 AM\n Creatinine:\n 0.5 mg/dL\n 05:02 AM\n Glucose:\n 115 mg/dL\n 05:02 AM\n Hematocrit:\n 26.6 %\n 10:56 AM\n Valuables / Signature\n Patient valuables: sent with patient\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 7 South\n Date & time of Transfer: 1430\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 664894,
"text": "Chief Complaint: Hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 56W widely metastatic breast ca, presented with LE swelling and pain.\n found to have larger right effusion and progressive mets in lungs.\n done. cause of LE edema unclear ? IVC occlusion (known tumor\n abutting IVC versus avastin and dex related).\n 24 Hour Events:\n THORACENTESIS - At 02:11 PM--1.2L removed. Exudative by\n LDH.\n History obtained from Medical records\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Levofloxacin - 08:53 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:52 PM\n Heparin Sodium (Prophylaxis) - 10:28 PM\n Other medications:\n Iron, Vit D, valsartin, decadron 4mg q12h\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 93 (92 - 117) bpm\n BP: 134/78(92) {115/54(84) - 154/92(102)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,605 mL\n 322 mL\n PO:\n 690 mL\n 200 mL\n TF:\n IVF:\n 855 mL\n 122 mL\n Blood products:\n 560 mL\n Total out:\n 697 mL\n 360 mL\n Urine:\n 697 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,908 mL\n -39 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: alopecia\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, pitting and non pitting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 120 K/uL\n 115 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 106 mEq/L\n 139 mEq/L\n 26.6 %\n 10.3 K/uL\n [image002.jpg]\n 09:41 AM\n 05:02 AM\n 10:56 AM\n WBC\n 9.7\n 10.3\n Hct\n 31.2\n 26.3\n 26.6\n Plt\n 118\n 120\n Cr\n 0.5\n 0.5\n Glucose\n 88\n 115\n Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,\n Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,\n Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3\n mg/dL\n Imaging: CXR: improved right effusion, extensive parehncymal\n opacities.\n Assessment and Plan\n 1) Hypoxemia:\n She has extensive pulmonary metastatic disease and a large right\n pleural effusion.\n Improved after thoracentesis. F/u studies though likely a malignant\n pleural effusion.\n Continue supplemental O2.\n Possible that she has a pneumonia as well--continue empiric levaquin.\n 2) LE edema:\n Ask radiology to reviewd chest CT to evaluate for IVC compression.\n 3) UTI:\n cont levoflox, check urine culture.\n 4) Anemia:\n No evidence of bleeding currently.\n will follow serial Hcts\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n ------ Protected Section ------\n I saw and examined the patient on am rounds with the fellow and ICU\n residents, overnight events reviewed. Patient notes that her breathing\n is much more comfortable this morning after diagnostic/therapeutic\n thorocentesis with removal of 1.2 L fluid, initial findings suspicious\n for malignant effusion. Evidence on CT of increasing tumor burden in\n the lung as well. Hct down albeit no evidence of hematoma around the\n thorocentesis site, no evidence of reaccumulation of fluid on CXR.\n Likely hct drop is dilutional, check serial CBCx. Agree with exam,\n assessment and plan as per Dr. \ns note. Patient is stable for\n transfer to OMED. Time spent: 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:27 ------\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664891,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5LNC. Sats 98%, RR 10\ns-20\ns. Pt appears very\n comfortable. Denies SOB. LS have diffuse crackles.\n Action:\n Oxygen lowered to 3LNC\n Response:\n Sats down to 90%. Team aware and accepts sats above 90%.\n Plan:\n Continue to monitor. Maintain sats above 90%. Called out to 7 South.\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 664858,
"text": "Chief Complaint: LE edema and pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 56W metastatic breast cancer, presented with LE edema since starting\n avastin and dexamethasone a few weeks ago. Also, recent URI. Came to ER\n because worsening LE pain. In ER hypoxemic requiring 5L NC. Worked up\n for DVT and PE which were negative. CT-A showed multiple bilateral\n metastatic lesions, large right and smaller left effusions and left\n greater than right ground glass and interstitial infiltrates.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n breast cancer lumpectomy and XRT, recurred , multiple\n therapies since, now on avastin\n ? hemophilia, ? anti-cardiolipin antibodies\n Sarcoidosis diagnosed radiographically 2 years ago\n breast cancer\n Occupation:\n Drugs:\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Musculoskeletal: leg swelling and pain\n Flowsheet Data as of 09:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 105 (99 - 118) bpm\n BP: 129/84(95) {129/78(93) - 145/88(102)} mmHg\n RR: 19 (7 - 24) insp/min\n SpO2: 97% on 5LNC\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,395 mL\n PO:\n 390 mL\n TF:\n IVF:\n 505 mL\n Blood products:\n Total out:\n 0 mL\n 258 mL\n Urine:\n 258 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,137 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, SOB and uncomfortable with any\n movement\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Crackles : anteriorly, Diminished:\n right)\n Abdominal: Soft, Non-tender\n Extremities: Right: 4+, Left: 4+, edema, tenderness throughout RLE soft\n tissue, petechiae right lateral leg\n Neurologic: Attentive, Oriented x3,\n Labs / Radiology\n 118\n 31\n 0.5\n 18\n 10\n [image002.jpg] PTT 70 INR 1.5\n Imaging: LENI negative\n CT-A no PE, large right and small left effusion, multiple lung masses,\n left greater than right GGO\ns and septal thickening\n Assessment and Plan\n Respiratory distress - related to effusion, infiltrates, tumor. Needs\n thoracentesis, treat with emperic antibiotics, obtain old records and\n films, touch base with outside oncologist\n LE edema - no DVT though may be more proximal ? IVC occlusion, will\n obtain echo, repeat LENI's,\n right leg pain\n likely related to edema, less likely bone met,\n consider x-rays\n UTI - levoflox should cover\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 02:48 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664860,
"text": "TITLE:\n Chief Complaint: 56 year old woman with metastatic breast cancer to\n bone, lung and brain, presenting with worsening lower extremity edema,\n found to be hypoxic and with new large right pleural effusion.\n 24 Hour Events:\n THORACENTESIS - At 02:11 PM\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Levofloxacin - 08:53 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Morphine Sulfate - 05:52 PM\n Heparin Sodium (Prophylaxis) - 10:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.2\n HR: 95 (95 - 119) bpm\n BP: 115/74(84) {115/54(84) - 154/94(104)} mmHg\n RR: 15 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,605 mL\n 76 mL\n PO:\n 690 mL\n TF:\n IVF:\n 855 mL\n 76 mL\n Blood products:\n 560 mL\n Total out:\n 697 mL\n 245 mL\n Urine:\n 697 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,908 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 120 K/uL\n 8.7 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 106 mEq/L\n 139 mEq/L\n 26.3 %\n 10.3 K/uL\n [image002.jpg]\n 09:41 AM\n 05:02 AM\n WBC\n 9.7\n 10.3\n Hct\n 31.2\n 26.3\n Plt\n 118\n 120\n Cr\n 0.5\n 0.5\n Glucose\n 88\n 115\n Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,\n Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,\n Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3\n mg/dL\n Fluid analysis / Other labs: Pleural Fluid\n Chemistry\n Protein 2.4\n Glucose 105\n Creat: 0.4\n LD(LDH): 428\n Albumin: 1.7\n Pleural Fluid\n WBC 225\n RBC 315\n Poly 7\n Lymph 37\n Mono 7\n EOs\n Meso: 2\n Macro: 43\n Other: 4\n Imaging: CTA\n 1. No definite evidence of pulmonary emboli.\n 2. Extensive lung masses and nodules involving both lungs, which\n appears to\n have increased when compared to prior exam. Some of these masses appear\n to\n encase the distal segmental pulmonary arteries.\n 3. Extensive ground-glass opacity and septal thickening. This could\n represent\n lymphangitic spread or edema.\n 4. Hypodense lesions in the liver concerning for metastasis and fluid\n within\n the perihepatic space.\n 5. Sclerotic lesions in the lower thoracic vertebral bodies with\n compression\n deformities.\n 6. Large left pleural effusion and small right pleural effusion.\n LENI\n IMPRESSION: No evidence of DVT.\n The study and the report were reviewed by the staff radiologist.\n Assessment and Plan\n RASH\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n #. RESPIRATORY DISTRESS: Currently on 4L O2, at baseline is 100%RA. As\n the pt has mets in lung and unclear history of sarciod it is difficult\n to discern whether the pt has pneumonia as well. No fever, minimal\n cough and nl WBC (although pt does have bands, and normal WBC may be\n elevated in the setting of recent Avastin and possible\n myelosuppression). Suspect effusion is most likely secondary to\n malignancy.\n -- Levaquin for CAP\n -- F/U Final chest CTA read given high risk of PE, especially in light\n of bevacizumab therapy\n -- Obtain OSH () onc records as unclear if pt has recently had\n any procedure for pleural effusions; then consider thoracentesis\n -- Supplemental oxygen, avoid hypoxia and resulting pulmonary\n vasoconstriction.\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction.\n -- F/U Final read of LENI\n -- Consider imaging of abd/pelvis (CT v MRI)\n -- Elevation of LE\n -- Consider ECHO\n #. BREAST CANCER: No plans for inpatient therapy\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n #. URINARY TRACT INFECTION: Levaquin for now.\n -- F/U Culture\n FEN: Regular diet\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n ACCESS: PIV's\n CODE STATUS: full\n DISPOSITION: ICU overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 664882,
"text": "Chief Complaint: Hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 56W widely metastatic breast ca, presented with LE swelling and pain.\n found to have larger right effusion and progressive mets in lungs.\n done. cause of LE edema unclear ? IVC occlusion (known tumor\n abutting IVC versus avastin and dex related).\n 24 Hour Events:\n THORACENTESIS - At 02:11 PM--1.2L removed. Exudative by\n LDH.\n History obtained from Medical records\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Levofloxacin - 08:53 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 05:52 PM\n Heparin Sodium (Prophylaxis) - 10:28 PM\n Other medications:\n Iron, Vit D, valsartin, decadron 4mg q12h\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: Edema\n Respiratory: Dyspnea\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:34 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.8\nC (96.5\n HR: 93 (92 - 117) bpm\n BP: 134/78(92) {115/54(84) - 154/92(102)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,605 mL\n 322 mL\n PO:\n 690 mL\n 200 mL\n TF:\n IVF:\n 855 mL\n 122 mL\n Blood products:\n 560 mL\n Total out:\n 697 mL\n 360 mL\n Urine:\n 697 mL\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,908 mL\n -39 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: alopecia\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 3+, Left: 3+, pitting and non pitting\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 120 K/uL\n 115 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 106 mEq/L\n 139 mEq/L\n 26.6 %\n 10.3 K/uL\n [image002.jpg]\n 09:41 AM\n 05:02 AM\n 10:56 AM\n WBC\n 9.7\n 10.3\n Hct\n 31.2\n 26.3\n 26.6\n Plt\n 118\n 120\n Cr\n 0.5\n 0.5\n Glucose\n 88\n 115\n Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,\n Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,\n Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3\n mg/dL\n Imaging: CXR: improved right effusion, extensive parehncymal\n opacities.\n Assessment and Plan\n 1) Hypoxemia:\n She has extensive pulmonary metastatic disease and a large right\n pleural effusion.\n Improved after thoracentesis. F/u studies though likely a malignant\n pleural effusion.\n Continue supplemental O2.\n Possible that she has a pneumonia as well--continue empiric levaquin.\n 2) LE edema:\n Ask radiology to reviewd chest CT to evaluate for IVC compression.\n 3) UTI:\n cont levoflox, check urine culture.\n 4) Anemia:\n No evidence of bleeding currently.\n will follow serial Hcts\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664892,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 5LNC. Sats 98%, RR 10\ns-20\ns. Pt appears very\n comfortable. Denies SOB. LS have diffuse crackles.\n Action:\n Oxygen lowered to 3LNC\n Response:\n Sats down to 90%. Team aware and accepts sats above 90%.\n Plan:\n Continue to monitor. Maintain sats above 90%. Called out to 7 South.\n Assessment:\n Lower extremities remain edematous at about 8mm. Pulses palpable\n bilaterally. Right foot not as painful as it was yesterday. Patient\n denied pain upon palpation of foot.\n Action:\n Feet elevated on bed. Pulses checked and are present\n Response:\n Still unclear what type of rash/cellulitis this is. Pt has remained\n afebrile, and is receiving heparin q 8 hrs.\n Plan:\n Cont to monitor\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 664736,
"text": "Chief Complaint: Syncope\n HPI:\n year old man with history of seizures, prior CVA, bilateral carotid\n endarterectomies, hypertension, prostate cancer, CAD s/p NTEMI,\n presenting after syncopal episode at home.\n .\n Patient was having dinner with his family when he was noted to slump\n down on his arm chair and becoming unresponsive. Drooling was noted\n from the left side of his mouth. Patients grandson is a police officer\n and reports not being able to find a pulse or to arouse him. Patient\n did not receive CPR, EMS was called and he was taken to nearby\n hospital.\n At , VS 211/120, HR 90, RR 26. Pt given IV\n labetalol 10mg x 2 with BP 185/92 at time of transfer. Non contrast\n head CT with preliminary read of no acute intracraneal hemorrhage.\n .\n Pacer pads, brady to 15s hypertensive 200's/.100's. NSGY BP goals less\n than 140, on nicardipine drip, lateral ST changes. Needs repeat head CT\n in AM.\n .\n Per neurosurgery, no immediate intervention needed. Patient will need\n repeat head CT in the morning. Although he received aspirin 325mg in\n ED, does not need platelets at this time. Asked to hold any further\n aspirin and plavix.\n Patient admitted from: ER\n History obtained from Family / Friend\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - CVA with residual speech impairments\n Seizure disorder, on tegretol\n Bilateral Carotid Endarterectomy\n Prostate Cancer treated with Casodex\n Hypertension\n Inguinal Hernia\n Aortic Sclerosis\n Arthritis\n - Upper GI bleed\n Psoriasis on elbows\n Depression\n BPH\n HOME MEDS:\n tegretol 200mg \n flomax .8mg\n plavix,\n sertraline 100\n lopressor 25mg \n simvastatin 80\n finasteride\n Digoxin 0.125\n Bicalutamide 50mg\n Aspirin 325mg\n Non contributory\n Occupation:\n Drugs: none\n Tobacco: None\n Alcohol: none\n Other: Lives with daughter, uses to ambulate\n Review of systems:\n Flowsheet Data as of 04:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (118 - 118) bpm\n BP: 142/88(101) {142/88(101) - 142/88(101)} mmHg\n RR: 7 (7 - 7) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -80 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n Physical Examination\n GENERAL: Pleasant, well appearing elderly man in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. (+) Tongue ecchymoses. Neck Supple, No LAD,\n No thyromegaly. Bilateral scars over carotid artery, no bruits.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI Systolic\n crescendo murmur. No rubs or gallops.\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. Large inguinal hernia, partially\n reducible, non tender or discolored. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Speech slurred, word finding difficulties (per family at\n baseline) Appropriate. CN 2-12 grossly intact although with poor effort\n on exam. Preserved sensation throughout. 5/5 strength throughout. +\n reflexes, equal BL. Normal coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 257\n 163\n 1.1\n 25\n 27\n 99\n 4.6\n 137\n 37.4\n 11.6\n [image002.jpg]\n Other labs: CK / CKMB / Troponin-T:CK: 154 MB: 6 Trop-T: <0.01\n Fluid analysis / Other labs: OSH Labs:\n Tegretol 7.1 []\n 13> 38 < 240\n 136 | 98 | 27\n ---------------< 150\n 5.1 | 28 | 1.1\n .\n Digoxin 1.29 [0.9 - 2.0]\n Imaging: CHEST X-RAY: ED \n Per personal review, AP Film with enlarged mediastinum, cardiomegaly,\n globular heart, mildly increased pulmonary vasculature and right upper\n lobe infiltrate.\n ECG: CARDIAC CATH: \n FINAL DIAGNOSIS:\n 1. Two vessel coronary artery disease.\n 2. Severe systemic hypertension.\n 3. Successful stenting of the D1 with a bare metal stent.\n ECG: Sinus rhythm with 1st degree AV block, inferior Q waves and 1-2mm\n lateral ST depressions. Likely left atrial abnormality.\n Assessment and Plan\n year old man with history of CVA, hypertension, seizure disorder,\n CAS s/p bilateral CAE and CAD, presenting with breakthrough seizure,\n found to have small subdural hematoma.\n .\n #. SYNCOPE: Unclear what the inciting event was. Although patient had\n ICH, this may have been secondary to fall after LOC or primary cause of\n seizure resulting in a fall. Given extensive cardiac history, would\n also consider arryhtmic event and or symptomatic bradycardia resulting\n in hemodynamic collapse. Given location of blood however, would not\n think this is in location consistent with trauma related bleed at\n temporal and occipital regions are spared. Although patient had seizure\n activity, this may have been due to relative hypotension/hypoperfusion\n or a primary event.\n .\n Most likely unifying explanation appears to be spontaneous SDH in the\n setting of hypertension leading to seizure activity.\n -- Continue tegretol\n -- Consider EEG\n -- Neurology consult for seizure management\n -- Telemetry monitoring\n .\n #. BRADYCARDIA: In seeting of acute ICH and administration of labetalol\n and metoprolol 25mg on patient therapeutic on digoxin. Tracings from\n that time reveal up to 6 second pauses with sinus arrest (no p waves).\n -- Atropine at the bedside\n -- Pacing pads on\n -- Would Hold beta blockers overnight\n -- Continue digoxin\n .\n #. SUBDURAL HEMATOMA: Relatively small amount of blood. Per\n neurosurgery will need follow up CT head in AM, no further\n intervention. Does not need platelet transfusion after receiving\n aspirin/ plavix.\n -- CT Head non contrast ordered\n -- Hold aspirin\n -- Hold plavix\n -- Seizure management per neurology\n .\n #. HYPERTENSION: As above, likely cause of SAH. In order to prevent\n re-bleed, will need tight monitoring.\n -- SBP goal less than 140\n -- Nicardipine if needed to maintain goal\n -- Would favor using oral, long acting to maintain BP\n (amlodipine)\n .\n #. ECG CHANGES: In setting of acute stress event, likely represent mild\n demand ischemia in setting of known completely obstructed RCA with left\n filling and likely steal\n -- ROMI\n -- ECG in am\n .\n FEN: NPO overnight, advance diet in AM\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n .\n ACCESS: PIV's\n .\n CODE STATUS: full\n .\n EMERGENCY CONTACT:\n .\n DISPOSITION: ICU overnight.\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664744,
"text": "Ms is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema since\n starting dexamethasone as part of her chemotherapy, as was noted in her\n neuro-oncology visit note. Patient reports she began having pain in her\n right leg that was worse with walking. She also reports having \"cold\n like symptoms\" with a cough and some runny nose, denies any fevers or\n chills. Patient decided to come into the ED after her symptoms were not\n improved with tylenol.\n .\n In the emergency department patient 97 114 127/103 93% on 4L. Lower\n extremity ultrasound was obtained to evaluate for DVT, CTA of the chest\n ordered to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia. Patient also given 500ml bolus.\n Patient noted to have transient desaturations to mid 80's with\n movement. Given tenuous stauts, patient admitted to for close\n monitoring.\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664885,
"text": "TITLE:\n Chief Complaint: 56 year old woman with metastatic breast cancer to\n bone, lung and brain, presenting with worsening lower extremity edema,\n found to be hypoxic and with new large right pleural effusion.\n 24 Hour Events:\n THORACENTESIS - At 02:11 PM\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Levofloxacin - 08:53 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Morphine Sulfate - 05:52 PM\n Heparin Sodium (Prophylaxis) - 10:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.2\n HR: 95 (95 - 119) bpm\n BP: 115/74(84) {115/54(84) - 154/94(104)} mmHg\n RR: 15 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,605 mL\n 76 mL\n PO:\n 690 mL\n TF:\n IVF:\n 855 mL\n 76 mL\n Blood products:\n 560 mL\n Total out:\n 697 mL\n 245 mL\n Urine:\n 697 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,908 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 120 K/uL\n 8.7 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 106 mEq/L\n 139 mEq/L\n 26.3 %\n 10.3 K/uL\n [image002.jpg]\n 09:41 AM\n 05:02 AM\n WBC\n 9.7\n 10.3\n Hct\n 31.2\n 26.3\n Plt\n 118\n 120\n Cr\n 0.5\n 0.5\n Glucose\n 88\n 115\n Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,\n Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,\n Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3\n mg/dL\n Fluid analysis / Other labs: Pleural Fluid\n Chemistry\n Protein 2.4\n Glucose 105\n Creat: 0.4\n LD(LDH): 428\n Albumin: 1.7\n Pleural Fluid\n WBC 225\n RBC 315\n Poly 7\n Lymph 37\n Mono 7\n EOs\n Meso: 2\n Macro: 43\n Other: 4\n Imaging: CTA\n 1. No definite evidence of pulmonary emboli.\n 2. Extensive lung masses and nodules involving both lungs, which\n appears to\n have increased when compared to prior exam. Some of these masses appear\n to\n encase the distal segmental pulmonary arteries.\n 3. Extensive ground-glass opacity and septal thickening. This could\n represent\n lymphangitic spread or edema.\n 4. Hypodense lesions in the liver concerning for metastasis and fluid\n within\n the perihepatic space.\n 5. Sclerotic lesions in the lower thoracic vertebral bodies with\n compression\n deformities.\n 6. Large left pleural effusion and small right pleural effusion.\n LENI\n IMPRESSION: No evidence of DVT.\n The study and the report were reviewed by the staff radiologist.\n Assessment and Plan\n RASH\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n #. RESPIRATORY DISTRESS: Currently on 4L O2, at baseline is 100%RA. As\n the pt has mets in lung and unclear history of sarciod it is difficult\n to discern whether the pt has pneumonia as well. No fever, minimal\n cough and nl WBC (although pt does have bands, and normal WBC may be\n elevated in the setting of recent Avastin and possible\n myelosuppression). Suspect effusion is most likely secondary to\n malignancy.\n -- Levaquin for CAP\n -- S/ \n -- Supplemental oxygen.\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction.\n -- Final LENI\ns negative for DVT\n -- Consider imaging of abd/pelvis (CT v MRI)\n -- Elevation of LE\n -- F/u final echo\n #. BREAST CANCER: No plans for inpatient therapy\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n #. URINARY TRACT INFECTION: Levaquin for now. X3d\n -- F/U Culture\n FEN: Regular diet\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n ACCESS: PIV's\n CODE STATUS: full\n -- Plan for family meeting today\n DISPOSITION: transfer to OMED\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664887,
"text": "TITLE:\n Chief Complaint: 56 year old woman with metastatic breast cancer to\n bone, lung and brain, presenting with worsening lower extremity edema,\n found to be hypoxic and with new large right pleural effusion.\n 24 Hour Events:\n THORACENTESIS - At 02:11 PM\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Levofloxacin - 08:53 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Morphine Sulfate - 05:52 PM\n Heparin Sodium (Prophylaxis) - 10:28 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 35.7\nC (96.2\n HR: 95 (95 - 119) bpm\n BP: 115/74(84) {115/54(84) - 154/94(104)} mmHg\n RR: 15 (15 - 27) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,605 mL\n 76 mL\n PO:\n 690 mL\n TF:\n IVF:\n 855 mL\n 76 mL\n Blood products:\n 560 mL\n Total out:\n 697 mL\n 245 mL\n Urine:\n 697 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,908 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 120 K/uL\n 8.7 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 106 mEq/L\n 139 mEq/L\n 26.3 %\n 10.3 K/uL\n [image002.jpg]\n 09:41 AM\n 05:02 AM\n WBC\n 9.7\n 10.3\n Hct\n 31.2\n 26.3\n Plt\n 118\n 120\n Cr\n 0.5\n 0.5\n Glucose\n 88\n 115\n Other labs: PT / PTT / INR:16.7/70.0/1.5, Differential-Neuts:86.0 %,\n Band:6.0 %, Lymph:2.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:2.6 mmol/L,\n Albumin:2.4 g/dL, LDH:830 IU/L, Ca++:8.3 mg/dL, Mg++:2.7 mg/dL, PO4:2.3\n mg/dL\n Fluid analysis / Other labs: Pleural Fluid\n Chemistry\n Protein 2.4\n Glucose 105\n Creat: 0.4\n LD(LDH): 428\n Albumin: 1.7\n Pleural Fluid\n WBC 225\n RBC 315\n Poly 7\n Lymph 37\n Mono 7\n EOs\n Meso: 2\n Macro: 43\n Other: 4\n Imaging: CTA\n 1. No definite evidence of pulmonary emboli.\n 2. Extensive lung masses and nodules involving both lungs, which\n appears to\n have increased when compared to prior exam. Some of these masses appear\n to\n encase the distal segmental pulmonary arteries.\n 3. Extensive ground-glass opacity and septal thickening. This could\n represent\n lymphangitic spread or edema.\n 4. Hypodense lesions in the liver concerning for metastasis and fluid\n within\n the perihepatic space.\n 5. Sclerotic lesions in the lower thoracic vertebral bodies with\n compression\n deformities.\n 6. Large left pleural effusion and small right pleural effusion.\n LENI\n IMPRESSION: No evidence of DVT.\n The study and the report were reviewed by the staff radiologist.\n Assessment and Plan\n RASH\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n #. RESPIRATORY DISTRESS: Currently on 4L O2, at baseline is 100%RA. As\n the pt has mets in lung and unclear history of sarciod it is difficult\n to discern whether the pt has pneumonia as well. No fever, minimal\n cough and nl WBC (although pt does have bands, and normal WBC may be\n elevated in the setting of recent Avastin and possible\n myelosuppression). Suspect effusion is most likely secondary to\n malignancy.\n -- Levaquin for CAP\n -- S/ \n -- Supplemental oxygen.\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction.\n -- Final LENI\ns negative for DVT\n -- Consider imaging of abd/pelvis (CT v MRI)\n -- Elevation of LE\n -- F/u final echo\n #. BREAST CANCER: No plans for inpatient therapy\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n #. URINARY TRACT INFECTION: Levaquin for now. X3d\n -- F/U Culture\n FEN: Regular diet\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n ACCESS: PIV's\n CODE STATUS: full\n -- Plan for family meeting today\n DISPOSITION: transfer to OMED\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Echo",
"chartdate": "2162-05-03 00:00:00.000",
"description": "Report",
"row_id": 62474,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 67\nWeight (lb): 148\nBSA (m2): 1.78 m2\nBP (mm Hg): 130/84\nHR (bpm): 92\nStatus: Outpatient\nDate/Time: at 09:44\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm) with >55%\ndecrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The estimated\nright atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (the apical\nLV is not well seen due to very poor apical images) (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. Minimal mitral regurgitation is seen. There is mild pulmonary\nartery systolic hypertension. There is an anterior space which most likely\nrepresents a fat pad.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with normal cavity sizes and global biventricular systolic\nfunction. Mild aortic valve sclerosis. Mild pulmonary artery systolic\nhypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2162-05-01 00:00:00.000",
"description": "Report",
"row_id": 122241,
"text": "Right-sided chest leads are submitted. Sinus tachycardia. Left atrial\nabnormality. Right-sided chest leads do not show evidence of elevation in\nlead V4R.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-05-01 00:00:00.000",
"description": "Report",
"row_id": 122242,
"text": "Sinus tachycardia. Left atrial abnormality. Possible prior inferior\nmyocardial infarction. Poor R wave progression. Consider prior anteroseptal\nmyocardial infarction. Compared to the previous tracing of poor\nR wave progression is seen on the current tracing and the rate is increased.\nThe other findings are similar.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1068983,
"text": " 10:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with hx of breast CA with brain bets c/o sob, confusion\n REASON FOR THIS EXAMINATION:\n Evaluate for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SUN 12:30 AM\n no sig change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old female with history of breast cancer with metastatic\n brain disease treated by radiation. Evaluate for hemorrhage.\n\n COMPARISON: Head MRI dated ; noncontrast head CT dated .\n\n TECHNIQUE: MDCT axial acquired images of the head were obtained. No IV\n contrast was administered.\n\n FINDINGS: There is hypodensity in the cerebellar hemispheres at the\n location of the known cerebellar masses, which are are poorly visualized.\n There are small foci of hyperdensity in the right cerebellar hemisphere,\n corresponding to the location of a metastasis which was previously shown to be\n hemorrhagic on MRI, without significant change compared to the CT.\n Otherwise, there is no new acute hemorrhage.\n\n Diffuse moderated prominence of the ventricles and sulci is unchanged compared\n to . The fourth ventricle has re-expanded compared to\n . Supratentorial white matter hypoattenuation is also unchanged,\n likely related to radiation therapy. There is no shift of normally midline\n structures.\n\n Three is no fracture. A right frontal burr hole is again seen. The visualized\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n\n 1. Unchanged small hyperdense foci in the right cerebellar hemisphere within\n a known metastasis. Otherwise, no acute hemorrhage.\n 2. The extent of metastatic disease is better assessed on the MRI.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-01 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1068984,
"text": " 10:37 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for PE/mass/infiltrate\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with hx of breast CA with brain bets c/o sob, confusion\n REASON FOR THIS EXAMINATION:\n Evaluate for PE/mass/infiltrate\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SUN 12:48 AM\n no definate pe. large right pleural effusion. extensive lung masses increased\n with ground glass opacities.\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE CHEST\n\n COMPARISON: Outside CT, .\n\n HISTORY: Shortness of breath.\n\n TECHNIQUE: MDCT axially acquired images of the chest were obtained. IV\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: Patient is status post bilateral mastectomy with bilateral breast\n implants identified. There is no axillary or mediastinal lymphadenopathy\n identified. Multiple lung masses seen throughout both lungs are identified,\n the largest at the right lung base measuring approximately 3.3 x 3.9 cm (3:61)\n and in the right upper lobe (3, 31) measuring approximately 5.1 x 3.0 cm.\n These appear to have increased in both size and number, when compared to the\n prior exam. Many of these masses and nodules appear to encase the distal\n branches of the pulmonary arteries. For example, in the right lower lung (3,\n 47). The pulmonary arteries, however, remain patent, and there are no\n apparent filling defects identified. There is a trace left pleural effusion\n and a large right pleural effusion identified. There is no evidence of\n pneumothorax. Extensive ground-glass opacities and septal thickening is\n noted, bilaterally. This may represent edema and/or lymphangitic spread of\n carcinoma.\n\n Limited views of the upper abdomen demonstrate fluid in the perihepatic space\n and multiple hypodense lesions throughout the liver concerning for metastases.\n\n BONE WINDOWS: Sclerotic thoracic vertebral bodies (400B, 30 and 400B, 27) is\n identified with associated compression wedge deformity of the lower thoracic\n vertebral body.\n\n IMPRESSION:\n 1. No definite evidence of pulmonary emboli.\n 2. Extensive lung masses and nodules involving both lungs, which appears to\n have increased when compared to prior exam. Some of these masses appear to\n encase the distal segmental pulmonary arteries.\n 3. Extensive ground-glass opacity and septal thickening. This could represent\n (Over)\n\n 10:37 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evaluate for PE/mass/infiltrate\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lymphangitic spread or edema.\n 4. Hypodense lesions in the liver concerning for metastasis and fluid within\n the perihepatic space.\n 5. Sclerotic lesions in the lower thoracic vertebral bodies with compression\n deformities.\n 6. Large left pleural effusion and small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1068998,
"text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with metastatic breast cancer, with pneumonia and large right\n sided effusion\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Evaluate for interval change, metastatic breast cancer,\n pneumonia.\n\n FINDINGS:\n\n Comparison is made to the prior study from . There are multifocal\n patchy airspace opacities, some of which appear nodular. These are consistent\n with known metastatic disease. There are small bilateral pleural effusions.\n There is probable mild superimposed congestive failure. The appearance of the\n chest has worsened overall since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-01 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1068985,
"text": " 10:37 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Evaluate for DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with bilateral LE swelling\n REASON FOR THIS EXAMINATION:\n Evaluate for DVT\n ______________________________________________________________________________\n WET READ: SBNa SAT 11:51 PM\n\n no dvt\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: None.\n\n HISTORY: Bilateral lower extremity swelling.\n\n FINDINGS: -scale and color Doppler son were performed of the\n bilateral common femoral, superficial femoral, and popliteal veins. These\n demonstrate normal compressibility, flow, and augmentation.\n\n IMPRESSION: No evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069108,
"text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval changes\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with metastatic breast cancer, pleural effusions s/ of\n right effusion (1.2L)\n REASON FOR THIS EXAMINATION:\n please eval interval changes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CHgc MON 12:41 PM\n Persistent diffuse patchy opacities consistent with known extensive lung\n masses. Left pleural effusion. Retrocardiac atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Right thoracentesis.\n\n FINDINGS: Comparison is made with prior radiograph from and CT from\n . There are diffuse patchy opacities bilaterally consistent\n with known pulmonary masses. There is no evidence of reaccumulation of the\n right pleural effusion. There is a probable small left pleural effusion.\n There is no pneumothorax. The bones are unremarkable.\n\n IMPRESSION: No reaccumulation of right pleural effusion. No pneumothorax.\n Diffuse patchy opacity consistent with known pulmonary masses. Probable small\n left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1068980,
"text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate/edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate/edema\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , AT 2201 HOURS.\n\n HISTORY: Shortness of breath.\n\n COMPARISON: Chest CT dated .\n\n FINDINGS: Additional history retrieved from the radiology database reveals a\n history of metastatic breast cancer. There are numerous rounded densities\n throughout the lungs, corresponding to the known metastatic disease. However,\n superimposed, there are low lung volumes with areas of somewhat ill-defined\n patchy opacity in predominantly a perihilar distribution with pulmonary\n vascular indistinctness. Bilateral pleural effusions are also evident. The\n mediastinum is otherwise unremarkable, although there is marked prominence in\n the right hilum. The cardiac silhouette is top normal for size. No\n pneumothorax appreciated. There is a dextroconcave curvature of the upper\n thoracic spine. The osseous structures are grossly unremarkable otherwise.\n\n IMPRESSION: Known metastatic disease to the lungs. There is apparent\n superimposed volume overload with bilateral pleural effusions. Repeat\n radiography following appropriate diuresis to assess for underlying infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-03 00:00:00.000",
"description": "RP FOOT 2 VIEWS RIGHT PORT",
"row_id": 1069112,
"text": " 5:18 AM\n FOOT 2 VIEWS RIGHT PORT Clip # \n Reason: please eval for evidence of septic joints, fractures or othe\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with right lateral foot pain\n REASON FOR THIS EXAMINATION:\n please eval for evidence of septic joints, fractures or other causes of pain.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right lateral foot pain.\n\n RIGHT FOOT, TWO PORTABLE VIEWS.\n\n There is diffuse soft tissue swelling, most pronounced along the dorsum of the\n ankle and foot. No fracture, dislocation, osteolysis or degenerative change\n is detected, except for mild degenerative changes of the first MTP joint. No\n soft tissue calcification or radiopaque foreign body is identified.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069048,
"text": " 2:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please rule out pneumothorax, assess for interval change\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with right sided effusion, status-post thoracentesis on right\n with removal of 1200 fluid.\n REASON FOR THIS EXAMINATION:\n please rule out pneumothorax, assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Assess for interval change, status post thoracentesis\n on the right with removal of 1200 cc of fluid.\n\n FINDINGS:\n\n Comparison is made to the study of the same date performed at 05:09 hours.\n Since the prior study, there has been interval decreased right-sided pleural\n effusion which is now very small. There are persistent bilateral patchy\n airspace opacities of unclear etiology, cannot exclude underlying tumor,\n metastases, or pneumonia. In addition, there is a small left-sided pleural\n effusion and increased interval opacification of the left mid and lower lung\n zones. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1069545,
"text": ", T. NMED 7S 11:10 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess for re-accumulation of right sided pleural eff\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with metastatic breast cancer with bilateral pleural\n effusions, recently underwent right sided pleural effusion though exam suggets\n re-accumulation.\n REASON FOR THIS EXAMINATION:\n please assess for re-accumulation of right sided pleural effusions\n ______________________________________________________________________________\n PFI REPORT\n Re-accumulation of right pleural effusion, now in small amount, with\n costophrenic angle still visible.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069109,
"text": ", MED 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval changes\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with metastatic breast cancer, pleural effusions s/ of\n right effusion (1.2L)\n REASON FOR THIS EXAMINATION:\n please eval interval changes\n ______________________________________________________________________________\n PFI REPORT\n Persistent diffuse patchy opacities consistent with known extensive lung\n masses. Left pleural effusion. Retrocardiac atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-04 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1069412,
"text": " 2:32 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for IVC obstruction\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with widely metastatic breast ca who p/w 3 weeks of increased\n bilateral LE swelling.\n REASON FOR THIS EXAMINATION:\n please assess for IVC obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKSb TUE 6:09 PM\n PFI: Attenuation of the intrahepatic IVC without severe stenosis or thrombus.\n Extensive metastatic disease involving the liver and lungs and bones. T9\n vertebral body compression.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with metastatic breast cancer presenting with\n three weeks of bilateral lower extremity swelling. Evaluate for IVC\n obstruction.\n\n COMPARISON: Chest CTA .\n\n TECHNIQUE: Multidetector helical scanning of the abdomen and pelvis was\n performed following the administration of oral and 130 cc of IV Optiray\n contrast. Coronal and sagittal reformats were displayed.\n\n CT OF THE ABDOMEN: The patient is status post bilateral mastectomy with saline\n breast implants identified. Right pleural effusion has decreased in size\n compared to three days prior, c/w history of interval thoracentesis. Smaller\n left pleural effusion is unchanged. Again there are large lobulated masses at\n both lung bases measuring 4.2 x 2.6 cm on the right and 3.3 x 2.0 cm on the\n left. Ground-glass opacity in the right middle and lower lobes may represent\n asymmetric edema or tumor infiltration.\n\n There is diffuse metastatic disease within the liver, predominantly in the\n right lobe. The IVC is attenuated during its intra-hepatic portion, however,\n remains patent without significant stenosis. There is no evidence of IVC\n thrombus. The infrahepatic IVC also is not significantly dilated to suggest\n significant hemodynamic effect of the intrahepatic attenuation. The lower\n IVC, common iliac and external iliac veins all remain patent.\n\n The pancreas, spleen, adrenal glands, kidneys, and intra-abdominal small and\n large bowel loops are normal. The aorta is of normal caliber. The appendix\n is normal.\n\n CT OF THE PELVIS: A moderate amount of nonhemorrhagic free fluid is seen\n within the pelvis. The uterus, sigmoid colon and rectum are normal. Foley\n catheter and air are seen within the bladder. There is a moderate amount of\n stool in the rectum.\n\n (Over)\n\n 2:32 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for IVC obstruction\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is diffuse osseous metastatic disease with complete sclerosis of the L5\n and T11 vertebral bodies as well as sclerosis and compression fracture of the\n T9 vertebral body with approximately 40% loss of vertebral body height and no\n retropulsed fragments identified.\n\n IMPRESSION:\n\n 1. Attenuation of the intrahepatic IVC due to extensive hepatic metastatic\n disease, without evidence of severe stenosis or thrombus. The infrahepatic\n IVC and iliac veins remain patent.\n\n 2. Known pulmonary metastases. Worsened ground-glass opacity within the\n right middle and lower lobes which may represent edema or tumor spread.\n\n 3. Decreased size of right pleural effusion which is now moderate. Unchanged\n small left pleural effusion.\n\n 4. Pelvic free fluid.\n\n 5. Osseous metastatic disease with T9 vertebral body compression fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1069544,
"text": " 11:10 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess for re-accumulation of right sided pleural eff\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with metastatic breast cancer with bilateral pleural\n effusions, recently underwent right sided pleural effusion though exam suggets\n re-accumulation.\n REASON FOR THIS EXAMINATION:\n please assess for re-accumulation of right sided pleural effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 2:22 PM\n Re-accumulation of right pleural effusion, now in small amount, with\n costophrenic angle still visible.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old female with metastatic breast cancer with bilateral\n pleural effusions, recently underwent a right-sided pleural effusion. The\n exam suggests reaccumulation. Please assess for reaccumulation of right-sided\n pleural effusion.\n\n COMPARISON: Most recent chest radiograph .\n\n PA AND LATERAL CHEST RADIOGRAPHS: There is reaccumulation of right pleural\n effusion, in small amount, but with still visible costophrenic sinus. Left\n pleural effusion is also slightly increased in amount. Again seen are\n bilateral interstitial, hilar and nodular opacities throughout both lungs,\n consistent with known pulmonary nodules and probably lymphangitic\n infiltration. No pneumothorax.\n\n IMPRESSION:\n 1. Reaccumulation of right pleural effusion, now in a small amount. Slight\n worsening of left pleural effusion.\n 2. Persistent diffuse patchy opacities in both lungs consistent with known\n lung masses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-05-04 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1069413,
"text": ", T. NMED 7S 2:32 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for IVC obstruction\n Admitting Diagnosis: METASTATIC CANCER;HYPOXIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with widely metastatic breast ca who p/w 3 weeks of increased\n bilateral LE swelling.\n REASON FOR THIS EXAMINATION:\n please assess for IVC obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Attenuation of the intrahepatic IVC without severe stenosis or thrombus.\n Extensive metastatic disease involving the liver and lungs and bones. T9\n vertebral body compression.\n\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664760,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n PMH:\n ONCOLOGICAL HISTORY:\n Breast cancer with metastases to cerebellum\n - Right breast mass found , s/p righ breast mass lumpectomy\n (T1N0M0), s/p chest XRT and CMF (cyclophosphamide, methotrexate, and\n 5-FU), adjuvant chemotherapy, followed by tamoxifen\n - with left breast mass, s/p left lumpectomy, chest XRT followed\n by tamoxifen, stopped in .\n - , recurrent disease in the left breast. Metastatic work up with\n metastases in lungs and bone, s/p Adriamycin and cyclophosphamide x 4\n cycles, also taxol from which she developed an anaphylactic reaction.\n -completed whole brain cranial irradiation on , adjuvant\n Herceptin and navelbine, followed by recent Herceptin and Xeloda\n -s/p a third ventriculostomy by , M.D. on ,\n -s/p Cyberknife radiosurgery on to a left cerebellar\n metastasis to 1,800 cGy at 82% isodose line and to a right\n cerebellar metastasis to 1,600 cGy at 73% isodose line on\n , and\n -has been getting lapatinib and carboplatin every 3 weeks\n since for her progressive disease; delayed because\n of her surgeries.\n -s/p second third ventriculostomy procedure by ,\n M.D. on .\n - she was scheduled to receive Doxil on but did not go.\n - She has started bevacizumab alone in .\n OTHER PAST MEDICAL HISTORY:\n h/o Factor VIII deficiency\n Suspected anti-cardiolipin antibody\n Hypertension\n Sarcoidosis\n s/p Lung biopsy \n ED:\n Chest CTA: no definite PE. Large R pleural effusion . Extensive lung\n masses increased with ground glass opacities.\n Chest CT: Known metastatic disease to lungs. Apparent superimposed\n volume overload with bilateral pleural effusions.\n CT head: No significant change.\n USG BLE: No DVT\n Respiratory distress/ pneumonia\n Assessment:\n A/O x3, forgetful at times. Sats maintaining well above 93%- 98% (when\n sleeping) with O2 4LNC. LS diminished with crackles in RLL. Pt had\n received 500cc fluid in ED. Foley catheter in place draining > 30cc/hr.\n Vancomycin 1gm and levoquin 750 mg IV given in ED. Pt has 6-8 mm edema\n of both legs, c/o pain in R ankle on touch ( on a scale of ,\n tolerable).\n Action:\n Followed hemodynamic state closely . RLE kept elevated.\n Response:\n Ongoing.\n Plan:\n Continue to monitor hemodynamic status, ? plan for therapeutic\n thoracentesis in a.m , ? echo.\n K+ 3.2 in ED: KCL po 40 meq given, IV 40meq in 500cc on flow.\n Labs to be drawn after K+ repletement.\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664765,
"text": "TITLE:\n Chief Complaint: 56 year old woman with metastatic breast cancer to\n bone, lung and brain, presenting with worsening lower extremity edema,\n found to be hypoxic and with new large right pleural effusion.\n 24 Hour Events:\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 103 (99 - 118) bpm\n BP: 137/83(97) {135/78(93) - 145/88(102)} mmHg\n RR: 19 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,042 mL\n PO:\n 150 mL\n TF:\n IVF:\n 392 mL\n Blood products:\n Total out:\n 0 mL\n 188 mL\n Urine:\n 188 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of \n 10:37 PM\n Wet Read:\n no definate pe. large right pleural effusion. extensive lung masses\n increased with ground glass opacities.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n #. RESPIRATORY DISTRESS: Multifactorial in this woman with lung\n metastasis, history of sarcoidosis, s/p XRT to both sides of the chest\n and now with likely obstructing lesions and pneumonia as well as large\n effusion. Suspect effusion is most likely secondary to malignancy.\n -- Vanc and levaquin for post obstructive pneumonia\n -- F/U Final chest CTA read given high risk of PE, especially in light\n of bevacizumab therapy\n -- Would strongly consider therapeutic thoracentesis in AM\n -- Supplemental oxygen, avoid hypoxia and resulting pulmonary\n vasoconstriction.\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction. Alghough\n no LE DVE was seen on US and chest clear for PE, given malignancy,\n history of pro-coagulable disorder and bevacizumab therapy, would still\n strongly consider -occlusive event, specifically of the IVC. Would\n also consider extrinsic compression of IVC, as well as massive fluid\n retention from corticosteroids and right sided heart failure (as\n evidenced by increased BNP). This however could be secondary to\n increased pulmonary pressures from large effusion.\n -- F/U Final read of LENI\n -- Consider imaging of abd/pelvis\n -- Elevation of LE\n -- Consider ECHO\n #. BREAST CANCER: No plans for inpatient therapy\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n #. URINARY TRACT INFECTION: Adequately convered on above antibiotic\n regimen.\n -- F/U Culture\n FEN: Regular diet\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n ACCESS: PIV's\n CODE STATUS: full\n DISPOSITION: ICU overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664768,
"text": "TITLE:\n Chief Complaint: 56 year old woman with metastatic breast cancer to\n bone, lung and brain, presenting with worsening lower extremity edema,\n found to be hypoxic and with new large right pleural effusion.\n 24 Hour Events:\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 103 (99 - 118) bpm\n BP: 137/83(97) {135/78(93) - 145/88(102)} mmHg\n RR: 19 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,042 mL\n PO:\n 150 mL\n TF:\n IVF:\n 392 mL\n Blood products:\n Total out:\n 0 mL\n 188 mL\n Urine:\n 188 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of \n 10:37 PM\n Wet Read:\n no definate pe. large right pleural effusion. extensive lung masses\n increased with ground glass opacities.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n #. RESPIRATORY DISTRESS: Multifactorial in this woman with lung\n metastasis, history of sarcoidosis, s/p XRT to both sides of the chest\n and now with likely obstructing lesions and pneumonia as well as large\n effusion. Suspect effusion is most likely secondary to malignancy.\n -- Vanc and levaquin for post obstructive pneumonia\n -- F/U Final chest CTA read given high risk of PE, especially in light\n of bevacizumab therapy\n -- Would strongly consider therapeutic thoracentesis in AM\n -- Supplemental oxygen, avoid hypoxia and resulting pulmonary\n vasoconstriction.\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction. Alghough\n no LE DVE was seen on US and chest clear for PE, given malignancy,\n history of pro-coagulable disorder and bevacizumab therapy, would still\n strongly consider -occlusive event, specifically of the IVC. Would\n also consider extrinsic compression of IVC, as well as massive fluid\n retention from corticosteroids and right sided heart failure (as\n evidenced by increased BNP). This however could be secondary to\n increased pulmonary pressures from large effusion.\n -- F/U Final read of LENI\n -- Consider imaging of abd/pelvis\n -- Elevation of LE\n -- Consider ECHO\n #. BREAST CANCER: No plans for inpatient therapy\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n #. URINARY TRACT INFECTION: Adequately convered on above antibiotic\n regimen.\n -- F/U Culture\n FEN: Regular diet\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n ACCESS: PIV's\n CODE STATUS: full\n DISPOSITION: ICU overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 664772,
"text": "Chief Complaint: Syncope\n HPI:\n year old man with history of seizures, prior CVA, bilateral carotid\n endarterectomies, hypertension, prostate cancer, CAD s/p NTEMI,\n presenting after syncopal episode at home.\n .\n Patient was having dinner with his family when he was noted to slump\n down on his arm chair and becoming unresponsive. Drooling was noted\n from the left side of his mouth. Patients grandson is a police officer\n and reports not being able to find a pulse or to arouse him. Patient\n did not receive CPR, EMS was called and he was taken to nearby\n hospital.\n At , VS 211/120, HR 90, RR 26. Pt given IV\n labetalol 10mg x 2 with BP 185/92 at time of transfer. Non contrast\n head CT with preliminary read of no acute intracraneal hemorrhage.\n .\n Pacer pads, brady to 15s hypertensive 200's/.100's. NSGY BP goals less\n than 140, on nicardipine drip, lateral ST changes. Needs repeat head CT\n in AM.\n .\n Per neurosurgery, no immediate intervention needed. Patient will need\n repeat head CT in the morning. Although he received aspirin 325mg in\n ED, does not need platelets at this time. Asked to hold any further\n aspirin and plavix.\n Patient admitted from: ER\n History obtained from Family / Friend\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n - CVA with residual speech impairments\n Seizure disorder, on tegretol\n Bilateral Carotid Endarterectomy\n Prostate Cancer treated with Casodex\n Hypertension\n Inguinal Hernia\n Aortic Sclerosis\n Arthritis\n - Upper GI bleed\n Psoriasis on elbows\n Depression\n BPH\n HOME MEDS:\n tegretol 200mg \n flomax .8mg\n plavix,\n sertraline 100\n lopressor 25mg \n simvastatin 80\n finasteride\n Digoxin 0.125\n Bicalutamide 50mg\n Aspirin 325mg\n Non contributory\n Occupation:\n Drugs: none\n Tobacco: None\n Alcohol: none\n Other: Lives with daughter, uses to ambulate\n Review of systems:\n Flowsheet Data as of 04:12 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 118 (118 - 118) bpm\n BP: 142/88(101) {142/88(101) - 142/88(101)} mmHg\n RR: 7 (7 - 7) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -80 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n Physical Examination\n GENERAL: Pleasant, well appearing elderly man in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. (+) Tongue ecchymoses. Neck Supple, No LAD,\n No thyromegaly. Bilateral scars over carotid artery, no bruits.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI Systolic\n crescendo murmur. No rubs or gallops.\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. Large inguinal hernia, partially\n reducible, non tender or discolored. No HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Speech slurred, word finding difficulties (per family at\n baseline) Appropriate. CN 2-12 grossly intact although with poor effort\n on exam. Preserved sensation throughout. 5/5 strength throughout. +\n reflexes, equal BL. Normal coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 257\n 163\n 1.1\n 25\n 27\n 99\n 4.6\n 137\n 37.4\n 11.6\n [image002.jpg]\n Other labs: CK / CKMB / Troponin-T:CK: 154 MB: 6 Trop-T: <0.01\n Fluid analysis / Other labs: OSH Labs:\n Tegretol 7.1 []\n 13> 38 < 240\n 136 | 98 | 27\n ---------------< 150\n 5.1 | 28 | 1.1\n .\n Digoxin 1.29 [0.9 - 2.0]\n Imaging: CHEST X-RAY: ED \n Per personal review, AP Film with enlarged mediastinum, cardiomegaly,\n globular heart, mildly increased pulmonary vasculature and right upper\n lobe infiltrate.\n ECG: CARDIAC CATH: \n FINAL DIAGNOSIS:\n 1. Two vessel coronary artery disease.\n 2. Severe systemic hypertension.\n 3. Successful stenting of the D1 with a bare metal stent.\n ECG: Sinus rhythm with 1st degree AV block, inferior Q waves and 1-2mm\n lateral ST depressions. Likely left atrial abnormality.\n Assessment and Plan\n year old man with history of CVA, hypertension, seizure disorder,\n CAS s/p bilateral CAE and CAD, presenting with breakthrough seizure,\n found to have small subdural hematoma.\n .\n #. SYNCOPE: Unclear what the inciting event was. Although patient had\n ICH, this may have been secondary to fall after LOC or primary cause of\n seizure resulting in a fall. Given extensive cardiac history, would\n also consider arryhtmic event and or symptomatic bradycardia resulting\n in hemodynamic collapse. Given location of blood however, would not\n think this is in location consistent with trauma related bleed at\n temporal and occipital regions are spared. Although patient had seizure\n activity, this may have been due to relative hypotension/hypoperfusion\n or a primary event.\n .\n Most likely unifying explanation appears to be spontaneous SDH in the\n setting of hypertension leading to seizure activity.\n -- Continue tegretol\n -- Consider EEG\n -- Neurology consult for seizure management\n -- Telemetry monitoring\n .\n #. BRADYCARDIA: In seeting of acute ICH and administration of labetalol\n and metoprolol 25mg on patient therapeutic on digoxin. Tracings from\n that time reveal up to 6 second pauses with sinus arrest (no p waves).\n -- Atropine at the bedside\n -- Pacing pads on\n -- Would Hold beta blockers overnight\n -- Continue digoxin\n .\n #. SUBDURAL HEMATOMA: Relatively small amount of blood. Per\n neurosurgery will need follow up CT head in AM, no further\n intervention. Does not need platelet transfusion after receiving\n aspirin/ plavix.\n -- CT Head non contrast ordered\n -- Hold aspirin\n -- Hold plavix\n -- Seizure management per neurology\n .\n #. HYPERTENSION: As above, likely cause of SAH. In order to prevent\n re-bleed, will need tight monitoring.\n -- SBP goal less than 140\n -- Nicardipine if needed to maintain goal\n -- Would favor using oral, long acting to maintain BP\n (amlodipine)\n .\n #. ECG CHANGES: In setting of acute stress event, likely represent mild\n demand ischemia in setting of known completely obstructed RCA with left\n filling and likely steal\n -- ROMI\n -- ECG in am\n .\n FEN: NPO overnight, advance diet in AM\n .\n PPX:\n -DVT ppx with pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n .\n ACCESS: PIV's\n .\n CODE STATUS: full\n .\n EMERGENCY CONTACT:\n .\n DISPOSITION: ICU overnight.\n .\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 07:51 ------\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 664778,
"text": "Chief Complaint: LE edema and pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 56W metastatic breast cancer, presented with LE edema worsened by\n dexamethasone. Also, recent URI. Came to ER because worsening LE pain.\n In ER hypoxemia. Worked up for DVT and PE which were negative. CT-A\n showed possible post-obstructive pneumonia.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n breast cancer lumpectomy and XRT, recurred , now on avastin\n ? hemophilia, ? anti-cardiolipin antibodies\n sarcoidosis\n breast cancer\n Occupation:\n Drugs:\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Musculoskeletal: leg swelling and pain\n Flowsheet Data as of 09:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 105 (99 - 118) bpm\n BP: 129/84(95) {129/78(93) - 145/88(102)} mmHg\n RR: 19 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,395 mL\n PO:\n 390 mL\n TF:\n IVF:\n 505 mL\n Blood products:\n Total out:\n 0 mL\n 258 mL\n Urine:\n 258 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,137 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : anteriorly, Diminished:\n right)\n Abdominal: Soft, Non-tender\n Extremities: Right: 4+, Left: 4+, edema\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: LENI negative\n CT-A no PE, large right small left effusion, multiple lung masses, left\n greater than right\n Assessment and Plan\n Respiratory distress - related to effusion, infiltrates, tumor. Needs\n thoracentesis, treat with emperic antibiotics.\n LE edema - no DVT though may be more proximal, will obtain echo,\n repeat LENI's,\n right leg pain - obtain outside images, likely\n UTI - levoflox should cover\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 02:48 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 664781,
"text": "TITLE:\n Chief Complaint: 56 year old woman with metastatic breast cancer to\n bone, lung and brain, presenting with worsening lower extremity edema,\n found to be hypoxic and with new large right pleural effusion.\n 24 Hour Events: Had CTA chest, prelim read\n for PE. Had LENIs with\n prelim\n for DVT.\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96.1\n Tcurrent: 35.6\nC (96.1\n HR: 103 (99 - 118) bpm\n BP: 137/83(97) {135/78(93) - 145/88(102)} mmHg\n RR: 19 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,042 mL\n PO:\n 150 mL\n TF:\n IVF:\n 392 mL\n Blood products:\n Total out:\n 0 mL\n 188 mL\n Urine:\n 188 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 854 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n GENERAL: Pleasant, well appearing woman with cushinoid features.\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. obese neck.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or gallops\n LUNGS: Decreased breath sounds at right base, (+) Egophony. Anterior\n rhonchi on right.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: Massive lower extremity edema to the thigh.\n SKIN: Rash along posterior surface of right leg.\n NEURO: A&Ox3. ? Cognitive slowing. Appropriate. CN 2-12 grossly intact.\n Preserved sensation throughout. 5/5 strength throughout. + reflexes,\n equal BL. Normal coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n Imaging: CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of \n 10:37 PM\n Wet Read:\n no definate pe. large right pleural effusion. extensive lung masses\n increased with ground glass opacities.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 56 year old woman with metastatic breast cancer to bone, lung and\n brain, presenting with worsening lower extremity edema, found to be\n hypoxic and with new large right pleural effusion.\n #. RESPIRATORY DISTRESS: Currently on 4L O2, at baseline is 100%RA. As\n the pt has mets in lung and unclear history of sarciod it is difficult\n to discern whether the pt has pneumonia as well. No fever, minimal\n cough and nl WBC (although pt does have bands, and normal WBC may be\n elevated in the setting of recent Avastin and possible\n myelosuppression). Suspect effusion is most likely secondary to\n malignancy.\n -- Levaquin for CAP\n -- F/U Final chest CTA read given high risk of PE, especially in light\n of bevacizumab therapy\n -- Obtain OSH () onc records as unclear if pt has recently had\n any procedure for pleural effusions; then consider thoracentesis\n -- Supplemental oxygen, avoid hypoxia and resulting pulmonary\n vasoconstriction.\n #. LOWER EXTREMITY EDEMA: Concerning for venous obstruction.\n -- F/U Final read of LENI\n -- Consider imaging of abd/pelvis (CT v MRI)\n -- Elevation of LE\n -- Consider ECHO\n #. BREAST CANCER: No plans for inpatient therapy\n #. BRAIN METASTASIS: CT stable, no significant change in cerebellar\n lesions\n #. URINARY TRACT INFECTION: Levaquin for now.\n -- F/U Culture\n FEN: Regular diet\n PPX:\n -DVT ppx with SQ Heparin and Pneumoboots\n -Bowel regimen\n -Pain management with Tylenol\n ACCESS: PIV's\n CODE STATUS: full\n DISPOSITION: ICU overnight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:48 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 664790,
"text": "Chief Complaint: LE edema and pain\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 56W metastatic breast cancer, presented with LE edema since starting\n avastin and dexamethasone a few weeks ago. Also, recent URI. Came to ER\n because worsening LE pain. In ER hypoxemic requiring 5L NC. Worked up\n for DVT and PE which were negative. CT-A showed multiple bilateral\n metastatic lesions, large right and smaller left effusions and left\n greater than right ground glass and interstitial infiltrates.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Taxol (Intraven.) (Paclitaxel\n Semi-Synthetic)\n Anaphylaxis;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n breast cancer lumpectomy and XRT, recurred , multiple\n therapies since, now on avastin\n ? hemophilia, ? anti-cardiolipin antibodies\n Sarcoidosis diagnosed radiographically 2 years ago\n breast cancer\n Occupation:\n Drugs:\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Musculoskeletal: leg swelling and pain\n Flowsheet Data as of 09:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 105 (99 - 118) bpm\n BP: 129/84(95) {129/78(93) - 145/88(102)} mmHg\n RR: 19 (7 - 24) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,395 mL\n PO:\n 390 mL\n TF:\n IVF:\n 505 mL\n Blood products:\n Total out:\n 0 mL\n 258 mL\n Urine:\n 258 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,137 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Crackles : anteriorly, Diminished:\n right)\n Abdominal: Soft, Non-tender\n Extremities: Right: 4+, Left: 4+, edema, tenderness throughout RLE soft\n tissue, petechiae right lateral leg\n Neurologic: Attentive, Oriented x3,\n Labs / Radiology\n 118\n 31\n 0.5\n 18\n 10\n [image002.jpg] PTT 70 INR 1.5\n Imaging: LENI negative\n CT-A no PE, large right and small left effusion, multiple lung masses,\n left greater than right GGO\ns and septal thickening\n Assessment and Plan\n Respiratory distress - related to effusion, infiltrates, tumor. Needs\n thoracentesis, treat with emperic antibiotics, obtain old records and\n films\n LE edema - no DVT though may be more proximal ? IVC occlusion, will\n obtain echo, repeat LENI's,\n right leg pain\n likely related to edema, less likely bone met,\n consider x-rays\n UTI - levoflox should cover\n ICU Care\n Nutrition: regular\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 02:48 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664755,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n PMH:\n ONCOLOGICAL HISTORY:\n Breast cancer with metastases to cerebellum\n - Right breast mass found , s/p righ breast mass lumpectomy\n (T1N0M0), s/p chest XRT and CMF (cyclophosphamide, methotrexate, and\n 5-FU), adjuvant chemotherapy, followed by tamoxifen\n - with left breast mass, s/p left lumpectomy, chest XRT followed\n by tamoxifen, stopped in .\n - , recurrent disease in the left breast. Metastatic work up with\n metastases in lungs and bone, s/p Adriamycin and cyclophosphamide x 4\n cycles, also taxol from which she developed an anaphylactic reaction.\n -completed whole brain cranial irradiation on , adjuvant\n Herceptin and navelbine, followed by recent Herceptin and Xeloda\n -s/p a third ventriculostomy by , M.D. on ,\n -s/p Cyberknife radiosurgery on to a left cerebellar\n metastasis to 1,800 cGy at 82% isodose line and to a right\n cerebellar metastasis to 1,600 cGy at 73% isodose line on\n , and\n -has been getting lapatinib and carboplatin every 3 weeks\n since for her progressive disease; delayed because\n of her surgeries.\n -s/p second third ventriculostomy procedure by ,\n M.D. on .\n - she was scheduled to receive Doxil on but did not go.\n - She has started bevacizumab alone in .\n OTHER PAST MEDICAL HISTORY:\n h/o Factor VIII deficiency\n Suspected anti-cardiolipin antibody\n Hypertension\n Sarcoidosis\n s/p Lung biopsy \n ED:\n Chest CTA: no definite PE. Large R pleural effusion . Extensive lung\n masses increased with ground glass opacities.\n Chest CT: Known metastatic disease to lungs. Apparent superimposed\n volume overload with bilateral pleural effusions.\n CT head: No significant change.\n USG BLE: No DVT\n Respiratory distress/ pneumonia\n Assessment:\n A/O x3, forgetful at times. Sats maintaining well above 93%- 98% (when\n sleeping) with O2 4LNC. LS diminished with crackles in RLL. Pt had\n received 500cc fluid in ED. Foley catheter in place draining > 30cc/hr.\n Vancomycin 1gm and levoquin 750 mg IV given in ED. Pt has 6-8 mm edema\n of both legs, c/o pain in R ankle on touch ( on a scale of ,\n tolerable).\n Action:\n Followed hemodynamic state closely . RLE kept elevated.\n Response:\n Ongoing.\n Plan:\n Continue to monitor hemodynamic status, ? plan for therapeutic\n thoracentesis in a.m , ? echo.\n K+ 3.2 in ED: KCL po 40 meq given, IV 40meq in 500cc on flow.\n"
},
{
"category": "Nursing",
"chartdate": "2162-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 664753,
"text": "This is a 56 year old woman with history of metastatic breast cancer\n affecting brain and lungs, sarcoidosis, coagulopathy, presenting with\n lower extremity edema for the last 3 weeks.\n Patient reports that she has noticed the lower extremity edema and\n pain in R leg ( worse when walking) since starting dexamethasone as\n part of her chemotherapy. She also reports having \"cold like symptoms\"\n with a cough and some runny nose, denies any fevers or chills..\n In ED ultrasound of BLE was done to evaluate for DVT, CTA of the\n chest to rule out PE. Patient given Vancomycin and levofloxacin for\n suspected post obstructive pneumonia She was also given 500ml fluid\n bolus. Patient noted to have transient desaturations to mid 80's with\n movement.\n PMH:\n ONCOLOGICAL HISTORY:\n Breast cancer with metastases to cerebellum\n - Right breast mass found , s/p righ breast mass lumpectomy\n (T1N0M0), s/p chest XRT and CMF (cyclophosphamide, methotrexate, and\n 5-FU), adjuvant chemotherapy, followed by tamoxifen\n - with left breast mass, s/p left lumpectomy, chest XRT followed\n by tamoxifen, stopped in .\n - , recurrent disease in the left breast. Metastatic work up with\n metastases in lungs and bone, s/p Adriamycin and cyclophosphamide x 4\n cycles, also taxol from which she developed an anaphylactic reaction.\n -completed whole brain cranial irradiation on , adjuvant\n Herceptin and navelbine, followed by recent Herceptin and Xeloda\n -s/p a third ventriculostomy by , M.D. on ,\n -s/p Cyberknife radiosurgery on to a left cerebellar\n metastasis to 1,800 cGy at 82% isodose line and to a right\n cerebellar metastasis to 1,600 cGy at 73% isodose line on\n , and\n -has been getting lapatinib and carboplatin every 3 weeks\n since for her progressive disease; delayed because\n of her surgeries.\n -s/p second third ventriculostomy procedure by ,\n M.D. on .\n - she was scheduled to receive Doxil on but did not go.\n - She has started bevacizumab alone in .\n OTHER PAST MEDICAL HISTORY:\n h/o Factor VIII deficiency\n Suspected anti-cardiolipin antibody\n Hypertension\n Sarcoidosis\n s/p Lung biopsy \n"
}
] |
5,397 | 101,339 | Assessment: 56yo man with h/o poorly controlled DM admitted with DKA secondary to medication non-adherence in the setting of depression. Hospital course is reviewed below by problem: 1. DKA - The patient was started on an insulin drip per standard protocol for ~30 hours. His anion gap closed, and he was started on NPH at 15u given his poor PO intake (on 25u at home). After adjustment during his hospital stay, he was discharged on 25 units NPH qam and 18 units NPH qhs. 2. Leukocytosis - The patient presented with a WBC of 24. This was initially thought to be a stress reaction similar to that evidenced in a prior admission, but after one blood culture grew E coli he was started on levofloxacin and flagyl. The remainder of the blood cultures were positive, including the other 3 from that day, and he had no source of infection, nor was he febrile. As such, the levofloxacin was continued only for a 7 day course for possible pneumonia (CXR with unclear basal opacities on initial read). Flagyl was discontinued given the culture results of E coli. His WBC trended down and was normal at discharge. 3. ARF - He was admitted with a Cr of 3.2, a similar elevation to his last admission for DKA. This was most likely secondary to dehydration from the hyperglycemia. He was aggressively hydrated with IVF and his Cr was 0.7 on discharge. 4. Hyperkalemia - On admission, he had peaked T waves on ECG and a K of 8.3. His hyperglycemia was treated with IVF and insulin, and he received calcium for the hyperkalemia. This resolved and was within normal limits once his anion gap closed. 5. CV - He had a h/o cardiomyopathy, but not CAD. He had no evidence of active ischemia during this admission. He was discharged on home regimen of ASA and lisinopril. Outpatient echo was recommended to re-assess his LVEF. 6. H/o EtOH - The patient denied recent EtOH use. He had no evidence of withdrawal. 7. Socioeconomic issues - The social worker was extensively involved in this hospitalization. At discharge, Pharmacare had been contact to waive the copay for his prescriptions and he was notified of this. He was given information about the resources available to him for aid and instructed on how to contact the agencies involved. 8. Code status - full. 9. depression- a major contributor to his original presentation. Pt requested an inpatient psychiatric consultation, which was obtained. | Right axisdeviation with right ventricular conduction delay. last longer than IV fentynal.Incision noted to have small round 1cm x 1cm area with purulent drg.BUN/Creat still high, u/o 30-60ml/hr.A:Pt hemodynamically stable.P:Address better pain control.Address wound care specifics. Sinus tachycardia with baseline artifact. Please evaluate right lower extremity to rule out deep venous thrombosis. Sinus tachycardia, rate 117. Grayscale and Doppler son of the right common femoral, superficial femoral, and popliteal veins were performed. Images of the right lower extremity veins were obtained at 06:25 and 12:58 on . Lungs clear bilat.GI/GU: abd soft, hypo bs, no BM, taking po fluids. Lungs clear bilat.GI/GU: abd soft, hypo bs, no BM, taking po fluids. Slight T wave peaking raising consideration of hyperkalemia.Compared to the previous tracing of the same date axis is not as rightward andintraventricular conduction delay is not seen. Troponin=0.06. Medium frequency atrial premature beats. Weak periph pulses, extrems a bit cool, no edema.Resp: 02sat 98-100% on r/a. Right-sided infiltrate on chest x-ray. Right basal lung consolidation. EKG, CXR, BCx2 done. Taking into account the difference in patient positioning, the heart, hilar, and mediastinal contours are unchanged. Weak periph pulses - checked w/ doppler, extrems cool, no edema.Resp: 100% on r/a. Weak periph pulses - checked w/ doppler, extrems cool, no edema.Resp: 100% on r/a. Occ congested cough.GI/GU: Abd soft, +BS, no BM. There are patchy opacities at the lung bases, possibly representing aspiration versus atelectasis. Supraventricular tachycardia, possibly sinus, at a rate of 130. The diaphragmatic contour is partially obliterated and linear densities are suggestive of some plate atelectasis. Peaked T waves consistentwith hyperkalemia. Minimal interstitial edema persists along with left lobe atelectasis. Plan to restart cardiac drugs today.Resp:breath sounds clear, resp nonlabored. A paucity vessels in the upper lobes suggest emphysema. blood sugar q1hr. EKG done. Complete PA and lateral chest view is recommended for further confirmation of the somewhat subtle findings. Last pH=7.39. Last pH=7.39. FULL CODE NKDA Contact Precautions - MRSA foot woundNeuro: Remains somewhat lethargic and 'grumpy'. Probable sinus tachycardia. ABDOMEN CT: In the limited images throughout the bases of the lungs, there are mild bilateral pleural effusions. FINDINGS: Single AP upright view of the chest dated is compared to same examination from . Inaddition, inferior Q waves and ST segment elevations are not seen and heartrate is slightly slower.TRACING #2 The cardiomediastinal silhouette is within normal limits. The overall impression, however, is if the patient has developed some pleural densities possibly layering posteriorly as the patient is in semi-upright position. Moderate ascites. FULL CODE NKDA Contact Precautions: MRSA foot woundNeuro: awake, but lethargic, MAEx4 - Able to get off ER stretcher and ambulate to ICU bed w/ min assistance.CV: HR=100s, ST, no ectopy. FULL CODE NKDA Contact Precautions: MRSA foot woundNeuro: awake, but lethargic, MAEx4 - Able to get off ER stretcher and ambulate to ICU bed w/ min assistance.CV: HR=100s, ST, no ectopy. IMPRESSION: Bilateral lower lobe opacities, possibly representing aspiration or atelectasis. Available for comparison is a previous portable chest examination of . IMPRESSION: PA and lateral chest compared to and , 9th, and 10th: Small bilateral pleural effusions have decreased since . Non-specificST-T wave changes. There is moderate ascites. On Room airGI:No c/o nausea overnoc. Possible left ventricular hypertrophy. resp rate 20-30's.cardiac: remains in nsr. EKG initially had peaked T-waves r/t to ^K, but now resolved w/ <K.PMH: IDDM/DKA (multi amdissions); CAD, MI , EF=20-30%; GERD, peripheral neuropathy and Charcot foot, MRSA in foot ulcers. Clinical correlation is suggested.TRACING #1 In segment III of the liver, adjacent to the fissure there is a hypodense non- well- defined area, likely focal fatty infiltration. stool x2.action: off insulin gtt. Pt presents w/ 1 week n/v, poor po intake. This finding is consistent with findings observed on the single portable chest view, which however, cannot present same detail as the CT examination. Bilateral pleural effusions. Monitor cardiac/resp/neuro status. Monitor cardiac/resp/neuro status. Monitor cardiac/resp/neuro status. (Over) 12:03 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: eval for source of infection Admitting Diagnosis: DIABETIC KETOCIDOSIS Field of view: 38 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) There exists another portable chest examination obtained with similar findings suggestive of bilateral posteriorly located pleural densities. Comparedto the previous tracing of atrial premature beats are new. IVF D5NS at 75/hr and after this liter will change to D5 .5ns.ID: afebrile. FINDINGS: AP single view of the chest has been obtained with the patient in sitting upright position. Abd to touch.GU:u/o adequate clear yellow.Coping:Pt short tempered at times.Plan:Continue fluids and insulin gtt as ordered. 5:37 AM CHEST (PORTABLE AP) Clip # Reason: ? D:Pain issue:Pt medicated with Fent 50mg for incisional pain decreases to .Need to reassess oxycontin sustained release which pt has not recieved due to NGT. IMPRESSION: No evidence of DVT in the right lower extremity. Non-specific ST-T wave changes. The aorta is normal in caliber. at times very cranky and only answers questions that is asked.resp: o2 sata 90's. Follow-up resuming cardiac meds 6:04 AM VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # Reason: LENI of Right lower extremity to rule out DVT Admitting Diagnosis: DIABETIC KETOCIDOSIS MEDICAL CONDITION: 56yo man p/w DKA and volume resuscitated w/ unequal LE edema REASON FOR THIS EXAMINATION: LENI of Right lower extremity to rule out DVT FINAL REPORT This examination had suboptimal images of the superficial femoral vein and was repeated. | 18 | [
{
"category": "Nursing/other",
"chartdate": "2149-11-13 00:00:00.000",
"description": "Report",
"row_id": 1333553,
"text": "focus hemodynmics\ndata: neuro: alert and oriented. moves about in the bed. oob to the commode. appears to be depressed and needs encouragement to participate in personal hygiene. at times very cranky and only answers questions that is asked.\n\nresp: o2 sata 90's. resp rate 20-30's.\n\ncardiac: remains in nsr. calicium 5.9 and repleted with 2 gms of calicum gluconate iv.\n\ngu: foley patent and draining yellow urine.\n\ngI abd soft with audible bowel sounds. stool x2.\n\naction: off insulin gtt. blood sugar q1hr. nph insulin 10units sc given. taking po's ok. no nausea or vomitting. to be transferred to the floor when bed available.\n\nresponse: monitor closely.\ns\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-11 00:00:00.000",
"description": "Report",
"row_id": 1333549,
"text": "FULL CODE NKDA Contact Precautions: MRSA foot wound\n\n\n\n\nNeuro: awake, but lethargic, MAEx4 - Able to get off ER stretcher and ambulate to ICU bed w/ min assistance.\n\nCV: HR=100s, ST, no ectopy. BP=100/50. Weak periph pulses - checked w/ doppler, extrems cool, no edema.\n\nResp: 100% on r/a. Lungs clear bilat.\n\nGI/GU: abd soft, hypo bs, no BM, taking po fluids. Foley cath w/ coudy yellow urine - 800cc from ER.\n\nAccess: PIV x2 #18.\n\nLabs: Last FS in ER was 185 and insulin gtt was < to 8 units/hr. FS in SICU=164, insulin gtt, to 6units/hr. Last pH=7.39. Chem 10 to be obtained.\n\nSkin: coccyx reddened (pt had been in ER since 4am). Bandaid on L small toe - small abrasion.\n\nPain: reports stabbing abd pain - he had been c/o of this in ER, but scan not done r/t ^BUN/CR. No pain med given by ER.\n\nID: T=99.6 oral. no antibx.\n\nPlan: titrate insulin gtt to FS. Finish 2nd liter of NS w/ 40 KCL at 250cc/hr. Monitor cardiac/resp/neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-12 00:00:00.000",
"description": "Report",
"row_id": 1333550,
"text": "Neuro:Awake alert Ox3, MAE equally.\nCV: ST 100-125, CK iso and troponin drawn at 0330, EKG done, pts beta blockers were held in light of DKA. EKG done. Plan to restart cardiac drugs today.\nResp:breath sounds clear, resp nonlabored. On Room air\nGI:No c/o nausea overnoc. No B.M. Abd to touch.\nGU:u/o adequate clear yellow.\nCoping:Pt short tempered at times.\nPlan:Continue fluids and insulin gtt as ordered.\n Follow-up resuming cardiac meds\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-12 00:00:00.000",
"description": "Report",
"row_id": 1333551,
"text": "D:Pain issue:Pt medicated with Fent 50mg for incisional pain decreases to .Need to reassess oxycontin sustained release which pt has not recieved due to NGT. last longer than IV fentynal.\nIncision noted to have small round 1cm x 1cm area with purulent drg.\nBUN/Creat still high, u/o 30-60ml/hr.\nA:Pt hemodynamically stable.\nP:Address better pain control.\nAddress wound care specifics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-12 00:00:00.000",
"description": "Report",
"row_id": 1333552,
"text": "FULL CODE NKDA Contact Precautions - MRSA foot wound\n\nNeuro: Remains somewhat lethargic and 'grumpy'. MAEx4 spont/command, able to move self in bed.\n\nCV: HR=90-100s, NSR/ST, no ectopy. BP=120-140s/50-60s. Weak periph pulses, extrems a bit cool, no edema.\n\nResp: 02sat 98-100% on r/a. Lungs clear bilat. Occ congested cough.\n\nGI/GU: Abd soft, +BS, no BM. Was taking liqs in the am, then NPO for CT scan for abd/pelvis - pt c/o pain since admission. Foley cath w/ clear yellow urine - 100-200cc/hr.\n\nAccess: PIVsx3\n\nLabs: At 11 am, given NPH 15units, then d/c'd the insulin gtt at 1200. Insulin gtt was going at 2 units/hr prior to this w/ FS=100s. IVF D5NS at 75/hr and after this liter will change to D5 .5ns.\n\nID: afebrile. Started on levaquin and flagyl for gram neg rods in blood cx from yesterday. Surv blood cx x2 obtained this afternoon.\n\nProcedures: CT abd/ pelvis at 1200.\n\nSocial: No calls or visitors as of yet today.\n\nPlan: Continue to monitor BS/ NPH/insulin gtt. Monitor cardiac/resp/neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-11 00:00:00.000",
"description": "Report",
"row_id": 1333547,
"text": "Admission Note\n\nReport from ED:\n56 yr-old male w/ mult adm for DKA w/ last hosp to . Pt presents w/ 1 week n/v, poor po intake. BS=1142. Received 8L IVF and insulin gtt, currently at 10units/hr. K initally was 8.2, down to 4.3 and on NS w/ 40 KCL at 250cc/hr. Initial venous pH=6.19, then 7.16 and repeat labs being drawn just before pt is leaving the ED. SBP on adm=60, but currently 100-90/50s. Troponin=0.06. EKG, CXR, BCx2 done. On R/A. C/O nausea as pt is drinking a lot of fluids - given anzimet w/ relief. EKG initially had peaked T-waves r/t to ^K, but now resolved w/ <K.\n\nPMH: IDDM/DKA (multi amdissions); CAD, MI , EF=20-30%; GERD, peripheral neuropathy and Charcot foot, MRSA in foot ulcers. Lost job in , depressed, decreased po intake and wasn't taking insulin - resulted in adm of .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-11 00:00:00.000",
"description": "Report",
"row_id": 1333548,
"text": "FULL CODE NKDA Contact Precautions: MRSA foot wound\n\n\n\n\nNeuro: awake, but lethargic, MAEx4 - Able to get off ER stretcher and ambulate to ICU bed w/ min assistance.\n\nCV: HR=100s, ST, no ectopy. BP=100/50. Weak periph pulses - checked w/ doppler, extrems cool, no edema.\n\nResp: 100% on r/a. Lungs clear bilat.\n\nGI/GU: abd soft, hypo bs, no BM, taking po fluids. Foley cath w/ coudy yellow urine - 800cc from ER.\n\nAccess: PIV x2 #18.\n\nLabs: Last FS in ER was 185 and insulin gtt was < to 8 units/hr. FS in SICU=164, insulin gtt, to 6units/hr. Last pH=7.39. Chem 10 to be obtained.\n\nSkin: coccyx reddened (pt had been in ER since 4am). Bandaid on L small toe - small abrasion.\n\nPain: reports stabbing abd pain - he had been c/o of this in ER, but scan not done r/t ^BUN/CR. No pain med given by ER.\n\nID: T=99.6 oral. no antibx.\n\nPlan: titrate insulin gtt to FS. Finish 2nd liter of NS w/ 40 KCL at 250cc/hr. Monitor cardiac/resp/neuro status.\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-15 00:00:00.000",
"description": "R VENOUS DUP EXT UNI (MAP/DVT) RIGHT",
"row_id": 888896,
"text": " 6:04 AM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: LENI of Right lower extremity to rule out DVT\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56yo man p/w DKA and volume resuscitated w/ unequal LE edema\n REASON FOR THIS EXAMINATION:\n LENI of Right lower extremity to rule out DVT\n ______________________________________________________________________________\n FINAL REPORT\n This examination had suboptimal images of the superficial femoral vein and was\n repeated. Please see the report of clip #: 387-4144.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888739,
"text": " 3:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for PNA vs atelectasis\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with DKA and leukocytosis, RLL opacity on CT\n REASON FOR THIS EXAMINATION:\n please eval for PNA vs atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: History of DKA and leukocytosis, right lower lobe opacity on CT,\n evaluate for pneumonia versus atelectasis.\n\n FINDINGS: AP single view of the chest has been obtained with the patient in\n sitting upright position. Available for comparison is a previous portable\n chest examination of . There exist now densities on the lung\n bases, slightly more on the left than on the right. The diaphragmatic contour\n is partially obliterated and linear densities are suggestive of some plate\n atelectasis. The overall impression, however, is if the patient has developed\n some pleural densities possibly layering posteriorly as the patient is in\n semi-upright position.\n\n There exists another portable chest examination obtained \n with similar findings suggestive of bilateral posteriorly located pleural\n densities. The lateral pleural sinuses, however, remain free.\n\n IMPRESSION: Basal densities developing over the last two days and\n are suggestive of bilateral pleural effusions. Complete PA and lateral chest\n view is recommended for further confirmation of the somewhat subtle findings.\n A previous abdominal chest CT of , included images of the\n basal portions of the lungs disclosed bilateral pleural effusions as well as\n some atelectasis in the dependent portion of the posterior segments. This\n finding is consistent with findings observed on the single portable chest\n view, which however, cannot present same detail as the CT examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 888820,
"text": " 9:15 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval opacity - pna vs atelectasis\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with DKA and leukocytosis with white count, R sided infiltrate\n on CXR\n REASON FOR THIS EXAMINATION:\n please eval opacity - pna vs atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM .\n\n HISTORY: DKA and leukocytosis. Right-sided infiltrate on chest x-ray.\n\n IMPRESSION: PA and lateral chest compared to and ,\n 9th, and 10th:\n\n Small bilateral pleural effusions have decreased since . Minimal\n interstitial edema persists along with left lobe atelectasis. No findings to\n suggest pneumonia. A paucity vessels in the upper lobes suggest emphysema.\n\n Heart size is normal and midline. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-15 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 888933,
"text": " 12:11 PM\n UNILAT LOWER EXT VEINS RIGHT; -76 BY SAME PHYSICIAN # \n Reason: ?right dvt\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ?dvt--right super femoral (approx 25% defect) on previous\n study\n REASON FOR THIS EXAMINATION:\n ?right dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Unequal lower extremity edema. Please evaluate right lower\n extremity to rule out deep venous thrombosis.\n\n Images of the right lower extremity veins were obtained at 06:25 and 12:58 on\n . Please refer to both sets of images.\n\n Grayscale and Doppler son of the right common femoral, superficial\n femoral, and popliteal veins were performed. Normal flow, augmentation,\n compressibility and waveforms were demonstrated. No intraluminal thrombus is\n identified.\n\n The suboptimal images of the right superficial femoral vein were repeated at\n no charge to the patient, to confirm complete compressibility and wall-to-wall\n color flow.\n\n IMPRESSION: No evidence of DVT in the right lower extremity.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-11 00:00:00.000",
"description": "Report",
"row_id": 278004,
"text": "Baseline artifact. Probable sinus tachycardia. Vertical QRS axis. Non-specific\nST-T wave changes. Slight T wave peaking raising consideration of hyperkalemia.\nCompared to the previous tracing of the same date axis is not as rightward and\nintraventricular conduction delay is not seen. T waves are not as peaked. In\naddition, inferior Q waves and ST segment elevations are not seen and heart\nrate is slightly slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-12 00:00:00.000",
"description": "Report",
"row_id": 278002,
"text": "Sinus tachycardia, rate 117. Medium frequency atrial premature beats. Compared\nto the previous tracing of atrial premature beats are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-11 00:00:00.000",
"description": "Report",
"row_id": 278003,
"text": "Sinus tachycardia with baseline artifact. Non-specific ST-T wave changes. Slow\nR wave progression. Possible left ventricular hypertrophy. Compared to the\nprevious tracing of precordial voltage is somewhat more prominent and\nT waves are less peaked. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-11 00:00:00.000",
"description": "Report",
"row_id": 278214,
"text": "Supraventricular tachycardia, possibly sinus, at a rate of 130. Right axis\ndeviation with right ventricular conduction delay. Peaked T waves consistent\nwith hyperkalemia. Inferior Q waves and ST segment elevations are not\ndiagnostic in this context but raise possibility of inferior wall myocardial\ninfarction, possibily acute. Compared to the previous tracing of \nfindings are new. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888347,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna. infiltrate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with DKA and ? source of infection.\n REASON FOR THIS EXAMINATION:\n ? pna. infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with diabetic ketoacidosis.\n\n FINDINGS: Single AP upright view of the chest dated is compared to\n same examination from . Taking into account the difference in patient\n positioning, the heart, hilar, and mediastinal contours are unchanged. The\n lung fields are clear. The surrounding osseous and soft tissue structures are\n unchanged.\n\n IMPRESSION: No definite evidence for an acute cardiopulmonary process,\n however, if symptoms persist, a dedicated PA and lateral chest radiograph\n should be obtained.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-12 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 888546,
"text": " 12:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for source of infection\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with acidosis, DKA, WBC 20K and abd TTP and GNR bacteremia\n\n REASON FOR THIS EXAMINATION:\n eval for source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Abdomen CT with oral and IV contrast.\n\n HISTORY: 56-year-old male with acidosis and bacteremia, assess for source of\n infection.\n\n TECHNIQUE: Multidetector CT through the abdomen and pelvis with oral and IV\n contrast.\n\n There are no prior CT studies available for comparison.\n\n ABDOMEN CT:\n\n In the limited images throughout the bases of the lungs, there are mild\n bilateral pleural effusions. Subsegmental adjacent atelectases are seen in\n the left side. There is important pulmonary opacities and consolidation in\n the basal segments of the lower right lobe.\n\n In segment III of the liver, adjacent to the fissure there is a hypodense non-\n well- defined area, likely focal fatty infiltration. There are no other focal\n intraparenquimal lesions. There is no biliary duct dilatation. The spleen,\n pancreas, adrenals, gallbladder, and kidneys are unremarkable. Normal\n excretion is seen from both kidneys. The bowel loops are unremarkable. The\n aorta is normal in caliber. There is moderate ascites.\n\n PELVIC CT:\n The bladder is distended with Foley catheter in its interior. The prostate is\n not enlarged. The rectum and sigmoid colon are unremarkable. There is free\n fluid within the pelvis. There is no lymphadenopathy.\n\n BONE WINDOWS: There are no concerning bone lesions.\n\n IMPRESSION:\n 1. Bilateral pleural effusions.\n\n 2. Right basal lung consolidation.\n\n 3. Moderate ascites.\n (Over)\n\n 12:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for source of infection\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888542,
"text": " 11:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: look for free air. please have pt sit up right\n Admitting Diagnosis: DIABETIC KETOCIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with DKA and ? source of infection. Also with rebound\n\n REASON FOR THIS EXAMINATION:\n look for free air. please have pt sit up right\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of DKA and possible infection, also with rebound\n abdominal tenderness.\n\n CHEST X-RAY, PORTABLE AP: There was a slight delay in reporting of this\n examination due to the original report being lost in the RTAS system.\n\n Comparison is made to prior study of . The lung volumes are\n low. There are patchy opacities at the lung bases, possibly representing\n aspiration versus atelectasis. Underlying effusion are also possible. There\n is no evidence of congestive heart failure. The cardiomediastinal silhouette\n is within normal limits. The osseous structures are unremarkable.\n\n IMPRESSION:\n\n Bilateral lower lobe opacities, possibly representing aspiration or\n atelectasis. Bilateral effusions are likely.\n\n At the time of dictation, several follow-up chest x-rays have been performed.\n Please refer to those reports for further evaluation.\n\n"
}
] |
9,306 | 193,341 | Respiratory status: The infant was intubated soon after admission. He received two doses of Surfactant. He was extubated to nasopharyngeal continuous positive airway pressure on day of life three and he was then weaned to nasal cannula oxygen on day of life number six and then weaned to room air on day of life number thirteen where he has remained. On examination his respirations are comfortable. Lung sounds are clear and equal. He had rare episodes of apnea and desaturation and never required any methylxanthine treatment. | Murmur as previously noted. NICU NPNAgree with above note. Cap refil WNL. stable with pt. O:Temp. Temp stable. Tolerating well. A: Stable resp. in Resp. LS clear/=. Tolereating well via gavage. VNA notified. Tolerating by gavage. Pedi appt. V/S, hem-. A: TF P: Continuecurrent.4. FEN: O: Current wt. O: Wt. Takes pacifier. exam benign, seeflowsheet. A: Toleratingfeeds. arranged for thisFriday. Mild subcostal retractions. Updated. A: AGA P: Continue tomonitor and support G&D. The cardiomediastinal contour is within normal limits. O:Pt. +Int murmur (ECHO: PPS). Br. Monitor for tolerance offeedings.#4Parenting. A:AGA. Plan to be d/ . Pt. Pt. RN didsome discharge teaching. +BS. Will move to low flow nasal cannula today. Circumcision done.Ready for discharge. Off photorx.Continue to assess resp status. Discharge teaching reviewed w/ . Check ET tube placement. status. A: ,invested . asp. PO/PG. No spells.A: Maturing behaviorsP: Continue to support developmental needs. V/S, heme neg. Rebound levelto be drawn in am. + B.S. Temp stable. Moderate retractions. LS cl and = withbaseline retractions noted. Mildsubcostal retractions noted during cares. rr 60-70 with mild retractions. Hem neg. Lungsare CL/=. P- Continue c current regime. Murmur heard. +BF. Maintaining sats93-99%. A- AGA. Abdomen benign, pos BS. NURSING NOTEO: AGREE W/ABOVE NOTE BY . Lungs cl and =. Updated. Veryindependent with cares. AG stable. Neonatology-NNP Physical ExamInfant remains in RA. Neonatology-NNP Physical ExamInfant remains in RA. Infantcontinues with baseline mod IC/SC retractions. and active c cares. A: AGA. A: Resolving hyperbili. Voiding 1.3cc/k/hr. Active, , AFOF, sutures oposed, good tone. O: Infant remians on TF's of 140cc/k/d. Abdomen- Benign. Minimal aspirates. Minimal aspirates. Minimal aspirates. A: Stable in RA. A: Remains in NC. PO/PG. bs clear. A: APPROPRIATE FOR AGE. Abdomenbenign. Baby does drift to 80's.QSR. PIV d/c'd thisa.m. Cont topromote G&D. A: Resolvinghyperbili. in resp. FEN: O: Current wt. Tolerating feedswithout emesis/residuals. Moderate baseline IC/SC retractions noted. On BM/E 24. V/S, hem-. Infant had circ done today. V/S. Temp stable in OC. A: TF P: Continue current.4. On BM/PE 24. Murmur present. Wakesfor feeds. A: AGA. A: AGA. A:Tolerating feeds thus far. NPN 0700-2. LS clear and =. +BS. ABDsoft, +bs. DEV: O: Pt. Asking appropriatequestions. LScl/=. PPS murmur. A: Involved, P:Continue to support and update.#6 DEVO: Infant remains in OAC, . Will change over to 24 cal Enfamil. NPN 0700-15303. ,starting to wake for cares. ; resolved ANDACTIVE W/ CARES. Neonatology-NNP Physical examInfant remains in RA. Neonatology-NNP Physical ExamInfant remains in RA. AG stable. P: Cont to support development.#7 O: Rebound bili this am was 8.4/0.5/7.9. P: Rebound bili pending this a.m. A: AGA P:Support g&d and prepare for D/c. Occ desats. Stable inRA. O: in for cares. Takes pacifier.A:AGA. Temp. Temp. +b.s. P- Continue c current regime. O: Wt. O: Wt. A:Pt. A:Pt. Respiratory O: Pt. swaddle & take tempindependently. Hem Neg. withcaares. Cont in RA. is stable in RA. O: Pt. O: Pt. A- AGA. VDg & hemeneg. and active c cares. Handles infantwell. Agree w/ above note by . A: AGA. P: Continue to eval. LS clear bilaterally.Occ. Pt. Pt. q.s. alt po/pg. asking appropriatequestions. Asking appropriatequestions. mild subcostal retraction. A; Stable inroom air. Holding on advancing Kcals for now. P:Continue to offer bottle with cares when. P: Continue to assess.3. Swaddled.MAe. CL/=. + B.S.Abdomen: Benign. Quick, self-resolved desaturations noted. PO/PG. Sucks on pacifierat times. A:Stable in RA. Nl S1S2, grade II/VI murmur audible. +BS, noloops/spits noted. 143.4.8/109.20. Active bowel sound. A- Tolerating Feeds. 1 side.#4O: in and independent with cares. Mild subcostal retractionsoccas. ABDOMENSOFT, BOWEL SOUNDS ACTIVE, NO LOOPS, GIRTH STABLE, VOIDINGAND . Mild subcsotal retractions noted. Cap gas 7.39/46 (since weaned to current settings). NGTreplaced today aspirits 0.8-1.0cc, Abdominal exam benign.Voiding and , guiac neg. Ng secure and placment verified by aspiration andauscultation. Infant able to maintainappropriate saturation. Abd soft and round with active bowelsounds. A: Stable in very little O2. P: Continue to monitor.3.O: Weight 2535gms no change. breath sounds areclear and equal. Perfusion/pulses good.FEN: Wt 2515. O: Infant remains on TF's of 150cc/k/d of PE24/BM24. soundsare clear with mild SC retractions.#3O: Total fluids at 150cc/kg/d BM24. Temp remainsstable. Voiding and normally.A&PPreterm infant with mild respiratory and feeding immaturity. Minimum gastric aspirates.Doing well overall. Wean vent as tolerated. Weaning as allowed. Nl S1S2, grade II/VI murmur audible. Mild retractions. Respiratory CareNPT retaped Cont to promote development.REVISIONS TO PATHWAY: 1 r/o sepsis; resolved 24hr U/O3.8cc/k/hr. Initial abg PO2 127 CO2 46 PH 7.37. LSclear and equal, moderate subcoastal and intercoastalretractions. Infants settingsweaned after latest CBG, 7.40/44/37/28/1. Mild-mod retraction. grunting apon admission, ptintubated and received survanta x1. TF 100/k/d; D10.5PNand IL via PIV. 4 ext BP wnl. Temp stable. Tolerating feeds of pe/bm24 well. in resp. Occasional saturation drifts- spontaneously resolved. Labs noted and PN adjusted accordingly. Amp/gent dc'd today. pt tachypneic.suvanta given x1 thus far tonight.A; pt appears more comfortable post intubation and survantagiven.P; cont to monitor3 - FEN - Tf=80cc/k of D10w. BF and held infant.Independent. Abd soft, round, +BS.Dstx-74. Admission Note1 r/o sepsis2 pot. Normal cardothymic silouette on CXR. Apgars . ABdsoft, +bs. Intermittently tachypneic with retractions. Infant NPO.Plan to obtain lytes and bili this am; see flowsheet forresults. Mild-Mod retractions. Bilirubin 11.7/0.3. Respiratory CarePt cont on NP CPAP. retractions noted.Sx npt for small cldy. A: Stable onCPAP. Abd benign. +bs. B.S. Lytes 144/3.2/107/25. ess. Monitoring murmur. Independent w/diaper andtemps. BW 2515gm. Continues on single phototherapy. Continues on single phototherapy. Suckles on pacifier forcomfort. P: Wean as tolerated. LS cl/=. Nlpulses. Nostool. Bilirubin 7.9. Ls clear. O: Under single phototherapy. A: Tol w/u on feeds so far. Metabolically well. Requiring cpap. Mild SC retractions. Lytes 148/4.1/108. Trace stool. Abdsoft. Sxn prn.3. TF 120/k/d; D10PNand IL at 100/k/d and enteral feeds at 10/k/d of PE20/BM20via NGT. Will continue CPAP for now. Will continue CPAP for now. Will follow up on bilirubin. Nl S1S2, grade II/VI murmur audible. P: Monitor. A: AGA P: cont to support G&D. Eye in place. NPO. RR 50-60's stable on CPAP cont to follow. Cont to monitor respstatus.3. | 135 | [
{
"category": "Radiology",
"chartdate": "2129-10-15 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 770057,
"text": " 8:27 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: ? ETT position, evaluate heart and lungs\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, 33 weeks gestation\n REASON FOR THIS EXAMINATION:\n ? ETT position\n evaluate heart and lungs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 33 week gestational age newborn with HMD.\n\n There are very subtle hazy opacities throughout the lungs. There are no focal\n areas of consolidation or atelectasis. Lung volumes are low. There are no\n pleural effusions. Endotracheal tube is at the level of the thoracic inlet.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-16 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 770134,
"text": " 9:55 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: r/o pneumothorax, assess for need for additional surfactant\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, currently on cpap\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax, assess for need for additional surfactant\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Prematurity on CPAP.\n\n Diffuse hazy opacification and hypoinflation of the lungs consistent with\n atelectasis and/or delayed clearing of fetal lung fluid. Overlying bones and\n soft tissues are unremarkable.\n\n IMPRESSION: Hypoinflation worsening since last examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-16 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 770137,
"text": " 11:03 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: check ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with rds\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infant with RDS. Check ET tube placement.\n\n FINDINGS: Endotracheal tube is just pass the thoracic inlet. The patient is\n slightly rotated on this radiograph. The lung volumes are somewhat lower than\n on the study of earlier the same day. Again seen are the coalescent, granular\n opacities, with air bronchograms, that are consistent with hyaline membrane\n disease. These opacities do not appear significantly changed. Due to these\n opacities, the cardiomediastinal contour cannot be evaluated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-17 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 770172,
"text": " 10:40 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: r/o atelectasis, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress\n REASON FOR THIS EXAMINATION:\n r/o atelectasis, ptx\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST at 1100 hours\n\n HISTORY: Respiratory distress.\n\n In follow up to , the patient remains intubated with ET tube just above\n the carina with the neck flexed. Diffuse mixed hazy and granular opacity\n persists throughout both lungs with obscuration of the heart margins in\n keeping with edema vs. RDS vs. pneumonitis. No significant pleural fluid or\n gas collections. Examination includes a majority of the abdomen demonstrating\n a nonspecific bowel gas pattern with no evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-10-25 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 770916,
"text": " 11:27 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: cardiac size\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with murmur\n REASON FOR THIS EXAMINATION:\n cardiac size\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST, :\n\n HISTORY: Infant with murmur. Check cardiac size.\n\n FINDINGS: Since the study performed , the lung volumes are improved as\n is the aeration. The ETT has been removed. A new NGT tip projects over the\n gastric bubble. The cardiomediastinal contour is within normal limits. Only\n mild hazy opacities, most consistent with hyaline membrane disease, persist.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-23 00:00:00.000",
"description": "Report",
"row_id": 1808430,
"text": "Nursing\n\n\n#2O: Infant remains with nasal cannula in place 400cc 25\n-40%. Br. sounds clear with mild SC retractions.\n#3O: Increased to 24cal today and iron to be started.\nBelly soft, voiding and , . asp. and no spits.\nPut to breast for the 1st time, latched on and took a few\nsucks.\n#4O: Mom and her mom into visit and was pleased that she\ncould put son to breast. Mom is updated and aware of\ncurrent plan and status. Will visit later and will put son\nto breast. Scheduled mom for Lactation consult for .\n#6O: Infant's temp stable in open crib. Alert and active\nwith cares. Loves pacifier and being held by mom.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-23 00:00:00.000",
"description": "Report",
"row_id": 1808431,
"text": "Neonatology-NNP Progress Note\n\n transitioned to an open crib, remains in nasal cannual O2, bbs cl= rrr very soft systolyc murmur, abd soft, nontender, V&S afso, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-24 00:00:00.000",
"description": "Report",
"row_id": 1808432,
"text": "npn 7p-7a\n\n\n(see nursing flowsheet)\n\n#2 Infant remains in NC 400cc flow FiO2 40% most of time to\nmaintain Sat >92%. LS cl and = with no retractions noted\nbut unable to wean NC at all without having cont desats\nnoted. No apnea or bradycardia noted and baseline RR better\ntonight 40-60. Monitor.\n#3 TF 140cc/kilo/d of BM/PE 24. Feeding gavaged over 30\n and tolerated well so far with no spits or aspirates\nnoted. Attempting to BF with mom when she visits and\nattempts to latch but not quite ready. Will introduce\nbottle when seeming ready. Wgt + tonight and gaining slowly.\nStarted on FeSO4 tonight and will monitor feeding tolerance.\n#4 in tonight and did cares independently. Very\ninvolved and loving. Asking appropriate questions and happy\nwith progress. Mom will continue to try to BF and lactation\nconsult for Tues around noon care time. Support and inform.\n#6 Infant is alert and active with cares maintaining temp\nin open crib and transitioned nicely to crib from isolette.\nSucks on pacifier to sooth and a very appropriate infant\ngestationally also bringing hands to face etc. Support.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-24 00:00:00.000",
"description": "Report",
"row_id": 1808433,
"text": "Neonatology-NNP Progress Note\n remains in his open crib, maintaining NTE, in nasal cannula O2, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, nl phallus, testes palpable in scrotum, afso, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-24 00:00:00.000",
"description": "Report",
"row_id": 1808434,
"text": "Neonatology Attending\n\nDay 9\n\nRemains on nasal cannula at 400 cc/- 25%. RR 30-70s. Mild subcostal retractions. Mild drifts. Clear breath sounds. Soft murmur heard this morning. Weight 2430 gms (+25). TF at 140 cc/kg/d- BM or PE 24. Tolerating by gavage. Minimal gastric aspirates. Stable abdominal girth. Started on iron. Put to breast last night. Stable temperature in open crib.\n\nResolving respiratory condition. Will move to low flow nasal cannula today. Adequate breathing control. Gaining weight now. Tolerating feeds well. Will advance to 150 cc/kg/d. Mother up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-22 00:00:00.000",
"description": "Report",
"row_id": 1808425,
"text": "Neonatology\nRA. No spells. AT times with moderate increased WOB. More comfortable on belly. Murmur as previously noted. CV stable.\n\nWt 2340 down 25 grams. TF at 140 cc/k/d of 20 cal. Up to full feeds this am. Tolereating well via gavage. Abdomen benign.\n\nClinically stable off abx.\n\nBili 8.9 this am. Off photorx.\n\nContinue to assess resp status. need placement back on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-09 00:00:00.000",
"description": "Report",
"row_id": 1808509,
"text": "NPN 0700-1900\n\n\n#3 FEN\nO: Adlib w/ TF=150cc/kg/day ofBM/E24, 69cc q4hr. Infant\ntook 80cc at 10:30am and BF for >30min at 3pm. No spits.\nV/S. Abdomen benign. Active bowel sounds. A: Tolerating\nfeeds. P: Continue to monitor.\n\n#4 Parenting\nO: Mom and came in at 1pm. Mom BF and held infant.\nIndependent w/cares. Asking appropriate questions. RN did\nsome discharge teaching. A: Involved, . P: Continue to\nsupport and educate.\n\n#6 DEV\nO: Infant remains in OAC, . Temp stable. Wakes q4\n1/2hr for feeds. A/A w/ cares. Sleeps well in between cares.\nSucks on pacifier. Circ is clean and vaseline applied with q\ndiaper change. Plan to be d/ . A: AGA P: Continue to\nmonitor and support G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-10 00:00:00.000",
"description": "Report",
"row_id": 1808510,
"text": "Co-Worker Note : \n\n\n3. FEN: O: Current wt. unchanged at 2975g. Bottling ad lib\namounts of BM/E24 with Tf of 140cc/k. Tf intake\nyesterday = 106cc/k plus breast feeding. Abdomen exam\nbenign. V/S, hem-. +BS. See flowsheet. A: TF P: Continue\ncurrent.\n\n4. PAR: O: No contact thus far. See flowsheet. A: ,\ninvested . P: Support, educate and prepare for\npossible d.c home today ( Thurs).\n\n6. DEV: O: remains in OAC, temps stable. Waking\nq4.5-5hrs for feeds, sleeping well between. Sucking on\nbinkie to pacify self. See flowsheet. A: AGA P:Support G&D\nand prepare for d/c home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-10 00:00:00.000",
"description": "Report",
"row_id": 1808511,
"text": "NICU NPN\n\nAgree with above note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-10 00:00:00.000",
"description": "Report",
"row_id": 1808512,
"text": "Neonatology Attending\n\nDay 26\n\nRemains in RA. Clear breath sounds. Weight 2975 gms (unchanged). Took 106 cc/kg and breast fed. Waking every 3-4 hours to feed. Circumcision done.\n\nReady for discharge. Adequate breathing control. Feeding improved. VNA to be set up. Follow up with Dr. . Discharge summary pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-10 00:00:00.000",
"description": "Report",
"row_id": 1808513,
"text": "Nursing Discharge Note\n\n\n is a former 33 weeker, now DOL #26. He is in RA,\nO2 sats>95%. LS clear/=. RR 30-60's. No increase work of\nbreathing noted. No A&B's noted. He is pink and well\nperfused. HR 130-160's. Cap refil WNL. He has + soft PPS\nmurmur. Weight today is 2.975kg. He is ad lib of E24/BM 24\ntakeing ~70-90cc Q feed. Abdomen is benign. +BS, soft,\npink, no loops/spits noted. He is voiding/ passing seedy\nyellow stools QS. is and appropriate w/ cares,\nsleeps well in between. He wakes for feeds. Temps stable\n in an open crib. Patient is stable and ready for\nD/C home. Discharge teaching reviewed w/ . They\nappear to have a good understanding of information reviewed.\n VNA notified. Refferal written and will be faxed. VNA\nplans to visit this Sat. Pedi appt. arranged for this\nFriday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-01 00:00:00.000",
"description": "Report",
"row_id": 1808472,
"text": "NNP Physical Exam\n\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, soft murmur LsB, abd soft, non distended, no rashes, active and with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-01 00:00:00.000",
"description": "Report",
"row_id": 1808473,
"text": "NPN 1500-2300\n\n#2 Alt. in Resp. Function\nO: Remains in RA with sats 95-100. RR 20's-60's. Breath sounds are clear and =. No spells.\nA: Doing well in RA\nP: Continue to monitor and document any spells.\n\n#3 Alt. in Nutrition\nO: TF=150cc/kg=67cc BM24 Q 4 hrs. Abd. exam is benign, voiding and , no spits. Breastfed well at 1700 then gavaged 60cc after. PO fed 60cc at 2100.\nA: Improving PO feeding\nP: Continue to encourage POs and follow daily wts.\n\n#4 Alt. in Parenting\nP: Mom in for 1700 feeding. Updated. Breastfed infant w/o assistance. Dad in at 1800.\nA: Involved, loving \nP: Keep informed and support.\n\n#6 Alt. in Development\nO: Temps stable in open crib, swaddled, positioned supine with boundaries in place. Starting to wake for some feeds and act hungry. Improving PO feeding. No spells.\nA: Maturing behaviors\nP: Continue to support developmental needs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-02 00:00:00.000",
"description": "Report",
"row_id": 1808474,
"text": "NPN 2300-0700\n\n\n#2Resp. O:Pt. remains in RA, RR 30-60, BS clear and equal,\nsat 95 and greater with occasional drifts to high 80s that\nQSR. A: Stable resp. status. P: Continue to monitor resp.\nstatus.\n\n#3FEN. O: Wt. 2725gms, up 40gms. ON TF of 150cc/k/day of\nBM24/PE24. Alternating po/pg feeds, last feeding given by\ngavage. No spits, minimal aspirates, abd. exam benign, see\nflowsheet. Pt. voiding with each care, had heme negative\nstoolx1. A: gaining wt, appears to be tolerating feeds.P:\nContinue to encourage po feeds. Monitor for tolerance of\nfeedings.\n\n#4Parenting. O: No contact with so far tonight.\n\n#6Dev. O:Temp. stable with pt. swaddled in open crib. Pt.\n with cares, sleeping between cares. Takes pacifier. A:\nAGA. P:Continue to support developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-02 00:00:00.000",
"description": "Report",
"row_id": 1808475,
"text": "Neonatology Attending\nDay 18, x33 \n\nRA. Reducing sat drifts. RR30-60s. +Int murmur (ECHO: PPS). HR 140-170s. Wt up 40 to 2725. TF 150 cc/k/day BM/PE 24. Tolerating well. PO/PG. In open crib.\n\nPlan:\nProgressing well.\n\nContinue CVR monitoring and encourage po skills.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-02 00:00:00.000",
"description": "Report",
"row_id": 1808478,
"text": "NPN\nThis RN agrees with above note by ; co-worker.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-03 00:00:00.000",
"description": "Report",
"row_id": 1808479,
"text": "Co Worker Note\n\n\nRESP: O- Baby is in RA. Breathing 30-50's. Sats>94%. Lungs\nare CL/=. No spells noted thus far. Baby does drift to 80's.\nQSR.\n A- Some drifts.\n P- Will continue to closely monitor.\n\nFEN: O- Weight 2760 up 35gm. TF 150cc/k/d of BM24 or PE 24.\n69cc Q4H. PO/PG. See Flowsheet. Baby is voiding and\n. Hem neg. + B.S. Abdomen- Benign. Belly is soft.\nMinimal aspirates. No spits.\n A- Tolerating Feeds.\n P- Continue c current regime.\n\n: Mom and dad in for 2100 cares. Updated on baby's\nstatus and immediate plan. Mom breast fed c maximum results.\n A- Loving, invested .\n P- Continue to support and educate.\n\nDEV: O- Baby is in open crib, Temp is stable. Has been\nwaking for feeds. and active c cares. Sleeping well.\nEnjoys his binkie.\n A- AGA.\n P- Continue to provide for developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-03 00:00:00.000",
"description": "Report",
"row_id": 1808480,
"text": "NPN 1900-0700\nI have read and agree with above note and assessments per flowsheet by coworker, .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-03 00:00:00.000",
"description": "Report",
"row_id": 1808481,
"text": "Neonatology Attending\n\nDay 19\n\nRemains in RA. Saturations > 96%. RR 50s. Murmur heard. HR 130-160s. Pale. BP mean 48. WEight 2760 gms (+35). TF at 150 cc/kg/d of BM 24. Po/pg feeds. Waking for feeds. Put to breast. Stable temperature in open crib.\n\nMonitoring for breathing immaturity. Still feeding poorly. Will continue to encourage po feeding. Gaining weight well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-03 00:00:00.000",
"description": "Report",
"row_id": 1808482,
"text": "NNP Physical Exam\n\nPE: pale pink, AFOF, sutures approximated, breath sounds clear/equal with easy WOB, soft murmur LLSB, normal pulses, abd soft, non distended, no rashes, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-03 00:00:00.000",
"description": "Report",
"row_id": 1808483,
"text": "Co-worker note 7a-7p\n\n\n#2. RES: remains in RA, sats >95%. RR 30's-50's. Mild\nsubcostal retractions noted during cares. LS cl/=.\n\n#3. FEN: Wt 2760, ^35g. TF: 150cc/k/d of BM24 or PE24 = 69cc\nq4hr. Infant PO'ed 40cc at 0900 very well and was PG'ed the\nrest of his feeding. At 1300, Mom came in to BF. Infant was\neager and did well for about 10min, tired easily,was gavaged\n60cc. Abd. is soft, no loops, +BS. Voidign qs and stooled\nx2, guaic negative. Infant will cont alternating PO/PG. Iron\ngiven by RN as ordered.\n\n#4. PAR: Mom in at 1300, independent with temp and diaper\nchange, gave a bath to and BF. Wil be back for\n1700cares with husband. Very and caring. Mom did\nstate that she would like her son to be circumsized.\n\n#6. G&D: Infant maintains stable temps in an OAC. Has not\nbeen waking for feeds but is and active during cares.\nLoves pacifier and enjoyed bath today!\n\n#7. C/V: Soft murmur noted on auscultation, will cont to\n monitor. BP today at 1200 was 77/42 with MAP of 48.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-03 00:00:00.000",
"description": "Report",
"row_id": 1808484,
"text": "NURSING NOTE\nO: AGREE W/ABOVE NOTE BY . , COWORKER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808417,
"text": "NNP Physical Exam\nPlease disregard above note as due to glitch in the system.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808418,
"text": "Respiratory Care\nPt trialling off CPAP today. Presently on nc O2. rr 60-70 with mild retractions. bs clear. No spells noted. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808419,
"text": "Nursing Progress Note\n\n\nRESP O/A: Infant received in NP CPAP of 6 this morning.\nTrialed off to RA @ 1300, sats dipping into the 80s w/\nincreased WOB noted. Placed in NC @ 1500, requiring\n200-400cc of flow w/ 40-80% Fi02. Aidan is currently in\n400cc of flow, 40%. LS clear/=, Moderate sc/ic retractions\nnoted throughout the day, no nasal flaring. Maintaining sats\n93-99%. No spells noted today. P: Cont provide respiratory\nsupport as needed.\n\nFEN O/A: TF @ 140cc/k/d. Infant is currently working up on\nfeeds. Enteral feeds to be increased @ ~12&12. 10cc\naspirate noted @ 1300 cares & increase held until 1700.\nEnteral feeds are currently @ 80cc/k/d of BM/PE20 pg. Infant\nreceives 34cc q4h. IVF decreased to 60cc/k of PN D10.\nInfusing into right foot. Abdomen benign, pos BS. Girths 27,\nno spits. P: Cont to monitor feeding tolerance & increase\nenteral feeds as ordered.\n\nPAR O/A: Mom in this afternoon to hold infant. Very\nindependent with cares. Asking approriate Q's r/t infant's\nresp progress & feeding plan. Will return this evening with\nDad. P: Cont to support first time parents.\n\nG&D O/A: transfered to air-isolette this morning.\nAfternoon temps 99.2-99.5, weaning iso accordingly.\nCurrently in 28 degrees, swaddled. Sleeps well between\nfeedings, A/A with cares. Quietly alert when held by Mom.\nPacifier for comfort. P: Cont to monitor temps.\n\nBili O/A: Infant received on single phototherapy this\nmorning. Light dc'd @ 1100 for level of 7.9. Rebound level\nto be drawn in am. P: Cont to monitor for s/s of hyperbili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-21 00:00:00.000",
"description": "Report",
"row_id": 1808420,
"text": "Nursing Progress Note\n\n\n#2. O: Infant remains in NCO2 in 400cc's at 40-60%. RR\n50's-70's. Breath sounds are clear and equal. Infant\ncontinues with baseline mod IC/SC retractions. No spells\novernight. Resting comfortably. A: Remains in NC. P:\nContinue to monitor resp status closely.\n\n#3. O: Infant remians on TF's of 140cc/k/d. IVF's of D10PN\ncurrently at 40cc/k/d. Feeds of BM advanced to 100cc/k/d. No\nspits. Minimal aspirates. AG stable. Abd soft and flat with\nactive bowel sounds. No loops. Voiding 1.3cc/k/hr. Small mec\nx2 tonight. Wgt is down 5gms tonight to 2365gms. A:\nTolerating feeds. P: Continue to advance feeds 20cc/k/ as\ntolerated.\n\n#4. O: Parents in this evening for visit. Mom independently\ntook temp and changed diaper. Dad held for ~40minutes.\nAsking appropriate questions. A: Involved family. P:\nContinue to inform and support.\n\n#6. O: Infant remains in air mode isolette with stable temp.\nHe is alert and active with cares. MAEW. Sucking on pacifier\nintermittently. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n#7. O: Infant remains jaundiced. Voiding and stooling.\nCurrently no phototherapy lights. A: Resolving hyperbili. P:\nCheck rebound bili in a.m.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-05 00:00:00.000",
"description": "Report",
"row_id": 1808491,
"text": "Neonatology Attending Note\nDay 21\n\nRA. RR40-50s. Lungs cl and =. +Sat drifts - SR. +murmur (ECHO-PPS). HR 130-150s. Good pulses. Pink, WP.\n\nWt 2890, up 90. TF 150 cc/k/day PE/BM24 po/pg. +BF. Nl voiding and .\n\nIn open crib.\n\nPlan:\n1. CVR monitoring\n2. Good weight gain, plus BFs -> will decrease TF to 140 cc/k/day\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-21 00:00:00.000",
"description": "Report",
"row_id": 1808421,
"text": "Neonatology Attending\n\nDay 6\n\nRemains on nasal cannula oxygen at 400 cc/min 40-60%. RR 50s. Clear breath sounds. Moderate retractions. No apnea. Occasional drifts. Intermittent murmur. HR 130-150s. Pink. Weight 2365 gms (-5). TF at 140 cc/kg/d. Enteral feeds at 100 cc/kg/d. IV PN 10 at 40 cc/kg/d. Blood glucose 83. Minimal aspirates. Rebound bilirubin 8.4/0.5. Stable temperature in servo-controlled incubator.\n\nResolving hyaline membrane disease. Will continue to monitor cardio-respiratory status closely. Will determine if reinstitution of CPAP is warranted. Tolerating feeding advance well. Will continue with advance at 20cc/kg twice daily. Slight bump in bilirubin. Will recheck tomorrow. Spoke with mother yesterday; she is up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-22 00:00:00.000",
"description": "Report",
"row_id": 1808426,
"text": "NURSING PROGRESS NOTES.\n\n\n#2 O: BABY REMAINS IN NASAL CANNULA OXYGEN, 400CC FLOW, 25\nTO 40% OXYGEN. BREATH SOUNDS CLEAR AND EQUAL, MILD TO\nMODERATE RETRACTIONS, NASAL FLARING AT TIMES. RESP RATES\nMOSTLY 70'S AND 80'S. NO INCREASE IN WORK OF BREATHING\nNOTED OVER THE COURSE OF THE DAY. NO APNEA, DESATS OR\nBRADYCARDIA NOTED A: BABY CONTINUES TO REQUIRE OXYGEN. P:\nCONTINUE TO MONITOR AND WEAN AS TOLERATED.\n#3 O: TOTAL FLUIDS REMAIN AT 140CC/KG/DAY OF BM/PE20. FEEDS\nGIVEN EVERY 4 HOURS OVER 50 MIN. NO SPITS OR LARGE\nASPIRATES. ABDOMEN SOFT, BOWEL SOUNDS ACTIVE, NO LOOPS,\nGIRTH STABLE. VOIDING AND STOOLING. HEP LOCK REMOVED.\nBABY DID NOT BREASTFEED TODAY DUE TO INCREASED RESPIRATORY\nRATE. A: NO PO FEEDING BUT BABY IS TOLERATING FULL FEEDS.\nP: CONTINUE WITH CURRENT FEEDS. BEGIN INCREASING CALORIES\nTOMORROW.\n#4 O: PARENTS IN TO VISIT AND HOLD BABY THIS AFTERNOON.\nPARENTS ASKING QUESTIONS ABOUT BABY'S EXPECTED PROGRESS OVER\nTHE NEXT WEEK OR SO. A: INVOLVED FAMILY. P: CONTINUE TO\nKEEP INFORMED.\n#6 O: TEMP STABLE IN ISOLETTE ON AIR MODE. ISOLETTE TEMP\nWEANED THIS MORNING. BABY IS AWAKE AND ALERT DURING CARES\nAND SLEEPS WELL BETWEEN CARES. A: APPROPRIATE FOR AGE. P:\nCONTINUE TO SUPPORT DEVELOPMENT.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-22 00:00:00.000",
"description": "Report",
"row_id": 1808427,
"text": "Neonatology-NNP Progress Note\n remaains in his isolette, in nasal cannula O2, bbs cl=, rrr very soft systolyc murmur, pulses 2+=, abd soft, nontender, afso, aga\n\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-23 00:00:00.000",
"description": "Report",
"row_id": 1808428,
"text": "npn 7p-7a\n\n\n(see nursing flowsheet)\n\n#2 Recieved infant on NC 400cc flow 30-40%. After cares,\ninfant Sat 100% and weaned NC to 200cc flow 21%. Tolerated\nwell x 3-4h and needing increased support so currently back\nat 400cc flow 21-30% to maintain Sat >92%. LS cl and = with\nbaseline retractions noted. Nares sx x1 tonight. Baseline\nRR 60-80 at times with infrequent desats noted which are\nQSR. support and wean as tolerated.\n#3 Infant remains with TF 140cc/kilo of BM 20: 59cc gavaged\nover 30min and tolerated well so far with no spits or\naspirates noted. Abd soft and full with +BS and is voiding\nand stooling. Wgt +65g. Cont to assess feeding tolerance\nand introduce breast or bottle when cues are seen from baby.\nMonitor.\n#4 contact from yet tonight, support.\n#6 Recieved infant in air control isolette with temp >98.5\nso isolette shut off x 4h and tolerated well so transferred\nto open crib and maintaining temp nicely swaddled with hat\nand blanket. Alert and active with cares and sucking on\npacifier and fingers to sooth. Support dev needs.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-23 00:00:00.000",
"description": "Report",
"row_id": 1808429,
"text": "Neonatology Attending Progress Note:\n\nDOL #8\nin 400cc NC Oxygen, RR=30-70/80's.\nwt=2405g (inc 65g), PG full feeds at 140cc/kg/d\n\nPE: slight jaundice see rest below\n\nImp/Plan:x-33 week with residual lung disease\n--wean oxygen as tolerated, monitor respiratory status closely\n--monitor murmur\n--increase to 24 calories\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-02 00:00:00.000",
"description": "Report",
"row_id": 1808476,
"text": "NPN 0700-1900\n\n\n#2 Resp\nO: Infant remains in RA. Resp rate=30-60's. O2 sats=96-100%.\nLS are clr/=. No spells thus far. A: Stable in RA. P:\nContinue to monitor.\n\n#3 FEN\nO: TF=150cc/kg/day of BM24/PE24, 68cc q4hr. Infant took 45cc\nat 9am and BF for about 5min at 1pm. Gavaged TF at 1pm over\n45min. No spits. Minimal aspirates. V/S, heme neg. Abdomen\nbenign. Active bowel sounds. A: Tolerating feeds P: Continue\nto monitor and encourage PO feeds.\n\n#4 \nO: Mom came in for 1pm cares. Independent. Asking\nappropriate questions. Updated. BF and held infant. Mom and\ndad plan to be in for the 5pm cares. A: Involved, loving P:\nContinue to support and update.\n\n#6 DEV\nO: Infant remains in OAC. Swaddled. Temp stable. A/A w/\ncares. Sucks on pacifier. Font. soft and flat. A: AGA P:\nContinue to monitor and support G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-02 00:00:00.000",
"description": "Report",
"row_id": 1808477,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, , AFOF, sutures oposed, good tone. BBS clear and equal with good air entry. Soft murmur, RRR, pink, well perfused. Abdomen soft, non-distended, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-05 00:00:00.000",
"description": "Report",
"row_id": 1808492,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr2/6 murmur over LLSB, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-05 00:00:00.000",
"description": "Report",
"row_id": 1808493,
"text": "CoWorker NICU note\n\n\n2. Infant remains in RA c sats >93%. No spells thus far.\nOccassional drifts with feeds to 80's-QSR. Continue to\nmonitor and intervene as needed.\n3. TF changed to 140cc/kg/d=67ccq4hPO/PNG. Pt pulled NG tube\nthis afternoon and has been receiving PO feeds since then.\nRefer to flowsheet for totals. ABS x4 quads, soft, benign,\nno loops. No spits. COntinue to encourage bottle feeds.\n4. and in this afternoon. Both held patient.\n and eager for infant to go home.Updated on progress\nof the day and requirements for D/C. Continue to monitor,\nsupport and educate.\n6. Temp stable, swaddled in OAC. Wakes for feeds, active c\ncares, and sleeps very well between.Continue to support and\nmonitor developmental needs and progress.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-05 00:00:00.000",
"description": "Report",
"row_id": 1808494,
"text": "CoWorker NICU note\nI examined infant and agree with coworkers note for this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-06 00:00:00.000",
"description": "Report",
"row_id": 1808495,
"text": "nursing progress note\n\n\n2 - RESP - BSC/=, mild SC retractins at times. Sats>95%RA.\nNo A/Bs, No Desats\n\n3 - FEN - Tf= 140cc/k of BM24. Pt tol feeds, breast\nfeeding well w/ Mom x1, taking 60cc PO following feed. ABD\nsoft, +bs. Pt voiding, sm. stool. Wt unchanged\n\n4 - pArent - MOm in to do cares and feed - independent w/\ncares. updated\n\n6 - DEV - Temp stable in open crib. pt swaddled. ,\nstarting to wake for cares. AFOF.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-06 00:00:00.000",
"description": "Report",
"row_id": 1808496,
"text": "Neonatology\nDoing well. RA. No spells. Comfortable appearing.\nMurmur due to PPS from previous echo.\n\nWt 2890 no change. Taking po well (bottle and BF). No gavage in past 24 hours. ABdomen bneign.\n\nTemp stable in open crib.\n\nCirc to be scheduled\n\nContinue to await maturation of feeds and demonstartion of adeqaute intake.\n\nHep B given.\nPassed hearing.\nCar seat test to be done.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-06 00:00:00.000",
"description": "Report",
"row_id": 1808497,
"text": "Neonatology-NNP Physical exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-21 00:00:00.000",
"description": "Report",
"row_id": 1808422,
"text": "NNP Physical Exam\n\nPE: pink, jaundiced, AFOF, breath sounds clear/equal with fair air entry, mild to moderate subcostal retracting, mild head bobbing but appears comfortable, very soft murmur LLSB, pulses full/equal, abd soft, non distended, active bowel sounds, no HSM, no rashes, sleeping with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-21 00:00:00.000",
"description": "Report",
"row_id": 1808423,
"text": "NPN 0700-1900\n\n\n#2 O: Received infant in NC o2 400cc's of flow and 40-60%\nFio2 where he currently remains. LS clear and =. RR\n60's-70's with mod IC/SC retractions. No spells but having\ncouple drifts in o2 sats. A: Requiring high flow NC. P: Cont\nto monitor.\n\n#3 O: TF= 140cc/kg/d. Infant taking gavage feedings of\n100cc/kg/d or 42cc's of BM20/PE20 q 4h. Abdomen benign;\nvoiding and stooling mec with every diaper change. AG\n26.0-26.5cm. No spits, minimal aspirates. DS 74. IV fluids\nare currently at 40cc/kg of TPN D10 infusing via PIV. A:\nTolerating feeds thus far. P: Cont to advance by 20cc/kg \nas tolerated. Will increase feeds again at 1600.\n\n#4 O: Mom in this am bringing in BM and visiting briefly. A:\nInvolved. P: Cont to support and update.\n\n#6 O: Infant maintaining temp in heated isolette set in\nservo mode. Awake and alert with cares; sucking on pacifier\nwhen offered. A: AGA. P: Cont to support development.\n\n#7 O: Rebound bili this am was 8.4/0.5/7.9. A: Hyperbili. P:\nCont to monitor and draw bili with lytes in morning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-22 00:00:00.000",
"description": "Report",
"row_id": 1808424,
"text": "Nursing Progress Note\n\n\n#2. O: Infant remains in NCO2 at 400cc's in 40-55% FiO2. RR\n40's-70's. Moderate baseline IC/SC retractions noted. Breath\nsounds are clear and equal. No spells noted thus far\ntonight. A: Stable in NC. P: Continue to monitor resp status\nclosely.\n\n#3. O: Infant remains on TF's of 140cc/k/d. PIV d/c'd this\na.m. Feeds advanced to 140cc/k/d of BM/PE20. No spits.\nMInimal aspirates. AG stable. Abd soft and round with active\nbowel sounds. No loops. Voiding 2.3cc/k/hr. Med transitional\nneg guiac stools noted. D/S 73. WGt is down 25gms tonight to\n2340gms. A: Advanced to full feeds. P: Continue to monitor\nfeeding tolerance. A.M. elec's pending.\n\n#4. O: Parents in this evening. Asking appropriate\nquestions. Mom independently took temp and changed diaper.\nBoth held infant. A: INvolved loving family. P: Continue to\ninform and support.\n\n#6. O: Infant remains in air mode isolette with stable temp.\nHe is alert and active with cares. MAEW. Sucking on pacifier\nduring pg feeds. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n#7. O: Infant remains pink/jaundiced. A: Resolving\nhyperbili. P: Rebound bili pending this a.m.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-07 00:00:00.000",
"description": "Report",
"row_id": 1808504,
"text": "#6 DEV\ns/o: Temp stable in open crib. Tone good. MAE, AFOF.\nAttempted to screen in car seat test-yet sats drifting while\nin carseat. Removed and returned to crib and sat > 95\nimmediately. A/P:Await further maturity- will need to repeat\ntest. Will advise of potential need for carbed.\n#4 PARENT\ns/o: called x1, mom visited and providing care\nindependently and confidently. Mom states with baby\nA: Invested family. P: Cont to provide ongoing support and\nreinforce discharge teaching.\n#3 FEN\ns/o: Infant wt up tonight 20 gms to 2940. Orderd for \nintake of 140cc/k/d- yet unable to accurately quantify as BF\nexclusively 2 full feedings today. Measured intake -97cc/k\nyet gaining steadily and mom reports sustained >20 \nA: BF/po well. P: Cont to support BF efforts, mtr daily wt.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-08 00:00:00.000",
"description": "Report",
"row_id": 1808505,
"text": "Neonatology Attending\n\nDay 24\n\nRemains in RA. RR 30-50s. Clear breath sounds. Murmur present. HR 130-140s. WEight 2940 gms (+20). On BM 24 or E24. Took 127 cc/kg yesterday. Passing guiaic negative stool. and active. Passed hearing screen.\n\nImproved feeding. Respiratory status appears much improved. No desaturation with feeding over last 24 hours. Gaining weight well. Will observe closely for next two days. Will discharge in two days if continues to improve over this period.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-08 00:00:00.000",
"description": "Report",
"row_id": 1808506,
"text": "NPN 0700-1900\n\n\n#3 FEN\nO: TF=140cc/kg/day of BM/E24. Infant took 73cc at 9am\nand 15cc at 10:30am. Mom BF infant for 15min at 2pm. No\nspits. V/S. Abdomen benign. Active bowel sounds. A:\nTolerating feeds P: Continue to monitor.\n\n#4 Parenting\nO: Mom came in for the 1pm cares. Independent w/ cares. BF\nand held infant. Asking appropriate questions. Both \nplan to come in for the 5pm cares. A: Involved, P:\nContinue to support and update.\n\n#6 DEV\nO: Infant remains in OAC, . Temp is stable. Wakes\nfor feeds. A/A w/ cares. Infant had circ done today. Cleaned\nand vaseline applied. A: AGA P: Continue to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-09 00:00:00.000",
"description": "Report",
"row_id": 1808507,
"text": "Co-Worker Note: \n\n\n3. FEN: O: Current wt. up 35g to 2975g. On Tf of\n140cc/k/d of BM/E24 = 69cc q4 hours. TF intake yesterday =\n105cc/k plus breast feeding. Abdomen exam benign. V/S, hem\n-. +BS. No loops. See flowsheet. A: TF P: Continue current.\n\n4. PAR: O: No contact thus far. See flowsheet. A: ,\ninvested family. P: Support, educate, and prepare fro D/c.\n\n6. DEV: O: Pt. remains in OAC, temps stable. Awake\nand with cares, sleeping well between. Rooting and\nsucking binkie to pacify self. Circ site appears clean and\ndry. Some scabbed areas noted. Vaseline applied each care.\nPt passed careseat test tonight. See flowsheet. A: AGA P:\nSupport g&d and prepare for D/c.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-09 00:00:00.000",
"description": "Report",
"row_id": 1808508,
"text": "Neonatology Attending\n\nDay 25\n\nRemains in RA. RR 30-50s. Saturations > 95%. PPS murmur. Pink, well-perfused. Weight 2975 gms (+35). On BM/E 24. Took 145 cc/kg and breast fed. Benign abdomen. Passing heme negative stool. Waking for feeds. Stable temperature in open crib. Most of discharge teaching completed.\n\nDoing well. Appears to be turning corner on feeds. Gaining weight well. Adequate breathing control. Anticipate discharge tomorrow if no further clinical issues encountered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-06 00:00:00.000",
"description": "Report",
"row_id": 1808498,
"text": "Co-worker note 7a-7p\n\n\n#2. RES: RA, RR 40's-60's. Maintaining sats > 96%.\nOccasionally drifts to high 80's during bottling, QSR. LS\ncl/=. No spells.\n\n#3. FEN: Wt: 2890, no change. TF: 140cc/k/d of\nBM24/PE24= 67cc q4hr. Infant Po'ed 72cc at 0900. BF very\nwell for 15min at next cares and supplemented with 20cc. NG\ntube dc'ed for infant took all PO feeds for over 24hrs. Abd\nbenign, no loops, +BS. Voiding qs, no stool on this shift.\nNo spits.\n\n#4. PAR: Mom, and infant's aunt in to visit today. Mom\nBF and participated in cares. RN reviewed drawing up PO Fe\ndose with Mom and Mom gave Fe to idependently. RN also\nnotified about possibility of d/c and to plan to\nmake Pedi appt. are and appropriate.\n\n#5. G&D: remains swaddled in an OAC with stable temps.\nWakes early for feeds but settles with pacifier. Loves to be\nheld! and active during cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-06 00:00:00.000",
"description": "Report",
"row_id": 1808499,
"text": "Co-worker note 7a-7p\nI examined infant and agree with coworkers note for this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-07 00:00:00.000",
"description": "Report",
"row_id": 1808500,
"text": "NURSING PROGRESS NOTE\n\n2 pot. alt. in resp.\n\n3 - FEN - TF= 140CC/K OF BM/PE24. PT TAKING IN 123CC/K\nAND BREAST FEEDING YESTERDAY. TOL ALL PO FEEDS. ABD SOFT,\n+BS. PT VOIDING, . WT=2.920(+30)\n\n4 - PARENT - MOM CALLING X1, ASKING APPROPQUESTIONS,\nUPDATED.\n\n6 - DEV - TEMP STABLE IN OPEN CRIB, PT . AND\nACTIVE W/ CARES. AFOF. MAEW\n\nREVISIONS TO PATHWAY:\n\n 2 pot. alt. in resp.; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-07 00:00:00.000",
"description": "Report",
"row_id": 1808501,
"text": "Neonatology Attending\n\nDay 23\n\nRemains in RA. Sa-O2 in mid-high 90s. RR 40-50s. Had mild desaturation event during feeding. No bradycardia. HR 130-160s. Murmur continues. Pink, well-perfused. Weight 2920 gms (+30). On BM/PE 24. Took 123 cc/kg yesterday. Feeding tube discontinued. Passing stool well. Stable temperature in open crib.\n\nSlowly advancing maturity of breathing control and feeding. Not quite ready to be discharged. Monitoring closely for apnea. Gaining weight. Will change over to 24 cal Enfamil. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-07 00:00:00.000",
"description": "Report",
"row_id": 1808502,
"text": "NPN 0700-1530\n\n\n3. On 140/k/d of now BM24/E24 with enfamil powder. Abd\nbenign, voiding and . Needs to take 68cc Q4hr.\nAble to bottle 55cc thus far. Nursed well for 20mins and\nable to PO 20cc after. Tires with feed. Cont to work up on\nPO feeds.\n\n4. Mother in to visit and independent with infant cares.\nMother able to give . Taught mother how to mix\nformula to 24cals. Cont to prepare for d/c in near future.\n\n6. Temp stable in OC. Infant awake and active\nwith cares. Tires easily with bottle/breast. MAE. Cont to\npromote G&D. Plan for circ tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-07 00:00:00.000",
"description": "Report",
"row_id": 1808503,
"text": "Neonatology-NNP Physical Exam\n\nInfant remains in RA. Active, in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. Gr murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-29 00:00:00.000",
"description": "Report",
"row_id": 1808459,
"text": "NPN 0700-\n\n\n2. Remains in RA with sats 94-99%. A few desats to 80's,\nall QSR. Lungs clear, RR 30-50's. No A&B's thus far. Cont\nto monitor for desats and A&B's.\n\n3. TF 150/k/d BM24/PE24. Abd benign, voiding and .\nInfant nursed for ~5mins this am and tired easily. Mom\nplanning to visit at 1700 to nurse again. Tolerating feeds\nwithout emesis/residuals. Requiring NGT feeds to meet\nTF-see flowsheet. Cont to encourage PO feeds as tolerated.\n\n4. Mother in to visit, independent with cares and update\ngiven. Demonstrated how to draw up, and administer\nFerinsol. Mother planning to visit at 1700 to breast feed\ninfant. Cont to support, update and prepare for near future\nd/c.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-01 00:00:00.000",
"description": "Report",
"row_id": 1808470,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats>95%. RR\n40-60's, no increase work of breathing noted. LS clear/=.\nHe has occasional sat drifts that are QSR. No A&B's. A:\nPt. is stable in RA. P: Continue to monitor respiratory\nstatus. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM/PE 24 =67cc Q 4hrs,\nalternateing PO/NG feeds. He took ~30cc this am. Pt.\nrequires encouragement and assist w/ feeds, appears\ndisinterested after a while. Abdomen is benign. +BS, no\nloops/spits noted. He is voiding/ tr yellow stool(-). A:\nPt. is tolerating current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance. Plan\nto continue to offer PO feeds as pt. looks interested and\ntolerates.\n\n#4. O: No contact from this shift thus\nfar. P: Continue to support and educate.\n\n#6. Growth/Development O: Pt. remains in an open crib w/\nstable temps. He is and active w/ cares, sleeps well\nin between. Fontanelle soft/flat. He loves to use his\npacifier, brings hands to face. A: AGA P: Continue to\nprovide environment appropriate for growth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-28 00:00:00.000",
"description": "Report",
"row_id": 1808452,
"text": "Neonatology Attending\nDOL 13\n\nHas remained in room air for 24 hours. No distress, no bradycardias, few .\n\nWt 2540 (+5) on TFI 150 cc/kg/day BM24/PE24, tolerating well with occasional partial oral feeds.\n\nTemperature stable in open crib.\n\nA&P\nPreterm infant with residual feeding immaturity. No changes in management as detailed above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-28 00:00:00.000",
"description": "Report",
"row_id": 1808453,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. nl S1S2, no murmur appreciated. Infant and active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-28 00:00:00.000",
"description": "Report",
"row_id": 1808454,
"text": "Coworker NICU note\n\n\n2. O/A Pt remains in RA sats> 94%. Bilat breath sounds c/=.\nNo desats or bradys. mild subcostal retraction. Stable in\nRA. P/ COntinue to monitor and intervene as needed\n3. TF 150cc/kal. Pt is receiving 64cc q4hr of BM24 or PE24.\nNo spits. Max aspirate 4.5cc. Mom put infant to breast this\nafternoon. Patient was acting tired. Learning to PO feed. P/\nContinue to encouragge, educate and teach the \n4. MOm in for afternoonVery . Handles infant\nwell. P/ Continue to educate and support .\n6.Temp stabe in OAC, swaddled with pacifier. with\ncaares. Slept most of the day today.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-28 00:00:00.000",
"description": "Report",
"row_id": 1808455,
"text": "NPNOte:\nI agree with above co-workers note. visited, asking app questions, mom will bring in car seat in am, baby had full volume bottle x1,hep B vaccine given.Mom is aware that baby may go home once po fed all feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-29 00:00:00.000",
"description": "Report",
"row_id": 1808456,
"text": "Co Worker Note\n\n\nRESP: O- Baby is in RA. Breathing 40-60's. CL/=. Sats > 94%.\nVery mild SCR. No spells or desats noted.\n A- No issues.\n P- Will continue to monitor closely.\n\nFEN: O- Weight 2.555, up 15gm. TF 150cc/k/d of BM 24 or PE\n24. 64cc Q4H. PO/PG. See flowsheet for examination of this\nshift. Baby is voiding and . Hem Neg. + B.S.\nAbdomen: Benign. Belly is soft and round. Max aspirate 3cc.\nNo spits.\n A- Tolerating Feeds.\n P- Continue c current regime.\n\n: No contact thus far this shift.\n\nDEV: O- In open crib. Temp. is stable. Slowly waking for\nfeeds. and active c cares. Mild mannered. Enjoys his\npacifier.\n A- AGA.\n P- Will continue to provide for developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-29 00:00:00.000",
"description": "Report",
"row_id": 1808457,
"text": "Agree w/ above note by . Infant is more pg than po at this point. He is still learning to eat.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-30 00:00:00.000",
"description": "Report",
"row_id": 1808460,
"text": "Nursing Progress Note\n\n\n#2. O: Infant remains in RA with O2 sats >95%. RR 40's-60's.\nBreath sounds are clear and equal. No spells thus far. A:\nStable in RA. P: Continue to assess resp status.\n\n#3. O: Infant remains on TF's of 150cc/k/d of BM24/PE24.\nMostly pg fed. PO fed 12cc's only tonight. Very\nuncoordinated. Abd soft and round with active bowel sounds.\nNo loops. Voiding qs. No stools thsu far. WGt is up 70gms\ntonight to 2625gms. A: Tolerating feeds. P: Continue to\nmonitor feeding tolerance.\n\n#4. O: MOm called x1 tonight for update. Asking appropriate\nquestions. Asking for family meeting for Monday afternoon.\nA: Involved . P: Continue to inform and support.\nCheck with team regarding FM for Monday.\n\n#6. O: Infant remains in open crib with stable temp. He is\n and active. MAEW. Sucking on pacifier during pg feeds.\nVery uncoordinated po feeder. ?Hearing screen to be done\ntonight. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-30 00:00:00.000",
"description": "Report",
"row_id": 1808461,
"text": "Neonatology Attending\nDOL 15\n\nRemains in orom air with no distress and no cardiorespiratory events.\n\nPPS murmur persists.\n\nWt 2625 (+70) on TIF 150 cc/kg/day BM24/PE24. Bottled full feed x 1 today. and voiding normally.\n\nA&P\nModerately preterm infant with residual feeding immaturity. We will schedule a family meeting for tomorrow afternoon. It appears that oral feeding skills are improving; he will be ready for discharge once he has fed orally for 24 hours.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-30 00:00:00.000",
"description": "Report",
"row_id": 1808462,
"text": "Neonatal NP-exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\naFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and well perfused. abd benign, no HSM. Active bowel sound. Infant and active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-01 00:00:00.000",
"description": "Report",
"row_id": 1808471,
"text": "Clinical Nutrition\nO:\n~36 wk CGA BB on DOL 17.\nWt: 2685 g (+10)(~50th to 75th %ile); birth wt: 2515 g. Average wt gain over past wk ~32 g/d.\nHC: 33 cm (~75th %ile); last: 31 cm\nLN: 46 cm (~25th to 50th %ile); last: 48 cm\nMeds include Fe.\n noted.\nNutrition: 150 cc/kg/d PE/BM 24, alternating po/pg feeds. Takes ~ of volume po; slow feeder. Average of past 3 d intake ~145 cc/kg/d, providing ~116 kcal/kg/d and ~3.2 to 3.5 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range except low PO4 level of 3.0; unclear why this value is so low; in face of nl alk phos level, it does not present as a rickets picture. Will recheck level in time. Current feeds meeting recommendations for kcals/pro/vits and mins. Growth is meeting recommendations for wt gain; exceeding recommended ~0.5 to 1.0 cm/wk for HC gain; LN shows 2 cm loss over past wk, but question accuracy of measurements. Will follow growth trends over time. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-29 00:00:00.000",
"description": "Report",
"row_id": 1808458,
"text": "Newborn Med Attending\n\nDOL#14. Cont in RA. Occ desats. AF flat, clear BS, + murmur, abd soft, MAE. Wt=2555 up 15. On Bm24 at 150 cc/kg. Feeds Po/PG.\nA/P: Growing infant working up on PO feeds. Monitor for spells.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-31 00:00:00.000",
"description": "Report",
"row_id": 1808466,
"text": "coworker \n\n\n#2RESP: infant stable in RA. lung sounds are cl/=.\nRR:40-50's. sats in high 90's with occassional drifts with\nbottling. no retractions noted. no spells. A: stable\nP:cont to monitor infant and intervene if necessary\n\n#3FEN: TF remains at 150cc/k/d of BM/PE 24. 67cc's Q4H\ngavaged over 40 . alt po/pg. at 0900 care bottled 30cc's\nbut tired quickly. will offer bottle at 1700 care. belly\nbenign, abd soft and round, +, no loops, no spits, \nasp, voiding and ; heme neg A:tol feeds well P:cont\nto monitor and encourage bottling.\n\n#4PARENTING: in for 1300 care and will be back for\n1700 care. ind with temp and diaper. asking appropriate\nquestions. A:loving vested family P:cont to support family\nneeds\n\n#6DEV: temp stable in open crib. infant swaddled. wakes for\nsome feeds. and active with cares. sleeps well between\ncares. sucks on pacifier. MAE. brings hands to face. A:AGA\nP:cont to support g/d of infant\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-31 00:00:00.000",
"description": "Report",
"row_id": 1808467,
"text": "NURSING 3p-7p\nOversaw care provided by co-worker and I agree with above note and with assessment. At 5 pm feeding infant BF eagerly so pg fed only vol. Will cont to mtr interest and encourage po and BF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-01 00:00:00.000",
"description": "Report",
"row_id": 1808468,
"text": "NPN 1900-0700\n\n\n#2Resp. O: Pt. remains in room air, breath sounds clear and\nequal, no spells. Maintaining sat 95 and above , with\noccasional drifts to high 80s that QSR.A:Stable resp.\nstatus. P: Continue to eval. resp status, monitor for apnea.\n\n#3FEN. O: Wt. 2685gms(up 10gms). On TF of 150cc/kg/d of\nBM24/PE24, 67cc every 4 hours. Pt. took 55cc and then 45cc\nwith attempts to po feed.Remainder of feeds given via NGT.\nPt. has good coordination with bottling, but tires quickly.\nMinimal aspirates, no spits. Abd. soft with active bowel\nsounds, no loops. Voiding, had one heme negative stool.\nNutrtional labs drawn this am.A: Pt. not taking full\nfeedings po. P:Continue to offer bottle with cares when\n. Monitor I/O.\n\n#4Parents. O: No contact with so far tonight.\n\n#6 Dev. O: Pt. swaddled in open crib. Temp. stable. Pt.\n with cares, sleeping between cares. Takes pacifier.\nA:AGA. P:Continue to support developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-01 00:00:00.000",
"description": "Report",
"row_id": 1808469,
"text": "Neonatology Attending\nDOL 17\n\nRemains in room air with occasional desaturations but no apnea/bradycardia.\n\nIntermittent PPS murmur persists (echo on ). BP 70/36 (55).\n\nWt 2685 (+10) on TFI 150 cc/kg/day BM24/PE24, tolerating well. Alternating oral and gavage with slow oral intake. Voiding and normally. 143.4.8/109.20. ALP 93.\n\nA&P\nPreterm infant with feeding immaturity. Continue to await maturation of oral feeding skills. No changes in management today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-27 00:00:00.000",
"description": "Report",
"row_id": 1808448,
"text": "Clinical Nutrition:\nO:\n35 CGA, BB now on DoL #12\nWt: 2535g (no change o/n)-(~50th%ile); gained an average of 9 g/kg/day over the last week (24 g/day)\nLN: 48cm (46.75)-(~75th%ile)\nHC: 31cm (30.5)-(25-50th%ile)\nLabs: None recent\nMeds: Iron (~3.2-3.3 mg/kg/day from feeds & supplement)\nNutrition: BM/PE24 @ 150 cc/kg/day\n3 day average intake: ~151 cc/kg= ~121 Kcals/kg & ~3.3-3.6 g/kg of protein\nGI: benign\n\nA/goals:\nTolerating feeds well, minimal spits/aspirates noted. Voiding & . Feeds are mostly gavage, took ~15cc PO this am. Wt gain slightly below goal range (~ g/kg/day), will monitor trends. Suspect will wt. gain will improve as PO feeding coordination develops. Holding on advancing Kcals for now. No changes to nutrition plan today, will cont. to follow w/team.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-27 00:00:00.000",
"description": "Report",
"row_id": 1808449,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal. Nl S1S2, grade II/VI murmur audible. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant and active with exam. .\n\n\nSpoke with mother at bedside about cardiology findings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-27 00:00:00.000",
"description": "Report",
"row_id": 1808450,
"text": "NPNote:\n\n\n#2 Remains in R. air, (nasal cannula 100%-13cc trail off at\n8.30am today) BBS clear and equal, mild intercostal/\nsubcostal retractions present, no spells,sat drifts to high\n80's QSR.A; Stable in R. air. P; continue to monitor.\n\n#3.Tf=150cc/kg/day, MBm24cal Po/ PG feds given, po fed about\nhalf volume rest pg fed at 8+4pm, breast fed at 12pm. BS+,\nno loops, voided and stooled, guaic negative.A; Feeds\ntolerated. P; continue current feeding plan.\n\n#4. Mom visited, asking app. questions,independent with care\nand breast feed. Pedi will be Dr. according to\nmom.A; Involved mom P; continue teaching and update.\n\n#6. and active with care, temp stable in a open crib.\nswaddled, with a hat on. Hep vaccine consent signed by\nmom.mom will bring in car seat this weekend, A; AGa P;\ncontinue dev support,needs hep vaccination.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-28 00:00:00.000",
"description": "Report",
"row_id": 1808451,
"text": "NPN 1900-0700\n\n\n2. O: Infant remains in room air since 0900am . RR\n40-60's with mild retractions noted. LS clear bilaterally.\nOcc. Quick, self-resolved desaturations noted. A; Stable in\nroom air. P: Continue to assess.\n\n3. O: Wt. +5g 2540g. TF=150cc/kg/d. Infant receiving\nBM24/PE24 64cc every 4 hours via gavage/bottle. No spits\nnoted. Max asp. 4cc. Abdomen soft. +b.s. VDg & heme\nneg. q.s. Will bottle at 0430am. Mom put infant to breast\n@. Infant did fair. A; Learning to bottle. P: Attempt to\nbottle every other feed as tolerated.\n\n4. O: in for cares. swaddle & take temp\nindependently. gave his first bath with\nassistance. eager to learn care of their son. Asking\nmany questions. Mom appears comfortable with handling infant\n& putting him to breast. A: Involved,loving . P:\nContinue to update,educate and support.\n\n6. O: maintaining temperature in open crib. Swaddled.\nMAe. with cares. Drowsy @2400 cares. Sucks on pacifier\nat times. A: AGA P: Continue to support development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-30 00:00:00.000",
"description": "Report",
"row_id": 1808463,
"text": "NPN 0700-1900\n\n\n#2 O: Infant on RA with sats 95-100%. RR 40-60 and infant\nhas no retractions. Lungs CTA all over. eposides of\ndesaturation to the high 80s, but was quickly self-resolved.\nA: Respiratory status stable. Infant able to maintain\nappropriate saturation. P: Monitor for signs of respiratory\ndistress.\n\n#3 O: Current weight 2625 (up 70 from yesterday). Receiving\n150cc/kilo/day of BM24. Abdomen soft, round, benign.\n and voiding with every diaper change. Took all of\nam feeding po, and used the NGT for afternoon feeding\n(infant was very tired and did not respond to either mom's\nbreast nor bottle). A: Growing appropriately. Tolerating\nfeeds with no aspirates or spits. P: Will continue\nattempting bottle feeding. Use NGT as necessary.\n\n#4 O: Mom was in today for about 2 hours. Attempted\nbreastfeeding and bottling, but infant was extremely tired.\nMom brings in steady supply of breast milk. Asks\nappropriate questions and shows interest in infant. A:\nLoving and attentive mom. P: Encourage breastfeeding and\nassistance with infant cares.\n\n#6 O: Infant currently swaddled in crib. Temp remains\nstable. Maintains eye contact and movements are equal all\nover. A: Developing at an appropriate rate. P: Continue to\ninteract positively with infant (both via mom and staff).\nUtilize suggestions made by OT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-31 00:00:00.000",
"description": "Report",
"row_id": 1808464,
"text": "Nursing Progress Note\n\n\n#2. O: Infant remains in RA with O2 sats >96%. RR 50's-60's.\nBreath sounds are clear and equal, no GFR noted. Brief\noccaisional desats to 88-89% noted, QSR. Otherwise no\nspells. A: Stable in RA. P: Continue to monitor resp status.\n\n\n#3. O: Infant remains on TF's of 150cc/k/d of PE24/BM24. PO\nfed volume x1. Abd soft and round with active bowel\nsounds. No loops. Voiding qs, stools neg heme. WGt is up\n50gms tonight to 2675gms. A: Tolerating feeds. P: Continue\nto monitor feeding tolerance.\n\n#4. No contact from family tonight. FM planned for today at\n1400.\n\n#6. O: Infant remains in open crib with stable temp. He is\n and active with cares. MAEW. Sucking on pacifier\nduring pg feeds. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-31 00:00:00.000",
"description": "Report",
"row_id": 1808465,
"text": "Neonatology Attending\nDOL 16\n\nRemains in room air with occasional mild desaturations.\n\nPPS murmur persists. BP 68/44 (51).\n\nWt 2675 (+50) on TFI 150 cc/kg/day PE24/BM24. Alternating oral and gavage feeds. Voiding and normally.\n\nA&P\nPreterm infant with mild respiratory and feeding immaturity. Continue to await consolidation of oral feeding skills. Family meeting will be held today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-26 00:00:00.000",
"description": "Report",
"row_id": 1808443,
"text": "NURSING PROGRESS NOTES.\n\n\n#2 O: BABY REMAINS IN NASAL CANNULA OXYGEN 13CC FLOW, 100%.\nBREATH SOUNDS CLEAR AND EQUAL, NO RETRACTIONS. NO SPELLS TO\nTIME OF REPORT. A: CONTINUES TO REQUIRE AS SMALL AMOUNT OF\nNASAL CANNULA OXYGEN. P: CONTINUE TO MONITOR AND WEAN AS\nTOLERATED.\n#3 O: TOTAL FLUIDS 150CC/KG/DAY OF BM/PE24. FEEDS GIVEN\nEVERY 4 HOURS OVER 45 . NO SPITS OR ASPIRATES. ABDOMEN\nSOFT, BOWEL SOUNDS ACTIVE, NO LOOPS, GIRTH STABLE, VOIDING\nAND . BABY BREAST FED FAIRLY WELL ONCE THIS\nAFTERNOON. A: LEARNING TO BREASTFEED, TOLERATING FEEDS\nWELL. P: CONTINUE TO ENCOURAGE BREASTFEEDING WHEN MOM\nVISITS.\n#4 O: MOTHER IN TO VISIT AND FEED BABY AT TODAY.\nMOTHER IS WITH DIAPER CHANGING AND NEEDED LITTLE\nASSISTANCE WITH BREASTFEEDING. A: INVOLVED FAMILY. P:\nCONTINUE TO KEEP INFORMED.\n#6 O: TEMP STABLE IN OPEN CRIB. BABY IS AND ACTIVE\nDURING CARES AND BEGINS TO STIR BEFORE CARES. BABY SETTLES\nTO SLEEP WELL BETWEEN FEEDS. BABY BREASTFED FAIRLY WELL\nTODAY BEFORE FALLING ASLEEP. A: APPROPRIATE FOR AGE. P:\nCONTINUE TO SUPPORT DEVELOPMENT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-26 00:00:00.000",
"description": "Report",
"row_id": 1808444,
"text": "NNP Physical Exam\n\nPe: pink, AFOF, breath sounds clear/equal with mild to moderate subcostal retracting, comfortable, soft murmur LLSB and left axilla, +2/= pulses, abd soft, non distended, active bowel sounds, no HSM, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-26 00:00:00.000",
"description": "Report",
"row_id": 1808445,
"text": "Nursing Note\n\n\n#2O: Remains in nasal cannula 100% 13 -25cc. Br. sounds\nare clear with mild SC retractions.\n#3O: Total fluids at 150cc/kg/d BM24. Belly soft, .\nasp. and no spits. Voiding and . Went to breast\nand did well latching and nsg. 1 side.\n#4O: in and independent with cares. Pleased son is\ndoing well and are aware that mom cant put her baby to\nbreast when she visssits and that we will offer bottles when\ninfant appears interested.\n#6O: Temp stable in crib. and active with cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-27 00:00:00.000",
"description": "Report",
"row_id": 1808446,
"text": "Nursing Progress Note\n\n\n2.O: Remains in NC 13cc's 100% this shift. O2 sats mid to\nhigh 90's. No desats or A's & B's noted. rr 40's-70'swith\nmild subcostal retractions noted. Breath sounds clear and\nequal, Lips and nailbeds pink.\n A: Slowly resolving RDS.\n P: Continue to monitor.\n3.O: Weight 2535gms no change. On BM 24 cal 63cc's q4h =\n150cc kg/d. Attempted to bottle at 4 AM taking 15cc's\nbottling slowly. Abdomen benign, voiding.\n A: Stil Slow with feeds.\nOffer bottles prn.\n4.O: No contact this shift.\n6.O: Active and for cares. Starting to wake for feeds.\nSwaddled and nested in the crib\n A: Gestationally appropriate.\n P: Continue to observe.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-27 00:00:00.000",
"description": "Report",
"row_id": 1808447,
"text": "Neonatology Attending\n\nDay 12\n\nRemains on nasal cannula at 13 cc/ flow. RR 50-70s. Clear breath sounds. Mild retractions. No bradycardia. Weight 2535 gms (unchanged). On BM 24 at 150 cc/kg/d. On po/pg feeds. Taking about half volume feeds. Benign abdomen. Stable temperature in open crib.\n in daily.\n\nDoing well on minimal oxygen flow. Monitoring for apnea closely. Tolerating feeds. Encouraging po feeds. Will obtain consent for hepatitis B vaccine. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-25 00:00:00.000",
"description": "Report",
"row_id": 1808439,
"text": "NPN days\n\n\nAlt in Resp: Baby in nasal cannula 100% at 13cc. O2 sats\ngreater than 95%, REsps40-50's. Lungs clear and equal. No\ndrifts today, and no brady's. Mild subcostal retractions\noccas. After breastfeeding today baby's work of breathing\nincreased for short period of time. Continue to monitor\nclosely.\n\nFEN: Total fluids 150cc of BM24 or PE24, on -4\nschedule, recieving 63cc per feeding via gavage. NGT\nreplaced today aspirits 0.8-1.0cc, Abdominal exam benign.\nVoiding and , guiac neg. abdominal girth stable.\nContinue per feeding plan\n\nParenting: Mother in today to breastfeed, lactation\nconsultant in with mother. Baby latched but was sleepy at\nbreast. Will continue to update and support.\n\nDEV: Infant in open crib swaddled, maintaining temps. Awake\nand alert with cares, sleeping well between cares.\nComforted by swaddling, and pacifier.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-25 00:00:00.000",
"description": "Report",
"row_id": 1808440,
"text": "NPN days\nCardiology Consult today d/t murmur persistant. 4 extremity BP's done today and CXR. No further testing recommended at this time by cardiology.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-24 00:00:00.000",
"description": "Report",
"row_id": 1808435,
"text": "NPN 0700-1900\n\n\nRESP: Received infant in NCo2, 400cc, 30-40%. Able to wean\no2 to 25% and infant was changed to low flow cannula.\nCurrently in 100%, 13cc with sats >94%. breath sounds are\nclear and equal. Mild subcsotal retractions noted. RR\n50-60's. No apnea/bradycardia or desaturations.\nA: Stable in low flow O2\nP: Cont to wean o2 as tolerated.\n\nF&N: Tf increased to 150cc/kg/d of BM/PE 24. Infant is\ntolerating gavage feeds over 30 minutes without spits. max\naspirate-5cc of partially digetsed BM/formula. Abd is round\nand soft with active bowel sounds and no loops. Ag 24.5cm.\nvoiding and with each diaper change.\n Infant went to breast with Mom at . He latched on and\nnursed for ~10minutes. Will evaluate infant at each feed to\nincrease po feeding opportunities.\nA/P: Learning to po feed. Follow weight.\n\n: Mom in at - independent with temp and diaper.\nNursed w / minimal assistance. Updated at bedside.\nreturned this afternoon with Grandmother. Did not nurse at\n1600- may return this evening to nurse.\nA/P: Involved, loving mother- cont to support and teach\n\nDEV: Temp 97.8-98.6 while swaddled in an open crib. \nis alert and active with cares. Nursed well for 10 minutes.\nA/P: Stable- appropriate\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-25 00:00:00.000",
"description": "Report",
"row_id": 1808436,
"text": "nursing note\n\n\n#2 RESP O: Child remains on nasal cannula on 100 percent at\n13cc. RR as noted. Breath sounds clear and equal. no desats\nor bradys noted. no increased WOB noted. P: Will continue on\nnasal cannula as needed and monitor WOB.\n#3 FEN O: Child remains on bm24 or pe24 at 150cc/k.\nTolerating gavage feeds of 63cc over 50 minutes without\nspits or significant residuals. Child voiding and \nwell. Ng secure and placment verified by aspiration and\nauscultation. Girth remains stable. Good bowel sounds heard.\nNo loops noted. Iron given as ordered. Weight increased by\n30 grams today. P: Will continue to gavage feed as tolerated\nand monitor his toleration. weigh child q day.\n#4 Parenting O: no contact as yet from his . P: will\ncontinue to support and inform his .\n#6 DEV O: Child remains in open crib. Temp is stable. Sleeps\nbetween cares. P: will continue to support his coping\nskills.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-25 00:00:00.000",
"description": "Report",
"row_id": 1808437,
"text": "Neonatology Attending\n\nDay 10\n\nRemains on nasal cannula at 13 cc/. RR 40-60. Clear breath sounds. No bradycardia. Mild retractions. Soft murmur persists. BP 73/31, 49. RR 130-160s. Weight 2460 gms (+30). On PE 24 at 150 cc/kg/d. Requiring gavage feeds over 45 minutes. No spits. Minimum gastric aspirates.\n\nDoing well overall. Weaning from oxygen nicely. Monitoring closely. Gaining weight. To see lactation consultant this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-25 00:00:00.000",
"description": "Report",
"row_id": 1808438,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, grade II/VI murmur audible. Pale, pink and well perfused. Abd benign, no HSM. Active bowel sounds. infant alert and active with exam.\n\n\nCardiology called to evalaute murmur.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-26 00:00:00.000",
"description": "Report",
"row_id": 1808441,
"text": "2. Resp: O: Infant received on O2 via a nc, low flow, 100%\nand in 13cc flow. He has not needed any additional O2, has\nnot desatted or had a spell. Ls are clear, color pink. RR\n40-50s. A: Stable in very little O2. P: Monitor. Wean as\ntol.\n\n3. F/N: O Infant is on 24cal BM or PE, q 4 hour feeds,\n150cc/k/d. He is mostly gavaged at this point. Attempted to\nbottle infant w/ the yellow nipple for @ 15 . He is\nuncoordinated and appeared to take @ 18cc, dribbling a lot\nonto the washcloth. He had no desats or choking spells\nhowever and needed no extra O2. Otherwise: Abd is benign, no\nspits, asps, voiding and only having small stool smears\nso far tonight. He gained 75g and is now above BW. A: Tol\nfeeds, starting to bottle, though is still uncoordinated. P:\nContinue to bottle once a day and BF w/ Mom once a day.\n\n4. : O: were in to visit and do cares and Mom\nheld while he was being gavaged. They expressed\nfrustration w/ the fact that isnt really eating yet\nbut also stated that they were forgetting that he had been\nborn 7 weeks early. We talked about this a bit and they\nseemed to have a pleasant visit. A: Loving , looking\nforward to taking their son home eventually. P: Continue to\nsupport.\n\n6. G/d: O: Infant's temp is stable in the open crib,\nswaddled w/ a t-shirt on. He wakes for cares and sucks\nvigorously on a binkie. A/P: Continue to support infant's\nneeds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-26 00:00:00.000",
"description": "Report",
"row_id": 1808442,
"text": "Neonatology Attending\n\nDay 11\n\nRemains on nasal cannula at 13. RR 40-50s. No bradycardia. Murmur continues. CXR was normal. Weight 2535 gms (+75). Taking po feeds of BM 24. Work of breathing increases after feeds. Passing stool. up to date.\n\nMinimal oxygen requirement. Weaning as allowed. Monitoring cardio-respiratory status closely. Gaining weight well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808387,
"text": "Neonatology Attending Note\nDay 1\n\nRESP: s/p one dose of surfactant. Currently 18 x 20/5, 21%. Cap gas 7.39/46 (since weaned to current settings). RR50-80s. Sm wh secretions.\n\nCV: No murmur. HR 140-150s. Mean BP 34-45. Ruddy/pink. Perfusion/pulses good.\n\nFEN: Wt 2515. TF 80 cc/k/day. NPO. Abd soft. BS more active.\n\nID: Started on amp/gent. Initial CBC left shifted and low platelets.\n\nUnder radiant warmer.\n\nA/P:\nPreterm newborn with RDS, presumed sepsis.\n1. Wean vent as tolerated. Transition to CPAP.\n2. Monitor for AOP, PDA.\n3. Decrease TF to 60 cc/k/day to encourage diuresis.\n4. Repeat CBC.\n5. Will need 7 day course of abx for presumed sepsis. Will need LP to complete evaluation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808388,
"text": "Respiratory Care\nPt recieved on IMV, rate of 18, pressures of 20/5 with the fio2 21%. Pt's respiratory rates 60s' to 80's. Pt extubated placed on NP-CPAP +6cm's with the fio2 30 to 45%. Pt suctioned for a sm amt of thickish white secretions. CBG results obtained with good results. Plan is to follow pt on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808389,
"text": "Nursing progress note\n\n\n#1 O: Remains on antibiotics as ordered with repeat CBC with\ndiff. drawn as ordered and documented, active and sucking on\npacifier, but sleepy with cares A: r/o sepsis coarse cont.\nP: administer antibiotics as ordered and monitor BC\n#2 O: Extubated to CPAP at 1200 at 6cms with O2 need\nincreasing to 35-40% on CPAP with slight increased RR-80's\nwith moderate retraction with CAP gas pH-7.37 with PCO2-46\nA: increase in resp. effort with increasing O2 need P:\nmonitor closely and intervene as indicated\n#4 O: Abdomen soft with hypoactive BS without\nloops/distention, IV fluids decreased to 60cc/kg, remains\nNPO A: NPO with question starting feeds this evening P:\nmonitor closely and assess, introduce feeds as indicated\n#4 O: Parents up numerous times thru shift with mom holding\nson for the first time, parents updated A: Involved P:\nsupport, teach and keep informed\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808390,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal, good CPAP transmission. Pectus excavatum present. Nl S1S2, no audible murmur. Pink, jaundiced. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808391,
"text": "Neonatology NP PRocedure Note\n\nEndotracheal Intubation\nIndication: need for additional dose of surfactant, Increasing FiO2 requirement and work of breathing on CPAP.\n\n3.0 ett passed orally through cords under direct laryngoscopy. tube secured at ~9 cm. Equal breath sounds and good chest wall movement present. CXR show tip of ett above carina. Infant tolerate procedure well. No complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808395,
"text": "Clinical Nutrition\nO:\n33 wk Gestational age BB, AGA, now on DOL 2.\nBirth wt: 2515 g (~75th %ile); current wt: 2380 g (-135) (wt down ~5% from birth wt.)\nHC at birth : 30.5 cm (~25th to 50th %ile)\nLN at birth : 46.75 cm (~50th to 75th %ile)\nLabs noted.\nNutrition: TF @ 100 cc/kg/d. NPO. PN to start today via PIV; projected intake from PN ~51 kcal/kg/d, ~1.9 g pro/kg/d, and ~1.0 g fat/kg/d. Glucose infusion rate from PN ~7.0 mg/kg/min.\nGI: Active BS. Bloody secretions suctioned from mouth and stomach at delivery; holding off enteral feeds for now.\n\nA/Goals:\nTolerating PIV of D10 w/ 2 NaCl. Expect good tolerance of PN. Labs noted and PN adjusted accordingly. Planning to start enteral feeds soon if abdomen remains benign. Goal for PN is ~90 to 110 kcal/kg/d, ~3.0 to 3.5 g pro/kg/d, and ~3.0 g fat/kg/d. Expect PN to taper as enteral feeds are started and advanced. Initial goal for enteral feeds is ~150 cc/kg/d of BM/PE 24, providing ~120 kcal/kg/d and ~3.3 to 3.6 g pro/kg/d. Further advancements in feeds as per tolerance and growth. Appropriate to start Fe supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/d for wt gain, ~1 cm/wk for LN gain, and ~0.5 to 1.0 cm/wk for HC gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808396,
"text": "NURSING PROGRESS NOTE\n\n\n1. Infant remains on amp and gent as ordered for a 48hr r/o,\nD/C tonight. Temps remains stable, no overt clinical signs\nof sepsis. Cultures remain negative to date, cont to monitor\ncultures for growth.\n\n2. Infant received on SIMV 20/5 x 20. Infants settings\nweaned after latest CBG, 7.40/44/37/28/1. Infant presently\non settings of 20/5 x 16, requiring mostly 21% FiO2. LS\nclear and equal, moderate subcoastal and intercoastal\nretractions. Sxn q3-4hrs for moderate pale white secretions.\nCXR done and showed no improvement. Cont to monitor and\nwean settings as tolerated.\n\n3. Infant TF increased to 100cc/kg/d of D10/2NaCl. IVF\ninfusing via PIV without incident. remains NPO. Plan\nto start infant on TPN later tonight. Abd soft, round, +BS.\nDstx-74. Generalized edema noted. Vdg adaquate amts, no\nstool since birth. Plan for lytes and a bili in the am. Cont\nto monitor.\n\n4. Mom in to visit x 2, and updated at the bedside.\nGrandmother in to visit x 1. Mom asking appropriate\nquestions. Plan for family meeting @ 4pm with parents. Plan\nfor mom to hold infant at next care. Cont to update and\neducate parents.\n\n5. CV: Soft murmur detected at latest care. Four extremity\nBP's done. EKG also done. NNP rivers aware and has reviewed\nthe EKG. Cont to monitor.\n\n6. DEV: Infant remains nested with boundaries on open\nwarmer. Temps remain stable. Alert and active with cares.\nOccassionaly irritable, sucking on pacifier. Fontanels soft\nand flat. Cont to monitor dev needs.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-15 00:00:00.000",
"description": "Report",
"row_id": 1808384,
"text": "Neonatology Attending\n\n2515 gram 33 week male admitted secondary to prematurity and respiratory distress.\n\n2515 gram 33 week male born to a 26 yo G1 P0->1 white female\nPNS: AB negative/Ab-/RPR NR/RI/HBsAg-/GBS unknown.\nUncomplicated pregnancy until SROM hours 13.5 hours ptd with premature labor. Treated with ampicillin (x 12 hrs ptd) and allowed to labor. No maternal fever or fetal tachycardia. Vaginal delivery with abruption noted at the time of delivery. Apgars . Grunting noted in delivery room. Deleed for a significant amount of blood.\n\nExam Premature male with significant retractions and grunting\nT 98.1 P 150 R 46 BP 50/28 mean 33 O2 sat 100% with BBO2\nWt 2515 grams (~90%) Lt 46.75 cm (~90%) HC 30.5 cm (~30%)\nAF soft, flat, nondysmorphic, intact palate, poor aeration, moderate retractions and grunting, no murmur, normal pulses, soft abd, 3 vessel cord, no hsm, normal male genitalia, testes descended into scrotum, patent anus, no hip click, no sacral dimple, decreased tone\n\nA: 33 week male with RDS, R/O sepsis\n\nP: Intubation\n Survanta\n CXR\n Follow ABG and wean as tolerated\n NS bolus. Monitor BP.\n NPO with IV fluids\n Follow DS\n CBC, BC\n A/G with course dependent on clinical status and labs\n Support family--I met with them in antenatal consult, was present at delivery and updated them on status and plans once in NICU\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808385,
"text": "Admission Note\n\n1 r/o sepsis\n2 pot. alt. in resp.\n3 fen\n4 parenting\n\npt admitted to nicu from l&d. grunting apon admission, pt\nintubated and received survanta x1. sc/ic retractions noted\nwith coarse to clear ls. vss stable . dstic 71. cbcd and bc\nsent, along with arterial gas. double abx initiated and ivf\nof d10w @ 80cckg started. voided in delivery room, no stools\nthus far this shift. bp means boarderline 34-45. parents in\nx2 to see baby. mom , dad supportive.\n\nREVISIONS TO PATHWAY:\n\n 1 r/o sepsis; added\n Start date: \n 2 pot. alt. in resp.; added\n Start date: \n 3 fen; added\n Start date: \n 4 parenting; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-16 00:00:00.000",
"description": "Report",
"row_id": 1808386,
"text": "RESPIRATORY CARE NOTE\nBaby 33 born via SVD apgars 7 & 8 received blow by O2 in the DR. to the NICU in O2. Wt 2515 grams. Suctioned lg amt of bloody secretions from the mouth and stomach. Baby had increased work of breathing and was grunting and retracting. Intubated with a 3.0 ETT taped at 8cm. CxR ETT in good position. Survanta 10cc given at 2030hrs tol well. Placed on vent settings 25/5 Rate 25 FiO2 weaned to 30%. Initial abg PO2 127 CO2 46 PH 7.37. Baby cont to wean through the night. Current settings 20/5 Rate 18 FiO2 21%. Will cont to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-04 00:00:00.000",
"description": "Report",
"row_id": 1808485,
"text": "NICU NPN 1900-0700\n\n\nRESP O: Baby remains in room air, no spells during the\nnight, o2 sats 94-99%. rr 40-60's. Mumur is louder at times\nthan others, bp's stable. Hr 130-150's.\n\n#3 FEN O: Tf remain at 150cc/k/d. Tolerating feeds of pe/bm\n24 well. Voiding and , abdominal eam benign.\n\n#4 Parernting O: No contact overnight.\n\n#6 DEV O: temps are stable, swaddled in crib. Baby is \nand active with cares, sleeps well in beteween cares. Takes\npacifier for comfort. Fontanells are soft amd flat.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-04 00:00:00.000",
"description": "Report",
"row_id": 1808486,
"text": "Neonatology Attending\n\nDay 20\n\nRemains in RA. Occasional saturation drifts- spontaneously resolved. No bradycardia. Murmur persists. Pale, pink. Weight 2800 gms (+40). TF at 150 cc/kg/d- BM/PE 24. Also breast feeding. Took 40-65 cc per bottle overnight. Passing stool. Waking for feeds. and active for cares. Stable temperature in open crib.\n\nAwaiting increased maturity of breathing control and feeding. Monitoring cardio-respiratory status closely. Encouraging po feeds. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-04 00:00:00.000",
"description": "Report",
"row_id": 1808487,
"text": "NPN 0700-1900\n\n\n#2 RESP\nO: Infant remains in RA. Resp rate=30-60's.O2 sats=94-100%.\nNo desats or spells thus far. LS are clr/=. No retractions.\nA: Stable in RA P: Continue to monitor.\n\n#3 FEN\nO: TF=150cc/kg/day of BM/PE24, 70cc q4hr. Infant took 65cc\nat 9am. At 1pm, infant BF for less than 5min and was gavaged\n65cc over 40min. No spits. Minimal aspirates. V/S. Abdomen\nbenign. Active bowel sounds. A: Tolerating feeds P: Continue\nto monitor and support G&D.\n\n#4 Parenting\nO: Mom came in for the 1pm cares. BF and held infant.\nIndependent. Asking appropriate questions. Some D/C teaching\ndone by RN. A: Involved, P: Continue to support and\nupdate.\n\n#6 DEV\nO: Infant remains in OAC, swaddled. Temp stable.\nOccasionally wakes for feeds. A/A w/ cares. Sucks on\npacifier. A: AGA P: Continue to support G&D.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-04 00:00:00.000",
"description": "Report",
"row_id": 1808488,
"text": "Nursing Addendum:\nAgree with above , co-workers note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-04 00:00:00.000",
"description": "Report",
"row_id": 1808489,
"text": "Nursing Progress Note\n\n\n#2 Resp-- O: RR 30s-50s; HR 130s-150s at rest. O2 sat92-100-\nocc brief drifts to 90-91 SR. No bradys. Pink. BS clear and\n=, no GFR. Murmer loud, well perfused. A: Stable in RA P:\nMonitor murmer and vital signs.\n\n#3 Nutrition-- O: 150cc/kg/d= 70ccBM24/PE24 q4h. BF x2 well\n10min and 15min. Po 5cc after one feed- too sleepy; pg fed\n20cc after each feed. Tol well. no spits, no asp. Abd exam\nbenign, VQS, no stool. A: po/pg feeds, adequate growth P:\nCont to enc po feeds, monitor wt\n\n#4 Parenting-- O: Mom here all eve for 1700 and 2100 feeds,\n in for 2100 feed. Mom independent with baby. asking\n. Updated re status and plan. wanting baby to\ntake all feeds po. A: Concerned, involved P: Cont to\nsupport, inform, discharge plan\n\n#6 Development-- O: and active with care. Sleepy after\nBF. Still req some pg feeds. Temp stable. Swaddled in crib\nwith boundaries. A: AGA P: Cont to support development\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-11-05 00:00:00.000",
"description": "Report",
"row_id": 1808490,
"text": "NURSING PROGRESS NOTE\n\n\n2. RESPIRATORY\nNO ISSUES.\n3. F/N\nTONIGHT'S WEIGHT UP 90 GRAMS TO 2.89KG. FEEDING WELL.\n4. PARENTING\nNO CONTACT.\n6. G&D\nWAKING FOR FEEDINGS. PREPARING FOR DISCHARGE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808392,
"text": "Nursing progress note\n\n\n1 - Sepsis - Temp stable. pt receiving amp and Gent as\nordered.\n\n2 - Resp - Pt received on CPAP, 40-50%. Pt reintubated at\n2300 and placed on settings: 20/5, x20 30%, for increased\nWOB, increased O2requirement. CBg at 0100 = 7.30/58/38. No\nchanges made. BSC/=, mild to mod IC /SC retractions noted -\nretractions decreased since intubated. pt tachypneic.\nsuvanta given x1 thus far tonight.\nA; pt appears more comfortable post intubation and survanta\ngiven.\nP; cont to monitor\n\n3 - FEN - Tf=80cc/k of D10w. infusing via PIV without\ndifficulty. Dstick=117. 24hr lytes = 141/5.3/105/23. ABd\nsoft, +bs. Pt voiding - 2.8cc/k yesterday. no stools.\nA: to start D10 w/ lytes. Wt=2.380(-135)\nP; cont to monitor\n\n4 - Parent - Mom and dad in to visit w/ extended family.\nasking approp questions, updated at bedside.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808393,
"text": "RESPIRATORY CARE NOTE\nBaby received on NP CPAP 6 FiO2 40-50%. At 11pm baby was reintubated due to increased O2 requirement. Intubated with a 3.0 ETT taped at 8.5cm. CxR ETT in good position. Survanta 10cc given at 11:30 pm. Placed on vent settings 20/5 Rate 20 FiO2 25-30%. Cap gas sent at 1am. PO2 38 CO2 58 PH 7.30. Decision made to hold on current vent settings. Baby is tachypneic at times, but looks comfortable intubated. Will cont to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808394,
"text": "Neonatology Attending\nDOL 2\n\n was reintubated after unsuccessful attempt at extubation yesterday secondary to increasing oxygen requirement. A second dose of surfactant was administered with only modest effect. Currently 20/5 x 18 in 21-28% FiO2. Intermittently tachypneic with retractions. CBG this am: 7.40/44.\n\nNo murmur. BP 65/38 (48).\n\nWt 2380 (-135) on TFI 80 cc/kg/day D10W with NaCl. Remains NPO for respiratory instability. D-stick normal. Abdomen benign. Urine output 2.8 cc/kg/hr in the past 24 hours. 141/5.1/105/23.\n\nBilirubin 6.0/0.2.\n\nOn ampicillin and gentamicin with negative blood culture.\n\nA&P\nModerately preterm infant with surfactant deficiency.\n\nIn light of the ongoing moderate respiratory distress, we will defer extubation and consider an additional dose of surfactant if FiO2 increases beyond 30%. Chest radiograph will be repeated if there are findings of ongoing respiratory distress.\n\nContinue vigilance for PDA and maintain mean BP > 36 mmHg.\n\nFluids will be advanced to 100 cc/kg/day. We will defer feeds at least until later today and start PN. Serum electrolytes will be checked again tomorrow.\n\nAlthough the initial WBC was left-shifted, this resolved very quickly and he has had no other clinical signs of infection such as lethargy or hypotension.\n\nFamily has been updated at bedside. We will plan for a family meeting tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808397,
"text": "5 cv\n6 dev\n\nREVISIONS TO PATHWAY:\n\n 5 cv; added\n Start date: \n 6 dev; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808398,
"text": "Respiratory Care\nPt recieved on SIMV, rate of 20, pressures of 20/5. with the fio2 26 to 35%. Pt suctioned for a mod amt of thickish yellow secretions. Pt extubated to NP-CPAP +6cm with the fio2 32%. Plan is to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-17 00:00:00.000",
"description": "Report",
"row_id": 1808399,
"text": "Neonatology - NNP Progress Note\n\n is active with good tone. AFOF. He is pink, CRF ~ 2 secs, soft sysolic murmur auscultated. 4 ext BP wnl. Normal cardothymic silouette on CXR. 12 lead EkG normal. He was extubated to CPAP this afternoon. Mild-mod retraction. Breath sounds clear and equal. He remains NPO. Total fluids @ 80cc/kg/day. Abd soft, active bowel sounds, no loops. Voidng, no stool yet. DS stable 80-100 rbnage. UO-2-3 cc/kg/hr. Amp/gent dc'd today. Met with family this afternoon. Discussed plan and anticipated NICU course. Parents asking appropriate questions and clear with plan. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808400,
"text": "NPN 1900-0730\n\n1 r/o sepsis\n\n2. On NP Cpap 6, 29-39%. Lungs clear, RR 50-70's with mild\nIC/SC retractions. Suction x1 for small cloudy. No A&B's\nthus far. Desat to 77% x1 while crying. Slight increase in\nFiO2 from day shift. Cont to monitor resp status for\nfurther increase WOB.\n\n3. Wt up 15gm to 2395gm. BW=2515gm. TF 100/k/d; D10.5PN\nand IL via PIV. Dstick 72. Abd benign. 24hr U/O\n3.8cc/k/hr. No stool thus far since birth. Infant NPO.\nPlan to obtain lytes and bili this am; see flowsheet for\nresults. Cont to monitor FEN status.\n\n4. Parents in to visit and updated on plan of care. Dad\nable to change diapher and take temp with assistance. Mom\nplanning to visit in am. Cont to support and update\nparents.\n\n5. HR 120-150 with soft murmur. Color pink, 2+PP, brisk\ncap refill. BP 69/38 MAP 51. Stable hemodynamically. Cont\nto monitor for s/sx of PDA.\n\n6. Temp stable nested on sheepskin under warmer. Infant\nirritable with cares, resting well inbetween cares. Suckles\nwell on pacifier. MAE. Cont to promote development.\n\nREVISIONS TO PATHWAY:\n\n 1 r/o sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808401,
"text": "Respiratory Care\nNPT retaped\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808402,
"text": "Respiratory Care\nBaby remains on NP CPAP 6 29-35%.RR 40-70.BS = clear.Some mod. retractions noted.Sx npt for small cldy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808403,
"text": "Neonatology Attending\n\nDay 3\n\nRemains on CPAP at 6 cm with fio2 -0.22-0.32. RR 50-70s. No bradycardia. Soft intermittent murmur. BP mean 51. Weight 2395 gms (+15). On TF at 100 cc/kg- PN 10 and lipids. NPO. Blood glucose 72-106. Lytes 148/4.1/108. Bilirubin pending. Trace stool. Urine output 3.8. Active. Family meeting yesterday.\n\nContinued oxygen requirement. Will continue with CPAP for now. Monitoring cardio-respiratory status closely. Plan to start feeds today. Metabolically fine. Will follow up on bilirubin. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808404,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal with good CPAP transmission. Nl S1S2, grade II/VI murmur audible. Pink, slightly jaundiced. Abd benign, no HSM. Active bowel sounds. infant alert and active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-19 00:00:00.000",
"description": "Report",
"row_id": 1808410,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal. Nl s1S2, no audible murmur. Pink and slightly jaundice. Abd benign, no HSM. Active bowel sounds. Infant alert and active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-19 00:00:00.000",
"description": "Report",
"row_id": 1808411,
"text": "Respiratory Care\nPt cont on NP CPAP. Fio2 .21, rr 50s, bs clear with mild retractions. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808405,
"text": "Respiratory Care\nBaby continues on cpap 6, fio2 24-30%, RR50-70's, Bs clear, no spells on shift so far. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-19 00:00:00.000",
"description": "Report",
"row_id": 1808412,
"text": "NPN 7a-7p\n\n\n\n RESP: Rec infant w/NP CPAP 6cms. FIO2 .21 Has req minimal\nincreases in O2 w/cares to 30%. Sats upper 90's. No spells\nor desats. RR 40-50's. LS cl/=. Mild SC retractions. Sux x1\nw/NS instillation for sm->mod amts thick white secretions.\nA: in NP CPAP. P: Wean as tolerated. Follow for\nspells and increased WOB.\n\n FEN: TF increased to 140cc/k and advancing enteral feeds\n. Presently on PN D10W w/Lipids infusing well in PIV at\n100cc/k. Enteral feeds BM/PE 20 increased to 40cc/k at \n(17cc pg'd over 20min). Abd full, gd BS, no loops, no spits,\nmax asp 1cc greenish material shown to fellow then discarded\nas ordered. Voiding 4.7cc/k/hr x12hrs. Only trace stool\ntoday. A: Tol adv feedings, needs to have BM. P: Cont to\nsupport nutritional needs.\n\n PARENTS: Mom in most of the day. Independent w/diaper and\ntemps. Held infant for 1 hour. Acts very comfortable\nw/infant cares. Updates on infant's progress given at the\nbedside. Asking approp questions. Dad in at 1800.\n\n DEV: Alert aND ACTIVE W/CARES. TEMPS STABLE, CHANGED TO\nISOLETTE FROM WARMER. AFSF. MAE. Sucks on pacifier. Brings\nhands to face. A: AGA P: cont to support G&D.\n\n BILI: Infant conts under single photo therapy. Eye \nin place. No stool today. Repeat bili ordered for am.\nA: Hyperbili P: Cont to follow labs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808413,
"text": "2. Resp: O: Received infant on CPAP of 6cm via np tube. Ls\nclear, RR 40-60s, FiO2 mostly 21%, when prone, and up to 25%\nwhen supine. His np tube was replaced and there was a large\nplug at the end of it. No spells. No desats. A: Stable on\nCPAP. P: Monitor. Sxn prn.\n\n3. F/n: O: Infant is on 140cc/k/d of TF, working up on\nfeeds. He has just been advanced to 60cc/k/d of pg feeds of\nBM/PE20. Abd is benign, he is voiding 2.7cc/k/hr and had a\nsmall mec stool w/ some rectal stim. No spits, min asps. He\ngained 10g. A: Tol w/u on feeds so far. P: Continue to\nadvance as per plan/as tol. Check d/s at next care time.\n\n4. Parents: O: Parents were in for the 8p cares and helped\nweigh, and held infant while his bed was being made. A:\nLoving, involved parents. P: Continue to support.\n\n6. G/d: O: Infant is under phototx on servo in a heated\nisolette. He is active and likes to suck on his binkie. A/P:\nContinue to support infant needs.\n\n7. Bili: O: Infant is jaundiced. He had a small stool w/\nrectal stim. He is currently under single phototx w/ his\neyes covered. A: Hyperbilirubinemia. P: Check bili at next\ncare time. Phototx as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808414,
"text": "RESPIRATORY CARE NOTE\nBaby remains on NP CPAP 6 FiO2 21-25%. At 12 midnight new NP tube was placed. Nares were suctioned for mod-lg amt of yellow secretions. Breath sounds are clear. RR 50-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-18 00:00:00.000",
"description": "Report",
"row_id": 1808406,
"text": "NPN Days\n\n7 Hyperbilirubinemia\n\n2. O: Received pt on NP CPAP of 6. Fio2 25-35%. Ls clear. RR\n50-70's. Mild-Mod retractions. No spells. A: Cont to require\nO2. P: Cont to monitor resp status.\n\n3. O: TF 120cc/kg. 100cc/kg is PN D10+IL infusing well via\nPIV. 20cc/kg of enteral feeds of BM 20 to start at 1600. Abd\nsoft. +bs. Voiding. No stool. A: Starting feeds. P: Cont to\nmonitor wt, abd, and tol of feeds.\n\n4. O: Mom and Dad in at 0800 +1200 cares. Mom independent\nwith cares. Asking appropriate questions. Mom and Dad to be\nback at care. A/P: Cont to educate and support family.\n\n5. O: +soft murmur. Hr 110-150's. Pink. Good perfusion. Nl\npulses. A/P: Cont to monitor CV status.\n\n6. O: Temp stable nested on open warmer. Alert and active\nwith cares. Sucks on pacifier. A/P: Cont to cluster care.\nCont to monitor temp.\n\n7. O: Under single phototherapy. Tf 120cc/kg. Voiding. No\nstool. A: Hyperbilirubinemia. P: Cont to monitor bili.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbilirubinemia; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-19 00:00:00.000",
"description": "Report",
"row_id": 1808407,
"text": "NPN 1900-0730\n\n5 cv\n\n2. Received infant in NP Cpap 6, 25-35%. Trial in NC for\n~3hr and failed; infant with GFR and tachypneic to 80's with\ndesats to 80's. Placed back on cpap 6 and has been in 21%.\nLungs clear, RR 50-60's with mild IC/SC retractions. No\nA&B's thus far. Requiring cpap. Cont to monitor resp\nstatus.\n\n3. Wt down 35gm to 2360gm. BW 2515gm. TF 120/k/d; D10PN\nand IL at 100/k/d and enteral feeds at 10/k/d of PE20/BM20\nvia NGT. Abd benign. Dstick 90. Small mec stool, 24hr U/O\n3.6cc/k/hr. Tolerating feeds without emesis/residuals.\nCont to monitor tolerance of feeds.\n\n4. Parents in to visit and updated on infants status. Mom\nable to take temp and change diapher independently. Dad\nheld infant. Mom planning to visit today. Cont to support\nand update parents.\n\n6. Temp stable nested under warmer. Infant awake and fussy\nwith cares, resting well inbetween. Suckles on pacifier for\ncomfort. MAE. AFSF. Cont to promote development.\n\n7. Color jaundiced. Remains under single photo therapy\nwith eye shields on. Stooling. Cont to monitor bili as per\nteam.\n\nREVISIONS TO PATHWAY:\n\n 5 cv; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-19 00:00:00.000",
"description": "Report",
"row_id": 1808408,
"text": "Respiratory Care Note\nPt remains on NP CPAP +6 FIO2 21%. B.S. ess. clear with good air entry. Attempted trial off CPAP, after 3 hours increased retractions noted, poor air entry. Pt placed back on NP CPAP without diff. Without apnea or bradys noted this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-19 00:00:00.000",
"description": "Report",
"row_id": 1808409,
"text": "Neonatology Attending\n\nDay 4\n\nRemains on CPAP in RA. Clear breath sounds with mild retractions. Was trialed off last night, but CPAP restarted for increased work of breathing. Soft murmur. HR 120-150s. BP mean 54. Jaundiced. Bilirubin 11.7/0.3. Continues on single phototherapy. Weight 2360 gms (-35). TF at 120 cc/kg/d. On PN and lipids at 100 cc/kg/d. Enteral feeds of breast milk/PE 20 at 20 cc/kg/d. Urine output 3.6 c/ckg/hr. Blood glucose 90. Stable temperature on open warmer.\n\nResolving hyaline membrane disease. Will continue CPAP for now. Monitoring respiratory status closely. Advancing feeds today. Continuing phototherapy. Metabolically well. Will keep family informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808415,
"text": "Neonatology Attending\n\nDay 5\n\nRemains on CPAP with fio2 0.21. Intermittent murmur. HR 120-140s. RR 50-60s. Pink, well-perfused. Weight 2370 gms (+10). TF at 140 cc/kg/d. Enteral feeds at 60 cc/kg- PE 20. On PN and lipids at 80 cc/kg/d. Advancing enteral feeds by 20 cc/kg twice daily. Blood glucose 64. Lytes 144/3.2/107/25. Benign abdomen. Continues on single phototherapy. Mild jaundice. Bilirubin 7.9. Stable temperature in servo-controlled incubator.\n\nContinued evidence of surfactant deficiency. Will continue CPAP for now. Monitoring murmur. Work-up thus far is reassuring. Will proceed to cardiology evaluation if persists or respiratory status not improving. Will discontinue phototherapy. Metabolically fine. Advancing feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-10-20 00:00:00.000",
"description": "Report",
"row_id": 1808416,
"text": "NNP Physical Exam\n\nPE: pink, mild jaundice, well\n\nWhile trying to escape through , Bin Laden found a bottle on\na beach and picked it up. Suddenly, a female genie rose from the bottle and\nwith a smile said, \"Master, may you one wish?\" \"You ignorant,\nunworthy daughter-of-a-dog! Don't you know who I am? I don't need a common\nwoman giving me anything!\" barked Bin Laden. The shocked genie said \"Please,\nI must you a wish or I will be returned to that bottle forever.\" \nthought a moment. grumbled about the impertinence of the woman, and\nsaid, \"Very well, I want to awaken with three white women in my bed in the\nmorning, so just do it and be off with you!\" The annoyed genie said, \"So be\nit!\" and disappeared. The next morning Bin Laden woke up in bed with \n, , and . His manhood was gone, his knee\nwas broken, and he had no health insurance.\n\nGod is good......\n\n\n\n\n\n\n\n perfused, AFOF, sutures approximated, NP CPAP in place, breath sounds clear/equal with fair to good air entry, mild subcostal retracting, soft 1-2/6 SEM LLSB, +2/= pulses, abd soft non distended, bowel sounds present, no rashes, active with good tone.\n"
}
] |
77,794 | 146,476 | The patient was brought to the operating room on where the patient underwent urgent coronary artery bypass graft x4 left inframammary artery to left anterior descending artery, and saphenous vein grafts to diagonal obtuse marginal and posterior descending arteries and endoscopic harvesting of the long saphenous vein. See operative note for full details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. Pt had to be reintubated d/t delerium tremons-airway/sternum protection on POD # 3. After CIWA scale initiated, pt was extubated without complication The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and titrated up for blood pressure and heart rate control. and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 10 the patient was ambulating freely, the wound was healing, he was neurologically intact and pain was controlled with oral analgesics. Orthopedics was consulted for 5 week old left DR which was casted. This was bivalved post surery in case of swelling. He is to follow up with on at 9:00 AM for cast removal. The patient was discharged to a rehab in good condition with appropriate follow up instructions. | Mild (1+) mitralregurgitation is seen.There is mild Tricuspid regurgitation.There is no pericardial effusion.Dr. Normal ascending aortadiameter. Normal aortic arch diameter. Normalregional LV systolic function. Noaortic regurgitation is seen.The mitral valve leaflets are structurally normal. Right ventricular chamber size and free wall motion are normal.The aortic root is mildly dilated at the sinus level. There is no pericardial effusion.IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved globaland regional biventricular systolic function. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Right IJ catheter remains in place and the nasogastric tube has been removed. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildy dilated aortic root. Mild (1+) MR.TRICUSPID VALVE: Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Written informed consent was obtained from the patient. No AR.MITRAL VALVE: Normal mitral valve leaflets. The left ventricular cavity size isnormal. Mildly dilated descending aorta. The mitral valve leaflets are mildly thickened.Trivial mitral regurgitation is seen. Left atelectasis and effusion unchanged with improved aeration of right lung. The aortic valve leaflets (3) are mildly thickened but aorticstenosis is not present. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There are lower lung volumes, though the pulmonary vascularity is now essentially within normal limits. LVEF 55%.Intact thoracic aorta.No n ew valvular findings.Mild MR and Mild TR.POST-BYPASS: Left ventricular function. Left ventricular function. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Regional left ventricular wall motion is normal. Mild interstitial pulmonary edema is seen. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. There arecomplex (mobile) atheroma in the aortic arch.The descending thoracic aorta is mildly dilated. Left atrial abnormality. Left atrial abnormality. Leftventricular wall thicknesses are normal. Preoperative assessment prior to CABG.Height: (in) 69Weight (lb): 235BSA (m2): 2.21 m2BP (mm Hg): 162/91HR (bpm): 60Status: InpatientDate/Time: at 15:32Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: OptisonTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). BorderlinePA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Preoperative assessment.Height: (in) 68Weight (lb): 240BSA (m2): 2.21 m2BP (mm Hg): 135/64HR (bpm): 61Status: InpatientDate/Time: at 08:54Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or theRA/RAA. Normal LV cavity size. There is left mid lung pulmonary nodule, approximately 13 mm in diameter as well as questionable right lower lung nodule, potentially obscured by vessel vasculature. Mildly dilated ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Right IJ catheter tip is in the mid SVC. There is borderline pulmonary arterysystolic hypertension. Overall leftventricular systolic function is normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal. FINDINGS: In comparison with study of , the endotracheal tube has been removed. There is moderate vascular congestion. There are low lung volumes. Prior inferior wall myocardialinfarction. There is mild symmetric left ventricularhypertrophy with normal cavity size and regional/global systolic function(LVEF>55%). The ascending aorta ismildly dilated. There is no ventricularseptal defect. Non-specific ST-T wave change. The right internal jugular line tip is at the mid SVC. Lung volumes low. See Conclusions forpost-bypass dataConclusions:PRE-BYPASS:No spontaneous echo contrast or thrombus is seen in the body of the leftatrium/left atrial appendage or the body of the right atrium/right atrialappendage. Heart size is normal. Bilateral pleural effusions are noted. Noresting LVOT gradient. No significant change from tracing #1.TRACING #2 RIJ unchanged. There are mediastinal and bilateral chest tubes. Decreased mediastinal width FINAL REPORT HISTORY: CABG. Minimal increased opacification is seen at the right base as well. Since the previous tracingof left atrial abnormality is not as apparent, without overalldiagnostic change. Sinus rhythm with baseline artifact. No pathologic valvularabnormality seen. The tip of the endotracheal tube is at the lower clavicular level, approximately 6.5 cm above the carina. There is no aortic valve stenosis. Bilateral pleural effusions are small larger on the left side. pulm process WET READ: 10:48 PM No acute cardiopulm process. was notified in person of the results before surgical incision.PostBypass:Preserved biventricular systolic function. PA and lateral upright chest radiographs were reviewed with no prior studies available for comparison. No significant changefrom tracing #2.TRACING #3 The patient appears to be in sinus rhythm. No TEE relatedcomplications. There is no pleural effusion or pneumothorax. No atrial septal defect is seen by 2D or color Doppler. Complex (mobile) atheroma in the aorticarch. There is no pneumothorax. Non-specific ST-T wave changes.No previous tracing available for comparison.TRACING #1 Portable AP radiograph of the chest was reviewed in comparison to . Heart size and mediastinum are grossly unremarkable. The NG tube passes below the diaphragm terminating in the stomach. Thepatient was under general anesthesia throughout the procedure. Complex (>4mm) atheroma in thedescending thoracic aorta.AORTIC VALVE: Three aortic valve leaflets. No AS. There are complex (>4mm)atheroma in the descending thoracic aorta.There are three aortic valve leaflets. Mediastinal width is less prominent than on the previous study, though this could reflect the differences in technique. Right IJ remains in position. Mediastinal silhouette is unremarkable. Diastolic function could not be assessed. Diastolic function could not be assessed. NG tube tip is in the stomach. If not available, correlation with chest CT might be considered for characterization of those abnormalities. FINDINGS: In comparison with the study of , there may be some increased haziness of the hemithoraces bilaterally, suggestive of layering pleural effusions with underlying compressive atelectasis. | 11 | [
{
"category": "Radiology",
"chartdate": "2158-04-06 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1232963,
"text": " 5:37 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ? pulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cad\n REASON FOR THIS EXAMINATION:\n ? pulm process\n ______________________________________________________________________________\n WET READ: 10:48 PM\n No acute cardiopulm process. - \n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Preoperative assessment of the patient with coronary\n artery disease.\n\n PA and lateral upright chest radiographs were reviewed with no prior studies\n available for comparison.\n\n Heart size is normal. Mediastinal silhouette is unremarkable. There is left\n mid lung pulmonary nodule, approximately 13 mm in diameter as well as\n questionable right lower lung nodule, potentially obscured by vessel\n vasculature. There is no pleural effusion or pneumothorax.\n\n Comparison with prior studies is highly recommended. If not available,\n correlation with chest CT might be considered for characterization of those\n abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233191,
"text": " 9:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal - please ealuate for pnuemothorax\n Admitting Diagnosis: CARDIAC ISCHEMIA; POSITIVE STRESS TEST \\LEFT HEART CATHERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p CABG, CT removed\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal - please ealuate for pnuemothorax\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after CABG with chest tube\n removed.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is 9 cm above the carina. The NG tube passes below the\n diaphragm terminating in the stomach. The right internal jugular line tip is\n at the mid SVC. Heart size and mediastinum are grossly unremarkable.\n Bilateral pleural effusions are noted. Mild interstitial pulmonary edema is\n seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-04-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1233057,
"text": " 11:55 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: CARDIAC ISCHEMIA; POSITIVE STRESS TEST \\LEFT HEART CATHERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p CABGx4\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST:\n\n REASON FOR EXAM: Status post CABG.\n\n ET tube tip is 6.5 cm above the carina. Right IJ catheter tip is in the mid\n SVC. There is no pneumothorax. There are mediastinal and bilateral chest\n tubes. NG tube tip is in the stomach. There are low lung volumes. There is\n moderate vascular congestion. There are large bibasilar atelectasis greater\n in the left side. Bilateral pleural effusions are small larger on the left\n side.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1233328,
"text": " 1:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ET position\n Admitting Diagnosis: CARDIAC ISCHEMIA; POSITIVE STRESS TEST \\LEFT HEART CATHERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for ET position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG, for endotracheal tube position.\n\n FINDINGS: In comparison with the study of , there may be some increased\n haziness of the hemithoraces bilaterally, suggestive of layering pleural\n effusions with underlying compressive atelectasis. The tip of the\n endotracheal tube is at the lower clavicular level, approximately 6.5 cm above\n the carina. Right IJ catheter remains in place and the nasogastric tube has\n been removed.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2158-04-07 00:00:00.000",
"description": "Report",
"row_id": 105140,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function. Preoperative assessment.\nHeight: (in) 68\nWeight (lb): 240\nBSA (m2): 2.21 m2\nBP (mm Hg): 135/64\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 08:54\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Complex (mobile) atheroma in the aortic\narch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the\ndescending thoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Written informed consent was obtained from the patient. The\npatient was under general anesthesia throughout the procedure. No TEE related\ncomplications. The patient appears to be in sinus rhythm. Results were\npersonally reviewed with the MD caring for the patient. See Conclusions for\npost-bypass data\n\nConclusions:\nPRE-BYPASS:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. There are\ncomplex (mobile) atheroma in the aortic arch.\nThe descending thoracic aorta is mildly dilated. There are complex (>4mm)\natheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. There is no aortic valve stenosis. No\naortic regurgitation is seen.\nThe mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\nThere is mild Tricuspid regurgitation.\nThere is no pericardial effusion.\nDr. was notified in person of the results before surgical incision.\nPost_Bypass:\nPreserved biventricular systolic function. LVEF 55%.\nIntact thoracic aorta.\nNo n ew valvular findings.\nMild MR and Mild TR.\n\nPOST-BYPASS:\n\n\n"
},
{
"category": "Echo",
"chartdate": "2158-04-06 00:00:00.000",
"description": "Report",
"row_id": 105141,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment prior to CABG.\nHeight: (in) 69\nWeight (lb): 235\nBSA (m2): 2.21 m2\nBP (mm Hg): 162/91\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 15:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Diastolic function could not be assessed. No\nresting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic function\n(LVEF>55%). Diastolic function could not be assessed. There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe aortic root is mildly dilated at the sinus level. The ascending aorta is\nmildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. No pathologic valvular\nabnormality seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-04-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1234159,
"text": " 5:42 PM\n CHEST (PA & LAT) Clip # \n Reason: f/u effusions, atx\n Admitting Diagnosis: CARDIAC ISCHEMIA; POSITIVE STRESS TEST \\LEFT HEART CATHERIZATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n f/u effusions, atx\n ______________________________________________________________________________\n WET READ: SHSf SAT 10:26 PM\n ET tube has been removed. RIJ unchanged. Left atelectasis and effusion\n unchanged with improved aeration of right lung. Lung volumes low. Decreased\n mediastinal width\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , the endotracheal tube has been\n removed. Right IJ remains in position. There are lower lung volumes, though\n the pulmonary vascularity is now essentially within normal limits.\n Mediastinal width is less prominent than on the previous study, though this\n could reflect the differences in technique.\n\n Increased opacification at the left base most likely reflects atelectasis and\n effusion. Minimal increased opacification is seen at the right base as well.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2158-04-07 00:00:00.000",
"description": "Report",
"row_id": 305093,
"text": "Sinus rhythm with baseline artifact. Prior inferior wall myocardial\ninfarction. Non-specific ST-T wave change. Since the previous tracing\nof left atrial abnormality is not as apparent, without overall\ndiagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-04-07 00:00:00.000",
"description": "Report",
"row_id": 305094,
"text": "Normal sinus rhythm. Left atrial abnormality. No significant change\nfrom tracing #2.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2158-04-06 00:00:00.000",
"description": "Report",
"row_id": 305095,
"text": "Normal sinus rhythm. No significant change from tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2158-04-06 00:00:00.000",
"description": "Report",
"row_id": 305096,
"text": "Normal sinus rhythm. Left atrial abnormality. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
30,322 | 151,234 | The initial picture was consistant with cholangitis. ERCP was done with biliary slude removal and new stent placement. LFT's and hyperbilirubinemia improved. Of ote, 4/4 bottles on blood cultures grew pneumococcus as above. Initiall on levofloxacin and flagyl. tailored to levofloxacin alone per ID recommendations. TTE was done that showed a small vegetaion on aortic valve vs thickened vale. TEE was recommended but patient left hospital against medical advice. Surveillance are pending at discharge. No clear source of strep pneumoniae bacteremia was found. CXR - no pneumonia. Could be from biliary source. Was initially hypotensive andin ARF - both resolved with volume resuscitation. | ERCP done and CBD unclogged. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. TrivialMR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. trace of edema on extremities.Respi: continues on neb treatment, no wheezing noted. Trivial mitralregurgitation is seen. The tricuspid valve leaflets are mildly thickened.There is no pericardial effusion.IMPRESSION: Normal left ventricular systolic and diastolic function. Mildly dilated ascendingaorta. now on PO dilt regimen; SBP 100's--90's; MAP's >60; no edema noted; plt 80's; am labs pending; repleted with total of 80meq KCL and 4grams mag sulfateRESP: LSCTA with occasional R/LUL wheezing; tonight c/o chest tightness and orthopnea, given alb/atr nebs and repeated alb neb with relief, EKG unchanged and CXR with atelectasis; sats 98-100% on RAGI/GU: +BS, loose stools tonight x2; abd soft non-tender, non-distended; tolerating clears; voids, although during day shift and once during NOC, refusing to void in urinal/allow for measurement of urine, tonight did void x1 in urinal for 500cc dark amber clear urine; pre-renal ARF vomiting/diarrheaSKIN: intact although pt generally jaundicedACCESS: 2x PIV WNLPOC: cont dilt for afib, fluid boluses for hypotension; f/u CT results; follow and replete lytes prn; cont to monitor for safety; nebs per RT q6h; follow BUN/cr, treat with IVF GETTING PRN ALB/ATR NEBS ON REQUEST. no c/o SOB.gi/gu: tolerating POs. New afib, strep pneumonia.Height: (in) 70Weight (lb): 235BSA (m2): 2.24 m2BP (mm Hg): 126/80HR (bpm): 69Status: InpatientDate/Time: at 16:20Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Transmitral Doppler and TVI c/w normal LVdiastolic function. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. WILL RECHECK WITH AM LABS.RESP: ON R/A WITH CLEAR LUNGS. PPP BIL.RESP: LUNGS HAVE REMAINED CLEAR AND DIM IN THE BASES. remains on afib, will start on coumadin. Tol cl liqs. K:remains low:3.1-3.3 desppite K repletion (80meq) Mg:2.2 BS:201-260 on SS Insulin coverage. OCC PVC NOTED. Resp: Pt ordered for nebs and administered alb/atr UD. pt uncooperative and irritable at times.cv: BP 70s-100s, responds to fluid boluses, 1LNSx3. CONT WITH SSIC. Mildly dilated aortic arch. MD notified. 4u RI given for FS 244. A-FIB WITH HR RANGING FROM 77-102 WITH NO ECTOPY OBSERVED. POS BS. No 2D or Doppler evidence of distal archcoarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). I/O's from midnoc:+360cc. BP stable. Last BM:. Mild thickening of mitral valve chordae. Diffuse non-specific ST-T wave changes. Voided x2. CONT WITH HEPARIN GTT AND COUMADIN. RR 19-25, NO RESP DISTRESS NOTED.NEURO: A&O. no c/o pain. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. LL arm IV infiltrated. Remains in AF rate 100-155. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. no c/o N/V or abdom pain. afebrile. Afebrile. MICU/SICU Nursing Progress Note 07:00-15:00See CareVue for Additional Objective Data#1:Infection associated with biliary obstructionD:Afebrile, WBC:4.1 Micro data: BC positive for GPC PTA Antibx=Cipro and Flagyl IV ERCP with stent placement to CBD BP stable today, no additional IVF boluses. Atrial fibrillation. The aortic arch is mildly dilated. The ascendingaorta is mildly dilated. NARRATIVE NOTE:CV: B/P HAS RANGED FROM 93/67-114/63. PPP BILAT. PT ON CARDIZEM 60MG PO QID. HAS PASSED FLATUS BUT NO STOOL THIS SHIFT. No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). ON CL LIQ DIET TOL WELL. DENIES DISCOMFORT.GU: VOIDING AMBER URINE IN MARGINAL AMTS.GI: DIET TOL WELL. Pt complains of tightness in chest and noted relief following neb treatments. There isa probable small (0.5x0.5cm) vegetation versus focal thickening on thenon-coronary cusp of the aortic valve. STATES SLIGHT DISCOMFORT BUT NOT PAINFUL.GU: VOIDING AMBER URINE IN ADEQUATE AMTS.GI: ABD SOFTLY DISTENDED WITH POS BS. MONITOR HEMODYNAMICS CONT WITH CARDIZEM PO. FOLLOW TEMPS. NO DISTRESS NOTED.NEURO: INTACT. NPO except meds/ice chips. Themitral valve leaflets are mildly thickened. Denies need for pain med/intervention. I just had pancreatitis"; informed team of this, pt has had CT showing large pancreatic mass consistent with pancreatic CA; denies pain as of ', follow up CT from ED report pending; moves all extremities; does follow commands but is difficult at timesCV: HR cont in afib no ectopy, 100's-90's. A TEE is recommended if clinically indicated. Maintaining gd O2sats. EKG done.resp: LSC, 94-98% on RA. Apossible small vegetation versus focal thickening of the non-coronary cusp ofthe aortic valve. urine and stoolx2. 94-99% SAO2. Was able to get out of bed, gait unsteady due to disformed L ankle from old dislocation.CV: started on low dose lopressor to control HR, continues on diltiazem. ON R/A SAO2 93-97%. KCl 40meq started, Mag sulfate 4gm to be given. Plan to continue current mgmt and observation. Left ventricular wall thickness, cavity size andregional/global systolic function are normal (LVEF >55%) Transmitral Dopplerand tissue velocity imaging are consistent with normal LV diastolic function.Right ventricular chamber size and free wall motion are normal. Probableaortic valve vegetation. HR:90-140's Afib. 64yr old admitted from via ER for abdom pain, N/V, fever, chills. Will continue to monitor and treat Q6/prn. BS reveal bilateral crackles in bases with occassonal exp wheeze in RUL. Probable right bundle-branchblock. NARRATIVE NOTE:CV: B/P HAS RANGED FROM96/59-142/61. MONITOR COAGS AND LYTES AND REPLENISH AS NEEDED. No AS. ABD SOFT AND NON TENDER. Abd soft, non-tender +BS, no stool. CONT TO MONITOR LYTES AND REPLENISH AS NEEDED. Reddness, inflammation resolving. SBP in the 90's after lopressor was started. Given 40MeQs KCl. PROVIDE EMOTIONAL SUPPORT AS PT IS HAVING A DIFFICULT TIME WITH PANCREATIC CA DX. BS 281 AT HS, NPH AND REG INSULIN GIVEN.PLAN: PT IS STATING THAT HE WOULD LIKE TO BE DISCHARGED TODAY. A&Ox3, conversant and generally cooperative with care regime. Lipomatous hypertrophy of theinteratrial septum. 1800 BS 198, no insulin given pt NPO. jaundice.access: R 20g PIV, L PIV.plan: monitor BP and cardiac rhythm. | 10 | [
{
"category": "Echo",
"chartdate": "2146-11-22 00:00:00.000",
"description": "Report",
"row_id": 78246,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. New afib, strep pneumonia.\nHeight: (in) 70\nWeight (lb): 235\nBSA (m2): 2.24 m2\nBP (mm Hg): 126/80\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 16:20\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler and TVI c/w normal LV\ndiastolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Mildly dilated aortic arch. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Probable\naortic valve vegetation. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild thickening of mitral valve chordae. Trivial\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%) Transmitral Doppler\nand tissue velocity imaging are consistent with normal LV diastolic function.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. There is\na probable small (0.5x0.5cm) vegetation versus focal thickening on the\nnon-coronary cusp of the aortic valve. No aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nNo mass or vegetation is seen on the mitral valve. Trivial mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nThere is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular systolic and diastolic function. A\npossible small vegetation versus focal thickening of the non-coronary cusp of\nthe aortic valve. A TEE is recommended if clinically indicated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-17 00:00:00.000",
"description": "Report",
"row_id": 1652754,
"text": "64yr old admitted from via ER for abdom pain, N/V, fever, chills. ?common bile duct stent clogged, hypotension.\nPMH: pancreatic CA, CBD stent placed , DM, HTN, asthma.\nAllergies: PCN, morphine, zosyn\n\nneuro: lethargic, orientedx3. no c/o pain. afebrile. pt uncooperative and irritable at times.\n\ncv: BP 70s-100s, responds to fluid boluses, 1LNSx3. NSR 60-70s until 1800 converted to Afib 110s-120s. MD notified. KCl 40meq started, Mag sulfate 4gm to be given. EKG done.\n\nresp: LSC, 94-98% on RA. no c/o SOB.\n\ngi/gu: tolerating POs. pt refuses to measure urine/stool output. urine and stoolx2. 1800 BS 198, no insulin given pt NPO. ERCP done and CBD unclogged. no c/o N/V or abdom pain. jaundice.\n\naccess: R 20g PIV, L PIV.\n\nplan: monitor BP and cardiac rhythm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-18 00:00:00.000",
"description": "Report",
"row_id": 1652755,
"text": "Nursing Progress Note:\nFULL CODE\n\nALLERGIES: PCN, Zosyn, morphine\n\nPt at , pt with cholangitis, c/o abd pain, fever, nausea, chills, diarrhea x2 days; transferred to ED, to ERCP to have new CBD stent placed; to MICU for further mgt and hypotension, also with new onset afib\n\nEVENTS: During evening, pt's HR remained in 120's-140's, up to 150's; pushed 35mg IV diltiazem: pt's HR now 90's-100's, cont in afib, SBP 109-98, with MAP's 70's; started on PO dilt\n\nROS\n\nNEURO pt A+Ox3; pt very uncooperative with care at times, also unsafe, attempting to get OOB by himself, despite many reminders to call for help as he is at risk for a fall; bed alarm on and all rails up currently; tonight pt denies having pancreatic CA, stating \"it was a misdiagnosis... I just had pancreatitis\"; informed team of this, pt has had CT showing large pancreatic mass consistent with pancreatic CA; denies pain as of ', follow up CT from ED report pending; moves all extremities; does follow commands but is difficult at times\n\nCV: HR cont in afib no ectopy, 100's-90's. now on PO dilt regimen; SBP 100's--90's; MAP's >60; no edema noted; plt 80's; am labs pending; repleted with total of 80meq KCL and 4grams mag sulfate\n\nRESP: LSCTA with occasional R/LUL wheezing; tonight c/o chest tightness and orthopnea, given alb/atr nebs and repeated alb neb with relief, EKG unchanged and CXR with atelectasis; sats 98-100% on RA\n\nGI/GU: +BS, loose stools tonight x2; abd soft non-tender, non-distended; tolerating clears; voids, although during day shift and once during NOC, refusing to void in urinal/allow for measurement of urine, tonight did void x1 in urinal for 500cc dark amber clear urine; pre-renal ARF vomiting/diarrhea\n\nSKIN: intact although pt generally jaundiced\n\nACCESS: 2x PIV WNL\n\nPOC: cont dilt for afib, fluid boluses for hypotension; f/u CT results; follow and replete lytes prn; cont to monitor for safety; nebs per RT q6h; follow BUN/cr, treat with IVF\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-18 00:00:00.000",
"description": "Report",
"row_id": 1652758,
"text": "MICU NSG COVERAGE 1500-1900\n\n\nSleepimg most of the time. Easily arousable. Says he hasn't slept for over 20hrs. Remains in AF rate 100-155. BP stable. Afebrile. Maintaining gd O2sats. Given 40MeQs KCl. 4u RI given for FS 244. Tol cl liqs. Voided x2. No stool. Plan to continue current mgmt and observation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-19 00:00:00.000",
"description": "Report",
"row_id": 1652759,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 93/67-114/63. A-FIB WITH HR RANGING FROM 90-112. PT ON CARDIZEM 60MG PO QID. OCC PVC NOTED. PPP BIL.\n\nRESP: LUNGS HAVE REMAINED CLEAR AND DIM IN THE BASES. GETTING PRN ALB/ATR NEBS ON REQUEST. ON R/A SAO2 93-97%. RR 19-25, NO RESP DISTRESS NOTED.\n\nNEURO: A&O. PT HAS BEEN SOMEWHAT IRRITABLE IN THE PAST FEW DAYS BUT WAS QUITE PLEASANT THROUGHOUT THE SHIFT. TALKATIVE BUT NOT ABOUT ILLNESS. STATES SLIGHT DISCOMFORT BUT NOT PAINFUL.\n\nGU: VOIDING AMBER URINE IN ADEQUATE AMTS.\n\nGI: ABD SOFTLY DISTENDED WITH POS BS. HAS PASSED FLATUS BUT NO STOOL THIS SHIFT. ON CL LIQ DIET TOL WELL. DID HAVE A COOKIE.\n\nID: ON FLAGYL, CIPRO, AND VANCO. T-MAX 99.4.\n\nENDO: ON SSIC WITH AM AND DINNER NPH INSULIN. MN FSBS 230, COVERED WITH 2 UNITS REGULAR INSULIN.\n\nPLAN: PT WILL BE CALLED OUT TO THE FLOOR. CONT TO MONITOR LYTES AND REPLENISH AS NEEDED. FOLLOW TEMPS. MONITOR HEMODYNAMICS CONT WITH CARDIZEM PO. CONT WITH SSIC. PROVIDE EMOTIONAL SUPPORT AS PT IS HAVING A DIFFICULT TIME WITH PANCREATIC CA DX. UPDATE FAMILY WITH ANY CHANGES AS THEY OCCUR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-19 00:00:00.000",
"description": "Report",
"row_id": 1652760,
"text": "Neuro: alert and oriented x 3, patient has been pleasant first half of the day, became irritated by 1530 refused blood draws and further assessment. Verbalized \" i cant get an hour of sleep with all this stupid monitor \", Patient was moving frequently the ECG leads keep coming off. Asking for razor to get rid of the wires off from another nurse who was trying to fix the leads on. ? irritated because of lack of sleep. Was able to get out of bed, gait unsteady due to disformed L ankle from old dislocation.\n\nCV: started on low dose lopressor to control HR, continues on diltiazem. SBP in the 90's after lopressor was started. remains on afib, will start on coumadin. trace of edema on extremities.\n\nRespi: continues on neb treatment, no wheezing noted. Sats > 95% at room air, lung sounds clear dim at bases.\n\nGI: poor appetite at lunch, denies any abdominal pain. No BM this shift, bowel sounds present.\n\nGU: voiding adequate amount of urine - 700 cc since MN\n\nEndo: glargine increased to 15 for better glucose control. coverage given\n\nSkin: intact\n\nSocial: called out to floor waiting for bed, patient's daughter called for updates.\n\nplan:\n\ncontinue to monitor hemodynamics, start patient on heparin drip however patient refusing blood draws; provide adequate sleeping time tonight, may be taken off telemetry if this is bothering patient. transfer to floor once available bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-20 00:00:00.000",
"description": "Report",
"row_id": 1652761,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM96/59-142/61. A-FIB WITH HR RANGING FROM 77-102 WITH NO ECTOPY OBSERVED. PPP BILAT. PTT AT 2300 28.2 BOLUSED WITH HEPARIN 1000 UNITS AND GTT INCREASED TO 1400 UNITS HR PER ORDER. WILL RECHECK WITH AM LABS.\n\nRESP: ON R/A WITH CLEAR LUNGS. 94-99% SAO2. RR 19-26. NO DISTRESS NOTED.\n\nNEURO: INTACT. DENIES DISCOMFORT.\n\nGU: VOIDING AMBER URINE IN MARGINAL AMTS.\n\nGI: DIET TOL WELL. ABD SOFT AND NON TENDER. POS BS. BS 281 AT HS, NPH AND REG INSULIN GIVEN.\n\nPLAN: PT IS STATING THAT HE WOULD LIKE TO BE DISCHARGED TODAY. CONT WITH HEPARIN GTT AND COUMADIN. MONITOR COAGS AND LYTES AND REPLENISH AS NEEDED. PROVIDE EMOTIONAL SUPPORT FOR PT AND FAMILY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-18 00:00:00.000",
"description": "Report",
"row_id": 1652756,
"text": "Resp: Pt ordered for nebs and administered alb/atr UD. BS reveal bilateral crackles in bases with occassonal exp wheeze in RUL. Pt complains of tightness in chest and noted relief following neb treatments. Will continue to monitor and treat Q6/prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-11-18 00:00:00.000",
"description": "Report",
"row_id": 1652757,
"text": "MICU/SICU Nursing Progress Note 07:00-15:00\nSee CareVue for Additional Objective Data\n#1:Infection associated with biliary obstruction\nD:Afebrile, WBC:4.1 Micro data: BC positive for GPC PTA\n Antibx=Cipro and Flagyl IV\n ERCP with stent placement to CBD\n BP stable today, no additional IVF boluses. HR:90-140's Afib. HR generally 100-115 at rest, develops increased tachycardia with any activity. Rare PVC\n BUN/Cr:WNL U/O:voids freely 450-500cc at a time q 3-4 hours,amber-clear urine. I/O's from midnoc:+360cc. K:remains low:3.1-3.3 desppite K repletion (80meq) Mg:2.2\n BS:201-260 on SS Insulin coverage.\n Abd soft, non-tender +BS, no stool. Last BM:. NPO except meds/ice chips.\n Pain: aching discomfort noted in LUQ. Patient states much improved from pre-procedure discomfort. Denies need for pain med/intervention.\n A&Ox3, conversant and generally cooperative with care regime. Refusing attempts to wash up, became a bit angry when he noted personal belongings were left in EW, otherwise, non-focal.\n Skin:Intact. LL arm IV infiltrated. Reddness, inflammation resolving.\n Hct stable:37\n\nA:Added Vancomycin\n Surviellance BC x2\n Increase po Dilt to 60mg QID\n Increased insulin coverage;added NPH\n Diet advanced to Clear liquid\n Personal belongings obtained from EW:full change of clothes, glasses and wallet\n Daughter in and updated on POC\n\nR/P:Resolving Coliangitis s/p ERCP with stent placement,BP now stable, HR improved with increased dose of Dilt, HR staying <115, remains afebrile on antibx, await BC results,continue to monitor for pain, follow CBC,Monitor LFT's and Renal fx, repleat electrolytes prn,continue with supportive care, ?transfer to floor in the morning\n\n"
},
{
"category": "ECG",
"chartdate": "2146-11-17 00:00:00.000",
"description": "Report",
"row_id": 190275,
"text": "Artifact is present. Atrial fibrillation. Probable right bundle-branch\nblock. Diffuse non-specific ST-T wave changes. No previous tracing available\nfor comparison.\n\n"
}
] |
9,851 | 185,834 | 1. RESPIRATORY: There was mild hypoxemia on admission with desaturation as low as 85% on room air. A chest x-ray done on admission showed low lung volumes and possible right middle lobe atelectasis, but no clear areas of abnormality or infiltrates. He was initially on nasal cannula but by hospital day number two was weaned to room air and has subsequently saturated greater than 95% on room air. The etiology of this transient hypoxemia is unclear, but may be related to the initial respiratory distress at birth and be an extension of retained fetal lung fluid/transient tachypnea of the newborn. He does not have any current respiratory issues. 2. CARDIOVASCULAR: He has been cardiovascularly stable throughout his admission. 3. FLUIDS, ELECTROLYTES, AND NUTRITION: On admission, he was 7% below birth weight and possibly mildly dehydrated. On admission, electrolytes showed a sodium of 144, potassium 4.7, chloride 109, bicarbonate 27. He was started on IV fluids at 120 cc per kilogram per day but weaned rapidly on IV fluids with excellent p.o. intake. At discharge, he was off IV fluids and taking ad lib p.o. breast milk and breast feeding with excellent intake. His weight at discharge was 2,500 grams, 20 grams above admission weight. 4. HEMATOLOGY/GI: On admission, at 5:00 p.m., his bilirubin was 20.1 with a direct bilirubin of 0.5. He was started on quadruple phototherapy and repeat bilirubin on hospital day number two at 10:00 a.m. was decreased to 12.4/0.5, at which time phototherapy was reduced to double phototherapy. On hospital day number three at 4:00 a.m., bilirubin had further decreased to 10.3/0.4 and phototherapy was discontinued. A rebound bilirubin eight hours following the disconinuation of phototherapy was 9.9 total, 9.5 indirect 0.4 direct. Maternal blood type was A positive, antibody negative. The baby's blood type was also A positive, direct antibody test negative. On admission, his hematocrit was 47%. 5. INFECTIOUS DISEASE: Sepsis evaluation was performed given hyperbilirubinemia, mild hypoxemia, and decreased energy. The initial CBC showed a white count of 9.9 with 29% polys, 48% lymphocytes, 16% monocytes; hematocrit 47; platelets 471,000. A blood culture was sent on admission and was no growth to date at the time of discharge. The patient was started on ampicillin and gentamicin which was continued until blood cultures were negative at 48 hours. There has been no evidence of active infectious disease issues. | Nursing admit note1 Hyperbili2 Alt. A/Sepsis eval. Nursing NICU NOte.1. updatedby this nurse, Fellow, and NNP. Ampi/Gent d/c'd (48hour r/ocomplete). NICU nursing noteAlert and active with cares. O/Remains on Amp and gent with bld cultures negto date. O/Mother in today. )Order written by NNP to d/c home. A/Improving hyperbili issue. PIV heplocked thisafternoon. spoke withhim and members of his family who are in the Medicalfield.Plan to keep family updated.3 F/N Abdomen soft, + bowel sounds, 0 loops, 0distention.Breast fed X1 early part of shift, a littlesleepy. To have f/u bili outpt. Plan to recheck levels in am.FAMILY: Parents and brother in for cares. Mother held pt. Updated atbedside by this RN, asking appropriate questions. tosupport and educate parents.3. Mother updated on pt's statusand plan of care. Dischargeteaching/paperwork completed with mom. More active now with caresVoiding,stooling.I.V. in Family dynamics3 Alt. O/Adlib breast feeding Q3 hours and offering bottleafter breastfeeding attempt. in Family dynamics; added Start date: 3 Alt. Temp stable swaddled on off warmer.Adlib breastfed with supplemental bottles all shift. O/Please see am bili result: decreasedphototherapy to two spot lights. Father described him as lethargic today. Noted to be jaundiced on visit to pediatrician today. S/w NNP - decisionmade to D/C antibiotics. P/Cont. P/Cont. P/Cont. P/Cont. Sepsis. Bottled rest of shift for Dad and nurse ,activitylevel improving. in feeding-hyperbili4 Infant with Potential SepsisBB () admitted to NICU for home secondary toelevated bili in private pedi office (see NEO note for hxand phy), arrived in NICU with T-97.5 and placed underradiant warmer, other VSS with lungs clear and equal withgood aeration to bases, breathing comfortably withoutcompromise but with drifting saturations noted with infantplaced in NC O2 to maintain saturations above 94, CBC withdiff., BC, lytes and bili drawn as ordered, eye patchesplaced on infant with quadruple phototx started, IV placedwith hydration ordered for 100cc/kg/day with infant stillencouraged to BF with mom, d/s-81, voided and stooled uponadmission, parents in and informed and spoke with , MD concerning son's plan and expected courseREVISIONS TO PATHWAY: 1 Hyperbili; added Start date: 2 Alt. NPN 1900-0700HYPERBILI: Pt continues under double phototherapy, eyeshields in place. in feeding-hyperbili; added Start date: 4 Infant with Potential Sepsis; added Start date: Infant remains under quadruple phototherapy,with 3 sets oflights and 1 bili blanket.Bili at 2300 was18.2/0.6/17.6.Reported results to NNP.Continue presentplans, repeat bili at 11 AM.2 Family Mom here early part of shift,went home to rest. Didwell. At 0200 feeding, didvery well bottling w/Dad.SEPSIS: Unable to flush IV - IV removed. to monitor for s/s ofsepsis. Continue perplans. tomonitor for s/s of feeding intolerance.4. Family. There is some haziness to the right heart border which could represent small area of atelectasis. Baby was admitted to the NICU for further evaluation.BW - 2645gm - Current weight 2480gm - down 6-7% since birth.PE - Baby is moderately jaundiced diffusely.VS - T 97.5 HR 124 RR 36 BP 67/52 57 O2 sat initially 97% down to 89-92% in RAHEENT - AF soft and flat, head slightly asymmetric with mild flattening on the left, palate intact.Resp - lungs clear and equal.CVS - S1 S21 normal intensity, no murmur, perfusion goodAbd - soft with no organomegaly, normal bowel soundsGU - normal male - circumcized - healing wellNeuro - tone on admission overall reduced - improved over 1-2 hours with IV fluids and bottle feedingHips stable.Labs: Bili 20.1/0.5/19.6Lytes 144 4.7 109 27Blood type A pos, DAT negative.DS - 81cbc - wbc 9,900 29P 0B 48L Hct 47% plat 471,000CXR - few patchy densities at the right heart border, lung volumes normal, normal situs, heart size normalAssessment: Preterm 35 week gestation male infant with hyperbilirubinemia - most likely exagerated physiologic jaundice exacerbated by poor feeding.With lethargy on admission and prematurity - unknown GBS status, decision made to cover with antibiotics - ampicillin and gentamicin.Lytes consistent with mild dehydration.Will treat with IV fluids overnight as well as ad lib feedings by breast or breastmilk by bottle.Will follow serial bilis.Baby will need another hearing screen - full diagnostic ABR, in the next 3 months at CH.Both parents informed of our assessment and plans for management. infusing in foot, total IV fluids 100cc per K.Continue present plans.4 Sepsis Infant remains on antibiotics as ordered. Double phototx shut off at 0900. and pedi aware.Discharged home with mom and dad at 1900. (Please refer to flowsheet for results. tomonitor effectiveness of phototherapy.2. Neonatology Attending Progress NoteNow day of life 6, CA 5/7 weeks.In RA, RR 30-50s.O2 sats >95%HR 120-140sWt. Voiding/stooling. A/Alt. Pt demonstrates differentdegrees of interest in nursing. 2500gm down 20gm - breastfeeding has improved - bottles 35-75cc.Excellent urine output, passing stools well.IV fluids dc'ed yesterday.ID - amp and gent dc'ed with 48 hour cultures no growthBili - down to 10.3 on double phototherapyAssessment/plan:Hyperbilirubinemia resolving nicely.Will plan on discontinuing phototherapy this morning - repeat bili in 8 hours - if stable or decreased will dc to home with FU with Dr. . Father calling for update.A/Parents are actively involved in pt's care. in F/N. Dad hereall shift,he fed a couple timesDr. Neonatology Fellow Exam NoteMother updated at bedside.Gen: asleep, easily aroused, vigorous, comfortable, NAD, off PTXSkin: mild to moderate jaundice, mildly mottled on off warming tableHEENT: AFOSFChest: good AE, CTA, no increased WOBCV: RRR no MAbd: soft, ND/NT, +bowel sounds, ND/NTExt: hips stable, 2+ UE / LE pulses, no cyanosisNeuro: vigorous, MAEE F/N. MOther demonstrates good breast feedingtechnique. 1 Bili. Hyperbili. He had juandice but did not require hospitalization for this.Labor and delivery: Delivery was b NSV route on at 4:25 AM.Apgars 8,9. 2520gm up 40gm today - on IV fluids of 120cc/kg/d overnight - now weaned down to 50cc/kg/d.Feedings have improved - bottle feeding up to 45 cc overnightDS 106UO 4.9cc/kg/hr, passing frequent bowel movements.Bili - 18.2 last night - down to 12.4/0.5 this morningID - CXR - RML density - atelectasis vs infiltratecbc unremarkable and blood culture negative so far.Assessment/plan:Hyperbilirubinemia - exagerated physiologic - will dc 2 of phototherapy lights and follow serial bilis.Will continue antibiotics for at least 48 hours.Mother updated at bedside this morning. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2174-03-14 00:00:00.000",
"description": "Report",
"row_id": 1816392,
"text": "Nursing admit note\n\n1 Hyperbili\n2 Alt. in Family dynamics\n3 Alt. in feeding-hyperbili\n4 Infant with Potential Sepsis\n\nBB () admitted to NICU for home secondary to\nelevated bili in private pedi office (see NEO note for hx\nand phy), arrived in NICU with T-97.5 and placed under\nradiant warmer, other VSS with lungs clear and equal with\ngood aeration to bases, breathing comfortably without\ncompromise but with drifting saturations noted with infant\nplaced in NC O2 to maintain saturations above 94, CBC with\ndiff., BC, lytes and bili drawn as ordered, eye patches\nplaced on infant with quadruple phototx started, IV placed\nwith hydration ordered for 100cc/kg/day with infant still\nencouraged to BF with mom, d/s-81, voided and stooled upon\nadmission, parents in and informed and spoke with , MD concerning son's plan and expected course\n\nREVISIONS TO PATHWAY:\n\n 1 Hyperbili; added\n Start date: \n 2 Alt. in Family dynamics; added\n Start date: \n 3 Alt. in feeding-hyperbili; added\n Start date: \n 4 Infant with Potential Sepsis; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-14 00:00:00.000",
"description": "Report",
"row_id": 1816393,
"text": "Neonatology Attending Admission Note\n\nBaby is a 35 week gestation male infant now 4 days of life readmitted for jaundice.\n\nPediatrician: Dr. \n\nPregnancy: Mother is 38 old G3 P1-2.\nPNS: A pos, Ab neg, RPR NR, RI, HBSAg neg, GBS unknown\nMother was treated with terbutaline since weeks.\n\nFirst son is now 2 old, he was also born at 35 1/2 weeks. He had juandice but did not require hospitalization for this.\n\nLabor and delivery: Delivery was b NSV route on at 4:25 AM.\nApgars 8,9. The baby did well after birth; he did transient respiratory distress with grunting noted prior to transfer to the Newborn Nursery however this resolved quickly.\n\nNeonatal course: Baby was reported to be breastfeeding well prior to discharge to home on .\nParents report that baby has been sleepy nursing for only brief periods of time at home after which he falls asleep. Father described him as lethargic today. Noted to be jaundiced on visit to pediatrician today. Bili checked in the office was 25? Baby was admitted to the NICU for further evaluation.\n\nBW - 2645gm - Current weight 2480gm - down 6-7% since birth.\n\nPE - Baby is moderately jaundiced diffusely.\nVS - T 97.5 HR 124 RR 36 BP 67/52 57 O2 sat initially 97% down to 89-92% in RA\nHEENT - AF soft and flat, head slightly asymmetric with mild flattening on the left, palate intact.\nResp - lungs clear and equal.\nCVS - S1 S21 normal intensity, no murmur, perfusion good\nAbd - soft with no organomegaly, normal bowel sounds\nGU - normal male - circumcized - healing well\nNeuro - tone on admission overall reduced - improved over 1-2 hours with IV fluids and bottle feeding\nHips stable.\n\n\nLabs: Bili 20.1/0.5/19.6\nLytes 144 4.7 109 27\nBlood type A pos, DAT negative.\nDS - 81\ncbc - wbc 9,900 29P 0B 48L Hct 47% plat 471,000\n\nCXR - few patchy densities at the right heart border, lung volumes normal, normal situs, heart size normal\n\nAssessment: Preterm 35 week gestation male infant with hyperbilirubinemia - most likely exagerated physiologic jaundice exacerbated by poor feeding.\nWith lethargy on admission and prematurity - unknown GBS status, decision made to cover with antibiotics - ampicillin and gentamicin.\nLytes consistent with mild dehydration.\nWill treat with IV fluids overnight as well as ad lib feedings by breast or breastmilk by bottle.\nWill follow serial bilis.\nBaby will need another hearing screen - full diagnostic ABR, in the next 3 months at CH.\n\nBoth parents informed of our assessment and plans for management.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-03-14 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 816202,
"text": " 10:13 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: HYPERBILIRUBINEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant 4 days old, with oxygen need\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n This is our initial film on this 4 day old. The lung volumes are somewhat low.\n There is some haziness to the right heart border which could represent small\n area of atelectasis. Pneumonia would be less likely but remains a possibility.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-15 00:00:00.000",
"description": "Report",
"row_id": 1816397,
"text": "Nursing NICU NOte.\n\n\n1. Hyperbili. O/Please see am bili result: decreased\nphototherapy to two spot lights. Skin remains ruddy and\nslightly jaundiced. A/Improving hyperbili issue. P/Cont. to\nmonitor effectiveness of phototherapy.\n\n2. Family. O/Mother in today. Mother updated on pt's status\nand plan of care. MOther demonstrates good breast feeding\ntechnique. Mother held pt. Father calling for update.\nA/Parents are actively involved in pt's care. P/Cont. to\nsupport and educate parents.\n\n3. F/N. O/Adlib breast feeding Q3 hours and offering bottle\nafter breastfeeding attempt. Pt demonstrates different\ndegrees of interest in nursing. PIV heplocked this\nafternoon. DS stable thus far. A/Alt. in F/N. P/Cont. to\nmonitor for s/s of feeding intolerance.\n\n4. Sepsis. O/Remains on Amp and gent with bld cultures neg\nto date. A/Sepsis eval. P/Cont. to monitor for s/s of\nsepsis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-15 00:00:00.000",
"description": "Report",
"row_id": 1816394,
"text": "1 Bili.\n Infant remains under quadruple phototherapy,with 3 sets of\nlights and 1 bili blanket.Bili at 2300 was\n18.2/0.6/17.6.Reported results to NNP.Continue present\nplans, repeat bili at 11 AM.\n2 Family\n Mom here early part of shift,went home to rest. Dad here\nall shift,he fed a couple timesDr. spoke with\nhim and members of his family who are in the Medical\nfield.Plan to keep family updated.\n3 F/N\n Abdomen soft, + bowel sounds, 0 loops, 0\ndistention.Breast fed X1 early part of shift, a little\nsleepy. Bottled rest of shift for Dad and nurse ,activity\nlevel improving. More active now with caresVoiding,\nstooling.I.V. infusing in foot, total IV fluids 100cc per K.\nContinue present plans.\n4 Sepsis\n Infant remains on antibiotics as ordered. Continue per\nplans.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-15 00:00:00.000",
"description": "Report",
"row_id": 1816395,
"text": "Neonatology Attending Progress Note\n\nNow day of life 5 for this 35 week gestation infant with hyperbilirubinemia.\nRR 40-80s.\nHR - 130-170s BP 78/51 57\n\nWt. 2520gm up 40gm today - on IV fluids of 120cc/kg/d overnight - now weaned down to 50cc/kg/d.\nFeedings have improved - bottle feeding up to 45 cc overnight\nDS 106\nUO 4.9cc/kg/hr, passing frequent bowel movements.\n\nBili - 18.2 last night - down to 12.4/0.5 this morning\n\nID - CXR - RML density - atelectasis vs infiltrate\ncbc unremarkable and blood culture negative so far.\n\nAssessment/plan:\nHyperbilirubinemia - exagerated physiologic - will dc 2 of phototherapy lights and follow serial bilis.\nWill continue antibiotics for at least 48 hours.\nMother updated at bedside this morning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-15 00:00:00.000",
"description": "Report",
"row_id": 1816396,
"text": "Neonatology Fellow Exam Note\nGen: asleep on warming table under overhead PTX x2, comfortable, NAD\nSkin: unable to estimate jaundice on PTX lights\nHEENT: AFOSF, off NC\nChest: good AE, CTA, no R/F/G\nCV: RRR no M\nAbd: soft, ND/NT, +bowel sounds, no masses\nExt: WWP, brisk cap refill, no cyanosis\nNeuro: asleep; did not wake with gentle exam\n\nUpdated mother.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-16 00:00:00.000",
"description": "Report",
"row_id": 1816398,
"text": "NPN 1900-0700\n\n\nHYPERBILI: Pt continues under double phototherapy, eye\nshields in place. Plan to recheck levels in am.\n\nFAMILY: Parents and brother in for cares. Updated at\nbedside by this RN, asking appropriate questions. Dad stayed\nin room sleeping in kangaroo chair for half of the night\nthen moved to family room w/cot.\n\nFEN: BF X1 @ cares then took 15cc of Breastmilk\nfrom bottle w/Dad @ 2100. Slept very well in between and did\nnot wake up for next feeding. At 0200 feeding, did\nvery well bottling w/Dad.\n\nSEPSIS: Unable to flush IV - IV removed. S/w NNP - decision\nmade to D/C antibiotics. BC remain negative, no s/sx of\ninfection - will continue to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-16 00:00:00.000",
"description": "Report",
"row_id": 1816399,
"text": "Neonatology Attending Progress Note\n\nNow day of life 6, CA 5/7 weeks.\nIn RA, RR 30-50s.\nO2 sats >95%\nHR 120-140s\n\nWt. 2500gm down 20gm - breastfeeding has improved - bottles 35-75cc.\nExcellent urine output, passing stools well.\nIV fluids dc'ed yesterday.\n\nID - amp and gent dc'ed with 48 hour cultures no growth\n\nBili - down to 10.3 on double phototherapy\n\nAssessment/plan:\nHyperbilirubinemia resolving nicely.\nWill plan on discontinuing phototherapy this morning - repeat bili in 8 hours - if stable or decreased will dc to home with FU with Dr. .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-16 00:00:00.000",
"description": "Report",
"row_id": 1816400,
"text": "Neonatology Fellow Exam Note\nMother updated at bedside.\n\nGen: asleep, easily aroused, vigorous, comfortable, NAD, off PTX\nSkin: mild to moderate jaundice, mildly mottled on off warming table\nHEENT: AFOSF\nChest: good AE, CTA, no increased WOB\nCV: RRR no M\nAbd: soft, ND/NT, +bowel sounds, ND/NT\nExt: hips stable, 2+ UE / LE pulses, no cyanosis\nNeuro: vigorous, MAEE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2174-03-16 00:00:00.000",
"description": "Report",
"row_id": 1816401,
"text": "NICU nursing note\n\n\nAlert and active with cares. Sleeping well between feeds.\nStable in room air. Temp stable swaddled on off warmer.\nAdlib breastfed with supplemental bottles all shift. Did\nwell. Voiding/stooling. Ampi/Gent d/c'd (48hour r/o\ncomplete). Double phototx shut off at 0900. Rebound bili\nsent at 1700. (Please refer to flowsheet for results.)\nOrder written by NNP to d/c home. Discharge\nteaching/paperwork completed with mom. updated\nby this nurse, Fellow, and NNP. To have f/u bili outpt.\n and pedi aware.\nDischarged home with mom and dad at 1900.\n\n\n"
}
] |
2,644 | 126,989 | A/P: 71 yo female, h/o multiple abdominal surgeries, CAD s/p CABG, CHF, p/w abdominal and back pain, hypotension, transferred for further management. . 1. Renal Failure and hyperkalemia: New renal failure (last Cr here in was wnl). She has been taking large doses of NSAIDS as an , AIN is a possibility. In addition, if she has been hypotensive at home, ATN is a possibility as well. Currently oliguric (had 100 cc UO at OSH when foley placed). No other new medications or exposures. be prerenal/dehydrated if has systemic infection. Labs, BUN, Cr, and lytes were monitored daily. Her meds were renally doseed. Her K was treated appropriate (hold home K supplements). She received 1 L HCO3. Her acidosis and hyperkalemia likely in setting of this ARF; may need HD if can't manage these metabolic derangements. Initial Cr 5.8, K 8.1. Oliguric. K better with HCO3 (was acidemic on admit). BUN/Cr peaked at 80/7.1, now coming down with increased UOP. Resp status good. Also hypoCa on admit, suspect vit D defic and sepsis. Repleting with IV CaGluc, po Ca, calcitriol. . 2. Non-gap acidosis: No diarrhea; ?renal failure or RTA. Very low serum bicarbonate (may be consistent with distal RTA). Most likely in setting of renal failure . 3. Abdominal pain: Surgery was consulted for the pain. An US showed Cholelithiasis without evidence of cholecystitis. Stone in distal CBD, with intrahepatic biliary dilatation. Distended GB w/ mult gallstones. On , she went to IR: perc. GB drainage. The Bile grew out GPR and GNR. She was started on Zosyn amd then switched to Augmentin when cultures grew out ENTEROCOCCUS. She will go home with the cholecystostomy tube in place and return in a couple weeks for a laparoscopic cholecystectomy. . 4. Hypotension: ?setting of infection /sepsis. Has received 2 L at OSH. On Dopa/Levophed. EF=25%. She received 1L with HCO3 (hyperchloremic acidosis). She was on pressors and theses were weaned (dopa first). On she was hypotensive to 80/60 with ambulation. She was encouraged to maintain hydration, especially in the presence of diarrhea. She received a 1L fluid bolus for hypovolemia. She then received 1 unit of PRBC on for symptomatic anemia and hypotension. Her pre-transfusion HCT was 26.9, and post-HCT was 28.4. She ambulated with PT and was assymptomatic. . 5. CAD: hold BB, spironolactone, nitrate for now; can continue ASA, EKG without acute changes (some peaked T-waves). ASA for now . 6. Resp: She had a small right pneumothorax on CXR and CT. IP placed a pigtail drain and had adequate drainage. The drain was clamped and subsequently pulled. A repeat CXR showed no pneumothorax. COPD: advair, albuterol nebs as needed . 7. FEN: NPO for now, IVF as above. She had a NGT placed for nausea and ileus. The NGt was removed on and she was started on a regular diet. She tolerated a diet. . 8. Stool: She reported loose stool on HD . Stool was sent for C.diff and was negative. . 9. Hypernatremia: on HD6 pt was noted to be nypernatremic, likely secondary to her post-ATN diuresis. She was treated with D5W, and her sodium was w/in normal limits by HD8. . 10. +UTI: a urine culture was + for yeast and she was started on Fluconazole on | IMPRESSION: AP chest compared to and 11: Right apical pleural catheter unchanged in position. Right IJ catheter terminates in the distal SVC. Incompletely visualized right-sided pneumothorax. Previous small right apical pneumothorax noted in retrospect has resolved. Right pneumothorax. Status post esophagojejunostomy, mild wall thickening of efferent limb. Dilaudid IV for pain mgmt with mod relief.R: RUL & LLL diminished- otherwise clear. A compression fracture of T12 again seen, unchanged from . CT OF THE PELVIS WITHOUT IV CONTRAST: Rectal tube is seen within the rectum. Small bilateral pleural effusions unchanged. Right apical pleural catheter still in place. Nonobstructing right renal stone. There appears to be mild intrahepatic biliary dilatation. Small amount of perihepatic ascites noted. Right pneumothorax seen on CT. Multiple diverticula are seen within the sigmoid colon and without evidence of acute diverticulitis. IMPRESSION: AP chest compared to : Mild cardiomegaly has progressed and minimal pulmonary vascular engorgement is new. TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained without IV contrast secondary to acute renal failure. Moderate conscious sedation was provided by Anesthesiology. R CT to waterseal- c/d/i. Small amount of perihepatic ascites. IMPRESSION: AP chest compared to 11:41 p.m. on : Small right apical pleural tube has been inserted. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Large right pneumothorax is seen, incompletely imaged on this study. Tiny nonobstructing stone noted in the right kidney. IMPRESSION: Bilateral effusions, left greater than right - no new focal consolidations. D5 with bicarb changed to KVO per Dr. .ID: low grade temp this shift, tmax 100.3. Small bilateral pleural effusions. Left lung grossly clear. Patient is status post esophagojejunostomy. eval for resolution of PTX. Hypotension. IMPRESSION: AP chest compared to : Mild cardiomegaly is stable. The patient is status post median sternotomy and CABG. FINDINGS: The NGT has been removed. Hct stable at 30.GI: + BS x4 abd appropiately tender, nondistended. Cholelithiasis without evidence of cholecystitis. Right jugular line tip projects over the superior cavoatrial junction. Right jugular line tip projects over the superior cavoatrial junction. Right jugular line tip projects over the superior cavoatrial junction. Stone seen in distal common duct, with intrahepatic biliary dilatation. MAE though hesistantly d/t abd pain. Heart size top normal. Assess for pneumothorax. 11:34 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: ?free air under diaphragmPlease do upright CXR! Gastrografin oral contrast is used. Sinus rhythmLeft axis deviationLeft bundle branch blockTall T waves - consider acute ischemia or hyperkalemiaSince previous tracing of , peaked T waves are noted Tip of the right jugular line projects over the SVC. Tiny right pleural effusion, not appreciably changed. Heart remains shifted slightly to the left, top normal size. There are bilateral effusions, left greater than right which, accounting for positional differences, probably not significantly changed. ionized ca low; repleted as ordered.Plan: continue w/ current plan of care per sicu team. +CSM + PPR: RUL & RLL diminished, &LL clear. bruit auscultated on r side of abdomen, abd very tender to palpation. tenderness on palpation and pos bowel sounds on auscultation. DILAUDID WITH EFFECT.LUNGS WITH DIMINISHED SOUNDS UPPER AND LOWER R SIDE. DENIED CP AT THE TIME, EKG WITH BASELINE L BUNDLE BRANCH BLOCK.CONTINUES WITH METABOLIC ACIDOSIS, 1 AMP BICARB GIVEN THIS AM FOLLOWED BY ANOTHER BOLUS. She was medicated w/ IV dilauded w/ + effect. Empirically on Zosyn.Currently awaiting perc bile duct drain. + BS x4 abd tender with mult healed incisions, nondistended (s/p mult abd surgeries). Dr informed. awating their recommendations.gi :ngt in place with good position noted by auscultation. Sodium bicarb currently infusing.ID: afebrile. foley caht in place with less then accurate hourly uo.id: afebrile with wbc=10 .pt receiving zosyn as ordered.social: pt is a full code. GIVEN DILAUDID FOR ABDOMINAL & BACK PAIN WITH FAIR EFFECT. dialysis. Resp. Resp. EKG performed, labs sent, scant additional u/o. Diet advanced to clears and tolerating well. NPNPlease see carevue for further detailsN: MAE, speech clear. NPNPlease see carevue for further detailspt transferred from MICU to SICU A. CXR UNCHANGED PER DR. . Pboots on. PO/IV calcium a/o. rectal tube in place with liq greenish liq stool which is heme pos but hct has been stable. rr 20. denies cp or sob.cv: received pt off dopamine gtt and has been weaned off levophed gtt since 0820 with sbp 99-130. checking lytes q 4 hrs and repleting as needed. Dilaudid IV given for pain with mod reliefC: NSR/ST 80-100s BP 120-140s with short episode of hypertension to 180s. See Carevue for additonal objective data. MARGINAL URINE OUTPUT, K STABLE, CREAT UP TO 7.1, CALCIUM PERSISTENTLY LOW, TREATED WITH MULTIPLE DOSES OF CA GLUCONATE.RLQ DRAIN WITH LARGE AMOUNTS OF BILIOUS DRAINAGE. SHE HAS AN ANTERIOR CT R SIDE TO SUCTION. Heparin SQ . Foley patent and draining adequate amts of clear urine. careBS clear. Hct dropped to 27.1- team aware. NGT clamped. Afebrile. PERRL. Cont IV ABX. Condition Update'Please see carevue for specifics.Pt alert and oriented x3. o2 2l/m nc with o2 sats> 98% .lungs cta but diminished at the bases. Zosyn empirically.PLAN: Continue to monitor VS, pain, GI, ? Pain mgmt. Pullmonary toilet. Pleurovac intact- 20 cm H20 suction. NEGATIVE LEAK/CREPITUS. RENAL FOLLOWING, IVF WITH BICARB STARTED AND ACIDOSIS IMPROVING. CHEST TUBE TO WATER SEAL THIS AM BY SURGERY, SITE WITHIN NORMAL LIMITS. HR 70s NSR no ectopy BP 120-140s significant cardiac hx - see FHP. PULMONARY HYGEINE. ATTEMPTED NASAL CANNULA, MAINTAINED SP02 94-95% BUT PATIENT FELT MORE SHORT OF BREATH. SR w/ PVC's. FOCUS; STATUS UPDATEDATA;PLEASE SEE CAREVUE FLOWSHEET FOR COMPLETE DETAILS.PATIENT ALERT AND ORIENTED X3. CONDITION UPDATEASSESSMENT: PATIENT ORIENTED X 3, BUT OCCASIONALLY FORGETTING TIME OF DAY. Given PO Coreg - BP 120-140s after. BUN/creat elevated. ABGs showing metabolic acidosis. carePt was assisted in the use of her ADVAIR 250/50. | 23 | [
{
"category": "Radiology",
"chartdate": "2137-02-03 00:00:00.000",
"description": "GB DRAINAGE,INTRO PERC TRANHEP BIL US",
"row_id": 952271,
"text": " 4:49 PM\n GB DRAINAGE,INTRO PERC TRANHEP BIL US; GUIDANCE PERC TRANS BIL DRAINAGE USClip # \n Reason: gallbladder drainage\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CBD stone\n REASON FOR THIS EXAMINATION:\n gallbladder drainage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Choledocholithiasis, sepsis, suspected cholangitis.\n\n PROCEDURE: The risks and benefits of the procedure were directly explained to\n the patient, who was alert, aware of her condition, and understood the risks\n and benefitis of the procedure. A pre-procedure timeout was performed. The\n area was prepped and draped in a sterile fashion. Approximately 10 cc of 1%\n lidocaine was used as a local anesthetic.\n\n Moderate conscious sedation was provided by Anesthesiology.\n\n The initial three attempts of deploying an 8 French pigtail catheter under\n son guidance, met with limited success; while the catheter was seen\n within the gallbladder lumen via ultrasound, minimal fluid could be aspirated.\n A final attempt using needle under ultrasound guidance yielded\n successful aspiration of 20 mL of black thin fluid. An 8 Fr catheter was\n deployed over wire into the gallbladder; the wire was removed, and\n the catheter pigtail formed. Another 150 mL of black thin fluid was aspirated,\n and subsequent ultrasound images show a decompressed gallbladder. Aspirated\n fluid was sent for microbiology and culture. A three-way valve with drainage\n bag was then attached to the catheter, which was fixed to the skin surface\n using an adhesive device.\n\n The patient tolerated the procedure well and there were no immediate post-\n procedure complications.\n\n Dr. performed the procedure and was present throughout.\n\n IMPRESSION: Technically difficult, but successful ultrasound-guided\n percutaneous\n cholecystostomy.\n\n\n\n\n\n\n\n\n (Over)\n\n 4:49 PM\n GB DRAINAGE,INTRO PERC TRANHEP BIL US; GUIDANCE PERC TRANS BIL DRAINAGE USClip # \n Reason: gallbladder drainage\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952289,
"text": " 3:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F h/o multiple abdominal surgeries, CHF, p/w abdominal pain, hypotension,\n right PTX noted on Chest CT\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:22 A.M., \n\n HISTORY: Multiple abdominal surgeries, pain, and hypotension. Right\n pneumothorax.\n\n IMPRESSION: AP chest compared to and 11:\n\n Right apical pleural catheter unchanged in position. No appreciable\n pneumothorax or right pleural effusion. Left lung grossly clear. Heart size\n normal. Nasogastric tube passes below the diaphragm and out of view. Right\n jugular line tip projects over the superior cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952196,
"text": " 6:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for acute lung process, infiltrate, edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with multiple abdominal surgeries, CHF, p/w abdominal pain,\n hypotension\n REASON FOR THIS EXAMINATION:\n evaluate for acute lung process, infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:59 P.M., .\n\n HISTORY: Multiple abdominal surgeries. Rule out infiltrate.\n\n IMPRESSION: AP chest compared to :\n\n Mild cardiomegaly has progressed and minimal pulmonary vascular engorgement is\n new. There is no right pleural effusion. Small left pleural effusion or\n pleural scarring is smaller than it was on . There is no\n pneumonia or pulmonary edema. Tip of the right jugular line projects over the\n SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-02 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 952204,
"text": " 9:41 PM\n RENAL U.S. Clip # \n Reason: rule out obstruction\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with COPD, CHF, s/p gastrectomy, with new renal failure,\n acidosis, hyperkalemia\n REASON FOR THIS EXAMINATION:\n rule out obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 71-year-old female with COPD, CHF, gastrectomy with new\n renal failure, acidosis, hyperkalemia. Rule out obstruction.\n\n COMPARISON: None.\n\n RENAL ULTRASOUND: Right kidney measures 10.7 cm. Left kidney measures 11.2\n cm. There is no hydronephrosis, mass, or obvious stone. The kidneys are\n slightly echogenic. Normal arterial waveforms are demonstrated in both\n kidneyds. A normal gallbladder containing a 9 mm stone is present. There is no\n significant pericholecystic fluid or gallbladder wall edema to suggest\n cholecystitis. The aorta maintains a normal caliber throughout. Small amount\n of fluid is seen within the hepatorenal recess.\n\n IMPRESSION: No hydronephrosis. Normal arterial waveform is seen within both\n kidneys. Cholelithiasis without evidence of cholecystitis.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-03 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 952227,
"text": " 5:53 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: PUD, LUQ PAIN, ? GJ ANASTOMIC PERF\n Admitting Diagnosis: SEPSIS\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with PMH of PUD, s/p Billroth II, eventually getting \n reconstruction due to GJ anastomotic stricture, with sudden onset of\n LUQ/epigastric pain x 15hrs, concerning for at least GJ anastomic perf and\n mayber perf. Pt also with ARF, Cr 5.9; CT done at earlier w/o\n po constrast. Please give PO contrast to look for leak and assess for free air\n REASON FOR THIS EXAMINATION:\n r/o UGI perforation\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with past medical history of peptic ulcer\n disease, status post Bilroth, subsequent a Roux-en-Y reconstruction, presents\n with sudden onset left upper quadrant/epigastric pain. Evaluate for\n anastomotic leak or perforation.\n\n COMPARISONS: .\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained\n without IV contrast secondary to acute renal failure. Gastrografin oral\n contrast is used.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Large right pneumothorax is seen,\n incompletely imaged on this study. Small bilateral pleural effusions are also\n seen. Bibasilar atelectasis seen.\n\n There appears to be mild intrahepatic biliary dilatation. Small amount of\n perihepatic ascites noted. Gallbladder appears distended with multiple\n gallstones. Stone also seen in distal common duct. Allowing for limitations\n of a non- contrast study, the pancreas, spleen, adrenal glands, and kidneys\n appear grossly unremarkable. Tiny nonobstructing stone noted in the right\n kidney.\n\n Patient is status post esophagojejunostomy. Mild wall thickening of efferent\n limb noted. No extravasation of contrast is seen from the bowel. There is no\n evidence of free air within the abdomen.No reflux into the afferent loop and\n the diatal jejuno-jejunostomy appears patent.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Rectal tube is seen within the rectum.\n Multiple diverticula are seen within the sigmoid colon and without evidence of\n acute diverticulitis. Air is seen within the bladder consistent with Foley\n catheterization. No free fluid is seen within the pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions identified. A\n compression fracture of T12 again seen, unchanged from . Grade I\n anterolisthesis L3 on L4 also again noted. Fixation screws are seen within\n (Over)\n\n 5:53 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: PUD, LUQ PAIN, ? GJ ANASTOMIC PERF\n Admitting Diagnosis: SEPSIS\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the left proximal femur.\n\n IMPRESSION:\n 1. Incompletely visualized right-sided pneumothorax. This was discussed with\n Dr. immediately upon completion of the study.\n 2. Stone seen in distal common duct, with intrahepatic biliary dilatation.\n Distended gallbladder with mutiple gallstones. Discussed with Dr. .\n 3. Status post esophagojejunostomy, mild wall thickening of efferent limb.\n 4. No evidence of contrast extravasation from the bowel. No free air seen\n within the abdomen.\n 5. Small amount of perihepatic ascites.\n 6. Nonobstructing right renal stone.\n 7. Small bilateral pleural effusions.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952266,
"text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p right pig tail via IP\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F h/o multiple abdominal surgeries, CHF, p/w abdominal pain, hypotension,\n right PTX noted on Chest CT\n REASON FOR THIS EXAMINATION:\n s/p right pig tail via IP\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:25 P.M., \n\n HISTORY: Pain following abdominal surgeries. Hypotension. Right\n pneumothorax seen on CT.\n\n IMPRESSION: AP chest compared to 11:41 p.m. on :\n\n Small right apical pleural tube has been inserted. Previous small right\n apical pneumothorax noted in retrospect has resolved. Mild atelectasis at the\n right base has improved. Heart remains shifted slightly to the left, top\n normal size. Left lung clear. Nasogastric tube ends in the stomach. Right\n jugular line tip projects over the superior cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 953104,
"text": " 9:08 PM\n CHEST (PA & LAT) Clip # \n Reason: asses for PNA, other CP process\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with cholecystitis, s/p perc drainage, now with T=101 and\n decreased BS\n REASON FOR THIS EXAMINATION:\n asses for PNA, other CP process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON , 21:10\n\n INDICATION: Temperature and decreased breath sounds at the bases.\n\n COMPARISON: .\n\n FINDINGS: The NGT has been removed. Right CVL remains in place, and there is\n no PTX. There are bilateral effusions, left greater than right which,\n accounting for positional differences, probably not significantly changed.\n\n There are no new focal consolidations. The pulmonary vascular markings are\n unchanged and remain within normal limits.\n\n CABG changes are evident.\n\n IMPRESSION: Bilateral effusions, left greater than right - no new focal\n consolidations. No significant hange versus prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952707,
"text": " 3:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p removal of pigtail catheter. eval for resolution of PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F h/o multiple abdominal surgeries, CHF, p/w abdominal pain, hypotension,\n right PTX noted on Chest CT, s/p WS\n REASON FOR THIS EXAMINATION:\n s/p removal of pigtail catheter. eval for resolution of PTX. please take after\n removal.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple abdominal surgeries and right pneumothorax, status post\n pigtail catheter removal. Assess for pneumothorax.\n COMPARISON: .\n\n SINGLE AP UPRIGHT BEDSIDE CHEST RADIOGRAPH: There is no evidence of\n pneumothorax. Right IJ catheter terminates in the distal SVC. NG tube\n descends below the diaphragm with the tip not visualized. The patient is\n status post median sternotomy and CABG. Small bilateral pleural effusions\n unchanged. No evidence of CHF.\n\n IMPRESSION: No evidence of pneumothorax on this semi-upright film.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952466,
"text": " 5:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? resolved PTX\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F h/o multiple abdominal surgeries, CHF, p/w abdominal pain, hypotension,\n right PTX noted on Chest CT, s/p WS\n REASON FOR THIS EXAMINATION:\n ? resolved PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:42 A.M., .\n\n HISTORY: Multiple abdominal surgeries. Abdominal pain and hypotension.\n\n IMPRESSION: AP chest compared to through 12.\n\n Right apical pleural catheter still in place. No pneumothorax. Tiny right\n pleural effusion, not appreciably changed. Lungs grossly clear. Heart size\n top normal. Nasogastric tube ends in the stomach. Tip of the right jugular\n line projects over the superior caval atrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 952212,
"text": " 11:34 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?free air under diaphragmPlease do upright CXR!\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with multiple abdominal surgeries, CHF, p/w abdominal pain,\n hypotension\n REASON FOR THIS EXAMINATION:\n ?free air under diaphragmPlease do upright CXR!\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:41 P.M \n\n HISTORY: Multiple abdominal surgeries, CHF and hypotension.\n\n IMPRESSION: AP chest compared to :\n\n Mild cardiomegaly is stable. Lungs grossly clear. No pneumothorax, pleural\n effusion or free subdiaphragmatic gas. Right jugular line tip projects over\n the superior cavoatrial junction.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-02-02 00:00:00.000",
"description": "Report",
"row_id": 159159,
"text": "Sinus rhythm\nLeft axis deviation\nLeft bundle branch block\nTall T waves - consider acute ischemia or hyperkalemia\nSince previous tracing of , peaked T waves are noted\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-05 00:00:00.000",
"description": "Report",
"row_id": 1296884,
"text": "NPN\nPlease see carevue for further details\nN: alert and oriented x 3. speech clear. MAE though hesistantly d/t abd pain. Dilaudid IV for pain mgmt with mod relief.\nR: RUL & LLL diminished- otherwise clear. R CT to waterseal- c/d/i. no leak/no fluctuation noted. Sats 98-100 on 50% face tent. ABGs showing metabolic acidosis though improved from yesterday.\nC: HR 90-100s ST occasional PVCs. BP 130-150s. Repleted with 20 K for K 3.3. Continues with hypocalcemia-frequent repletions of calcium a/o. Hct stable at 30.\nGI: + BS x4 abd appropiately tender, nondistended. R pigtail drain with minimal amounts of green bilious drainage. NGT to low continuous wall suction. c/o abd pain (particularly RLQ pain) with movement and positioning. Dilaudid a/o with mod relief.\nGU: Foley draining marginal amounts of clear yellow urine. BUN/Cr remain elevated. ? dialysis today.\nENDO: SSRI a/o- FS wnl (70-90s). D5 with bicarb changed to KVO per Dr. .\nID: low grade temp this shift, tmax 100.3. Dr. aware. Pt also c/o feeling flushed and itchy. Team notified. no interventions at this point.\nPLAN: ? HD today but needs dialysis cath first. continue to monitor labs- lytes, ABGs, FS- VS, pain, wound and drains, closely monitor neuro and respiratory status and provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-05 00:00:00.000",
"description": "Report",
"row_id": 1296885,
"text": "Condition Update'\nPlease see carevue for specifics.\n\nPt alert and oriented x3. MAE. PERRL. Pt c/o back and abdominal pain. She was medicated w/ IV dilauded w/ + effect. Afebrile. SR w/ PVC's. BBB. SBP 120's-140's. No c/o sob. 02 sats 95-97% on 4L 02 via n/c. Chest tube intact. No crepitus/fluctuation/leak noted. Diet advanced to clears and tolerating well. Foley patent and draining adequate amts of clear urine. NGT clamped. D5W w/ 100meq sodium bicarb infusing x 1500ml. Integ intact. ionized ca low; repleted as ordered.\n\nPlan: continue w/ current plan of care per sicu team. Xfer to the floor when bed available. Pt will not need HD per renal team. Cont IV ABX. Pain mgmt. Pullmonary toilet. Continue to closely monitor ionized calcium and replete prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-06 00:00:00.000",
"description": "Report",
"row_id": 1296886,
"text": "NPN\nPlease see carevue for further details\nN: MAE, speech clear. alert and oriented x3 though perseverated about \"getting her walker\" overnight. mult sleep aides given per pt's home regimen. Dilaudid IV given for pain with mod relief\nC: NSR/ST 80-100s BP 120-140s with short episode of hypertension to 180s. Given PO Coreg - BP 120-140s after. Multiple calcium repletions yet remains persistently low. PO/IV calcium a/o. Hct dropped to 27.1- team aware. Pboots on. Heparin SQ . +CSM + PP\nR: RUL & RLL diminished, &LL clear. R ant CT intact with small amount of serosang drainage (20ccs)\nGI: + BS x4 abd soft tender, non distended R pigtail drain with small amount of bilious drainage.\nGU: foley draining clear yellow urine adq amounts.\nENDO: SSRI a/o, FS wnl. Sodium bicarb currently infusing.\nID: afebrile. Zosyn empirically.\nPLAN: Continue to monitor VS, pain, GI, ? transfer to floor, lytes, provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-06 00:00:00.000",
"description": "Report",
"row_id": 1296887,
"text": "Resp. care\nPt was assisted in the use of her ADVAIR 250/50. She had no complaints. Her BS were clear & her respirations regular & unlabored\nalbuterol was not requested\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-04 00:00:00.000",
"description": "Report",
"row_id": 1296881,
"text": "Resp. care\nBS clear. & respirations seem unlabored. She is responsive & alert taking her ADVIR with out any trouble only needing a small amount of assistance working the device. She did have a drop of her BP during the shift. And her abgs show a Metabolic acidosis (7.26, 36, 69) on FIO2 0.40 via face tent O2 increased back to 0.50 post abg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-04 00:00:00.000",
"description": "Report",
"row_id": 1296882,
"text": "FOCUS; STATUS UPDATE\nDATA;\nPLEASE SEE CAREVUE FLOWSHEET FOR COMPLETE DETAILS.\n\nPATIENT ALERT AND ORIENTED X3. MOVING ALL EXTREMITIES BUT STIFFLY DUE TO PAIN AT TIMES. SHE COMPLAINS OF L LOWER ABDOMINAL PAIN AND PAIN AT THE DRAIN INSERTION IN RLQ. DILAUDID WITH EFFECT.\n\nLUNGS WITH DIMINISHED SOUNDS UPPER AND LOWER R SIDE. CLEAR ON LEFT. CXR UNCHANGED PER DR. . SHE HAS AN ANTERIOR CT R SIDE TO SUCTION. NO DRAINAGE OVERNIGHT. NEGATIVE LEAK/CREPITUS. SATS 93-98%. CURRENTLY ON 50% FACE TENT.\n\nEPISODE OF HYPOTENSION WITH SYMPTOMS OF \"FEELING FUNNY, AS IF FLOATING\", BOLUSED WITH IMPROVEMENT OF BP AND RESOLUTION OF SYMPTOMS. DENIED CP AT THE TIME, EKG WITH BASELINE L BUNDLE BRANCH BLOCK.\n\nCONTINUES WITH METABOLIC ACIDOSIS, 1 AMP BICARB GIVEN THIS AM FOLLOWED BY ANOTHER BOLUS. MARGINAL URINE OUTPUT, K STABLE, CREAT UP TO 7.1, CALCIUM PERSISTENTLY LOW, TREATED WITH MULTIPLE DOSES OF CA GLUCONATE.\n\nRLQ DRAIN WITH LARGE AMOUNTS OF BILIOUS DRAINAGE. MUSHROOM CATHETER IN PLACE WITH LIQUID GREENISH/BROWN STOOL.\n\nPLAN:\nF/U ABG AT 0630. CONTINUE TO MONITOR LABS CLOSELY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-03 00:00:00.000",
"description": "Report",
"row_id": 1296879,
"text": "altered gi status\nd: pt lethargic and has not received any further doses of dilaudid. pt comfortable but with any movement pt screams out in pain. as the morning has progressed she has been more interactive with nursing and medical staff.\n\nresp: according to surgeons pt has mod to lg pneumothorax to r lung most likely from cl placed at osh. most likely pt will have ct placed when she is transfered to sicu. o2 2l/m nc with o2 sats> 98% .lungs cta but diminished at the bases. rr 20. denies cp or sob.\n\ncv: received pt off dopamine gtt and has been weaned off levophed gtt since 0820 with sbp 99-130. checking lytes q 4 hrs and repleting as needed. see for specific meds.pt hypernatremic with na=152 and presently receiving d5w at 50cc's/hr and surgeons are recommending more ivf. awating their recommendations.\n\ngi :ngt in place with good position noted by auscultation. abd distended without guarding. tenderness on palpation and pos bowel sounds on auscultation. rectal tube in place with liq greenish liq stool which is heme pos but hct has been stable. surgeons to bedside and infoemed her that she has cholangitis and will need surgery most likely planned for Thursday. also plan is to place pigtail today.\n\ngu: renal consult team following pt regarding her possible need for dialysis in the setting of arf. foley caht in place with less then accurate hourly uo.\n\nid: afebrile with wbc=10 .pt receiving zosyn as ordered.\n\nsocial: pt is a full code. her husband ahs been called regarding her transfer to sicu a on the .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-03 00:00:00.000",
"description": "Report",
"row_id": 1296880,
"text": "NPN\nPlease see carevue for further details\npt transferred from MICU to SICU A. Arrived at approx 1230. Nonintubated, no gtts on 2L n.c. VSS. alert and oriented, speech appropriate. MAE. c/o abd pain pain with movement. + BS x4 abd tender with mult healed incisions, nondistended (s/p mult abd surgeries). HR 70s NSR no ectopy BP 120-140s significant cardiac hx - see FHP. BLSCTA, diminished at bases, 02 sats 98-100 on 40% humidified face tent. denies SOB. Foley draining clear yellow urine marginal amounts. BUN/creat elevated. ? dialysis. K 4.5 (was 7.6 upon admission) Mushroom cath draining liquid green stool. R pigtail chest drain placed today by IP at bedside- withdrew approx 150 ccs of air. Pleurovac intact- 20 cm H20 suction. A line placed. ABGs showing metabolic acidosis. Repleted with 2 gram calcium. FS wnl, continue to closely monitor, D5 at 150, Afebrile- WBC 10. Empirically on Zosyn.\nCurrently awaiting perc bile duct drain. Awaiting eval from anesthesia d/t need for conscious sedation. Closely monitor lytes & ABGs, renal, assess need for dialysis, pain, drains, provide comfort and support.\nHusband in to visit. will be spokesperson- # in room.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-03 00:00:00.000",
"description": "Report",
"row_id": 1296877,
"text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: sepsis; new ARF/ATN; abdl and back pain;\n\n71 yo femaled w/ hx mult abdn; surgeries for PUD, gastrectomy ', mult revisions, also w/ hx CA 5-vessel CABG EF 25%;\n has been taking celebrex and ibuprofen for for joint pain; new sudden decrease in urine production ;\n pt's husband states pt had mild slurred speech 1 day PTA;\n\nwent to for fall a.m., couldn't get up;\nu/s neg for AAA, non-contrast CT neg; new elevated creat 5.8, K+ 7.6--received Kayexelate, D50, insulin, HCO3; started on Dopamine and levophed for hypotension, started on Meropenum;\n\ntransferred to , arrove approx 17:30;\n\ncreatinine cont to rise, resulting also in metabolic acidosis;\nseen by renal, surgery; received again Kayexelate, insulin, D50, Calcium, bicarb;\n\npt initially abit hypothermic at arrival, T max 98.8 (o) at midnight;\nrenal and abdn bedside u/s done, reportedly gallstone found; (pt w/ c/o RLQ pain);\n\ndopamine weaned off in short order at beginning of this 12 hours, levophed increased to accomodate wean of dopamine, then weaned as able;\n\npt w/ adequate resp status, on 2 l nc O2;\n\nabd tender, finally at midnight started putting out stool d/t Kayexelate, mushroom cath in use (fecal inc bag did not work);\n\nreceived 1 mg IV dilaudid at approx 00:30, prior to turning from side to side for clean of of stool, and application of fecal collection method; as of 2 1/2 hours later, dilaudid still in effect, likely d/t renal failure, kidneys likely not clearing med;\n\npt to have CT this night, after drinks PO contrast.\n\nwill addendum note toward end of shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-03 00:00:00.000",
"description": "Report",
"row_id": 1296878,
"text": "npn 7p-7a addendum\n\n06:50\npt down for CT at approx 06:15, pending;\nNGT inserted to give pt po CT contrast, to prevent aspiration d/t pt's grogginess since :30 1 mg IV dilaudid;\n\nreportedly pt w/ pneumothorax, nonetheless, pt still w/ good O2 sats (97-100), resp rate and effort w/ extra effort;\n\n05:15 labs w/ continued acute derangements, despite medical attempts all night at moving labs toward nl; (see med sheets);\n\ncurrently receiving 2 mor gms IV Calcium, plus 500 cc LR at 100 cc/hr;\n\nPt likely to need urgent dialysis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-02 00:00:00.000",
"description": "Report",
"row_id": 1296876,
"text": "Admission note from 1700\nPt arrived from @ 1700 via ambulance w/BP being supported by Dopamine @20mcg/kg, Levophed 0.02mcg/kg, Bicarb @150. Pt was hypothermic w/T ax 94.5, c/o great pain in back, u/o only 22cc of clear lt yellow urine. Alert, oriented x3 but did not know the name of this institution. EKG performed, labs sent, scant additional u/o. Of note, ? bruit auscultated on r side of abdomen, abd very tender to palpation. Dr informed. +PP, maintaining sat of >95% on 2L NC. See Carevue for additonal objective data.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-02-04 00:00:00.000",
"description": "Report",
"row_id": 1296883,
"text": "CONDITION UPDATE\nASSESSMENT:\n PATIENT ORIENTED X 3, BUT OCCASIONALLY FORGETTING TIME OF DAY. DOZING ON/OFF THROUGHOUT THE DAY. GIVEN DILAUDID FOR ABDOMINAL & BACK PAIN WITH FAIR EFFECT. HEART RATE 90'S SINUS WITH BBB (BASELINE). SBP RANGING 100-130'S, PATIENT MAKING 30-40 CC URINE HOURLY. RENAL FOLLOWING, IVF WITH BICARB STARTED AND ACIDOSIS IMPROVING. REPLETING CALCIUM FREQUENTLY. LUNG SOUNDS MOSTLY CLEAR, CRACKLES LEFT BASE IN AFTERNOON. BREATHING UNLABORED WITH HIGH FLOW FACE TENT @ 40 %. ATTEMPTED NASAL CANNULA, MAINTAINED SP02 94-95% BUT PATIENT FELT MORE SHORT OF BREATH. CHEST TUBE TO WATER SEAL THIS AM BY SURGERY, SITE WITHIN NORMAL LIMITS. ABDOMEN SOFT, BILE DRAIN WITH MOD GOLDEN/BROWN DRAINAGE. BLOOD GLUCOSE NORMAL. NG TUBE WITH MINIMAL CLEAR DRAINAGE.\nPLAN:\n CONTINUE TO FOLLOW ABGS EVERY 4-6 HOURS AS NEEDED. ? DIAYLSIS CATHETER AND HEMODIALYSIS TOMORROW IF CREAT CONTINUES TO INCREASE. PULMONARY HYGEINE.\n"
}
] |
26,381 | 108,223 | He was admitted and brought to the Angiography Suite on . He underwent coiling of the residual aneurysm. He tolerated this procedure well. Postoperatively, systolic blood pressure was kept between 100 and 140. He had frequent neuro checks. Later on in the postoperative day he did develop atrial fibrillation. His vital signs were stable with heart rate 90 to 110, blood pressure 130 to 140/80 to 90, respirations 15, O2 sat 99 to 100. He had no complaints of pain, headache, chest pain, shortness of breath, or dizziness. Dorsalis pedis pulses were felt post procedure, and he had no hematoma at the groin site. A left sheath did remain in place, and he received prophylactic antibiotics. He was neurologically intact and appeared to be. The sheath was removed without incident on the second hospital day. The patient continued taking Plavix and aspirin. He continued to have frequent neuro checks and tight blood pressure control. His atrial fibrillation did spontaneously resolve. He advanced his activity and his diet and continued to be neurologically intact. | POSTOPERATIVE DIAGNOSIS: Same status post GDC coil embolization of the aneurysm residual. After placement of the guidecatheter into the right common carotid artery an angiographic run (Over) 7:38 AM CAROT/CEREB Clip # Reason: SAME DAY UNIT. IMPRESSION: Endovascular coil embolization of an anterior communicating artery residual using a superselective transarterial intracranial procedure. Next, a diagnostic catheter was used to selectively catheterize the following vessels: right common carotid artery, right internal carotid artery, right anterior cerebral artery intracranial artery, right anterior communicating artery residual aneurysm. This enabled us then to use an SL-10 microcatheter which was threaded over a microwire into the right A1 segment of the anterior cerebral artery followed by its entrance into the anterior communicating aneurysm residual. The guidecatheter was then placed into the right internal carotid artery under roadmap technique. He subsequently underwent a followup cerebral angiogram in , which demonstrated a persistent residual filling in the inferiorly pointing proximal portion which may represent small amount of recannalization. He underwent endovascular embolization of this aneurysm. INDICATION: Mr. is a patient who initially presented with a ruptured anterior communicating artery aneurysm. After deployment and prior to detachment of each coil angiographic run was performed in order to rule out impingement on the anterior communicating complex or interference with the flow in either cerebral arteries. Diagnostic cerebral angiogram w/coil embolization. Diagnostic cerebral Contrast: OPTIRAY Amt: 260 ********************************* CPT Codes ******************************** * EMBO TRANSCRANIAL SEL CATH 3RD ORDER * * -51 MULTI-PROCEDURE SAME DAY TRANSCATH EMBO THERAPY * * F/U TRANS CATH THERAPY CAROTID/CEREBRAL UNILAT * * CAROTID/CEREBRAL UNILAT * **************************************************************************** MEDICAL CONDITION: 50 year old man with s/p aneurysmal subarachnoid hemorrhage. ANESTHESIA: General endotracheal anesthesia. With the guidecatheter in this position a biplane angiographic run, as well as a three-dimensional rotational angiogram, was performed which demonstrated the residual filling. A 19-gauge single-wall needle was then used to puncture the right common femoral artery, and upon the return of brisk arterial blood, a 5 Fr vascular sheath was inserted over a guidewire and kept on a heparinized saline drip. FINAL REPORT PREOPERATIVE DIAGNOSIS: Previously ruptured anterior communicating artery aneurysm status post repeat delayed diagnostic angiography at six months demonstrating persistent residual filling within the inferior-medial portion. Excellent flow was noted throughout and after detachment of all the GDC coils an angiographic run was performed in biplane projection as well as three- dimensional rotational angiography which revealed persistent filling of bilateral distal anterior cerebral artery territories with no evidence of persistent residual in the coiled pocket. CONSENT: The patient and his wife were given a full and complete explanation of the procedure. With the microcatheter in this position a series of GDC coils were deployed. In order to provide optimal protection he was planned to undergo additional coil embolization for this residual. 7:38 AM CAROT/CEREB Clip # Reason: SAME DAY UNIT. Atrial fibrillation.Since previous tracing, atrial fibrillation is new Specifically, the indications, risks, benefits, and alternatives to the procedure were explained in detail. PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and placed on the table in supine position. REASON FOR THIS EXAMINATION: SAME DAY UNIT. In addition, the possible complications, such as the risk of bleeding, infection, stroke, neurological deficit or deterioration, groin hematoma, and other unforeseen complications, including the risk of coma and even death, were outlined. The patient and his wife understood and wished to proceed with the operation. The right groin area was prepped and draped in the usual sterile fashion. Diagnostic cerebral Contrast: OPTIRAY Amt: 260 FINAL REPORT (Cont) revealed no evidence of carotid stenosis or dissection this segment. START TIME 2:00 PM. START TIME 2:00 PM. | 2 | [
{
"category": "Radiology",
"chartdate": "2143-02-12 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 819858,
"text": " 7:38 AM\n CAROT/CEREB Clip # \n Reason: SAME DAY UNIT. START TIME 2:00 PM. Diagnostic cerebral \n Contrast: OPTIRAY Amt: 260\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CEREBRAL UNILAT *\n * CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p aneurysmal subarachnoid hemorrhage.\n REASON FOR THIS EXAMINATION:\n SAME DAY UNIT. START TIME 2:00 PM. Diagnostic cerebral angiogram w/coil\n embolization.\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Previously ruptured anterior communicating artery\n aneurysm status post repeat delayed diagnostic angiography at six months\n demonstrating persistent residual filling within the inferior-medial portion.\n\n POSTOPERATIVE DIAGNOSIS: Same status post GDC coil embolization of the\n aneurysm residual.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Mr. is a patient who initially presented with a ruptured\n anterior communicating artery aneurysm. He underwent endovascular embolization\n of this aneurysm. He subsequently underwent a followup cerebral angiogram in\n , which demonstrated a persistent residual filling in the\n inferiorly pointing proximal portion which may represent small amount of\n recannalization. In order to provide optimal protection he was planned to\n undergo additional coil embolization for this residual.\n\n CONSENT: The patient and his wife were given a full and complete explanation\n of the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications, including the risk of coma and even death, were outlined. The\n patient and his wife understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19-gauge single-wall needle was then\n used to puncture the right common femoral artery, and upon the return of brisk\n arterial blood, a 5 Fr vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: right common carotid artery,\n right internal carotid artery, right anterior cerebral artery intracranial\n artery, right anterior communicating artery residual aneurysm. After placement\n of the guidecatheter into the right common carotid artery an angiographic run\n (Over)\n\n 7:38 AM\n CAROT/CEREB Clip # \n Reason: SAME DAY UNIT. START TIME 2:00 PM. Diagnostic cerebral \n Contrast: OPTIRAY Amt: 260\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n revealed no evidence of carotid stenosis or dissection this segment. The\n guidecatheter was then placed into the right internal carotid artery under\n roadmap technique. With the guidecatheter in this position a biplane\n angiographic run, as well as a three-dimensional rotational angiogram, was\n performed which demonstrated the residual filling. This enabled us then to use\n an SL-10 microcatheter which was threaded over a microwire into the right A1\n segment of the anterior cerebral artery followed by its entrance into the\n anterior communicating aneurysm residual. With the microcatheter in this\n position a series of GDC coils were deployed. After deployment and prior to\n detachment of each coil angiographic run was performed in order to rule out\n impingement on the anterior communicating complex or interference with the\n flow in either cerebral arteries. Excellent flow was noted throughout and\n after detachment of all the GDC coils an angiographic run was performed in\n biplane projection as well as three- dimensional rotational angiography which\n revealed persistent filling of bilateral distal anterior cerebral artery\n territories with no evidence of persistent residual in the coiled pocket.\n\n IMPRESSION: Endovascular coil embolization of an anterior communicating artery\n residual using a superselective transarterial intracranial procedure.\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2143-02-12 00:00:00.000",
"description": "Report",
"row_id": 178713,
"text": "Atrial fibrillation.\nSince previous tracing, atrial fibrillation is new\n\n"
}
] |
84,615 | 167,023 | In brief, Ms. is a 75-year-old woman with Crohn's with known abdominal abcesses who presented with fever and hypotension in the setting of coag-neg Staph blood culture (likely contaminant). . 1) Abdominal abscesses: Patient initially presented with fever and hypotension, concerning for sepsis in the setting of abdominal abscesses revealed on CT, and was admitted to the ICU for stabilization. She had an IR study which indicated presence of sigmoid fistula likely contributing to the persistent abscesses. Approximately 5cc of fluid was able to be drained from the abscess and a drain was left in place. The fluid was sent for cultures, and given that she became afebrile and BP was normotensive, she was transferred out of MICU to the medical floor. Her fluid culture revealed enterococcus and E. coli (ESBL) as well as non-C. albicans yeast. Per ID recs, she was started on a 3-wk course of Abx, Daptomycin (day 1 = ), Meropenem (day 1 = ), and Micafungin (day 1 = , LFTs obtained prior). We have informed the patient that while on these antibiotics, she needs to have weekly CK, CBC, BUN, Creatinine, LFTs checked. She was afebrile and BP remained stable while on the medical floor. The patient was instructed to continue taking all three antimicrobials through , when she will see her ID provider in clinic. IR was contact on day of discharge, and provided a pager number for the IR nurse practicioner. The rehab center was instructed to call IR on Monday , to coordinate drain removal at the appropriate time. . 2) UTI: Urine cultures were sent which revealed VRE UTI. She had urinary frequency and urgency, infrequent dysuria, but no hematuria, CVA tenderness or fever. Per ID recs, she was started on a 3-wk course of Daptomycin (day 1 = ). She will follow up with clinic on . . 3) Hypotension: She presented w/ BP low in the 80-90 range, likely sepsis given known UTI and intra-abdominal abscesses per above. It was fluid-responsive, and ACTH stim test showed good response. On regimen of maintenance IV fluids and Abx treatment per above, her hypotension resolved to SBP 110s-120s and remained stable for the rest of her hospital stay. . 4) Pancytopenia: She presented w/ pancytopenia which began in late and had previously been attributed to Abx use (Ceftriaxone) given correlation in timing. Formal work-up for this had never been pursued. We monitored her CBC daily to ensure that platelets remained > 50K, and followed ANC to monitor for neutropenia. She did receive 1 unit of PRBCs while in the ICU for her hypotension and anemia, but did not require any additional transfusions during the admission. . 5) Crohn's disease: Her initial CT abd/pelvis did show sigmoid inflammation, and she had many episodes of loose BM / watery diarrhea which were increased in frequency (often occurring w/ urination) compared to her known baseline diarrhea. She denied any abdominal cramping or pain, bowel incontinence, or blood in stools during the admission. We continued her on mesalamine 800 mg . We tested her stools for C. diff which came back negative twice. Therefore, we started her on PRN loperamide for the diarrhea. Per nutrition and GI recs, she was kept NPO and on TPN, slowly transitioned to PO liquids and TPN, with daily Chem-10 and QID FSBG. . 6) Anxiety/depression: Pt was anxious about her infections, and concerned about her urinary and bowel frequency. She was continued on lorazepam 0.25-0.5 mg PO prn for anxiety and mirtazapine 15 mg qHS for depression. Social work also followed her while on the medical floor. . 7) Code: FULL. . | Since the previous tracing of sinusbradycardia and low voltages are now present. TECHNIQUE: Chest PA and lateral radiograph obtained. There is tethering of the sigmoid to an adjacent fluid collection, (2:63), in a region of previously known fistula, and although no direct fistulous tract is demonstrated on the current scan, and persistent fistulous tract is likely. FINDINGS: Left trace pleural effusion is noted as well as atelectasis at the lung bases. admitted w/ intraabdominal abscesses REASON FOR THIS EXAMINATION: effusion? admitted w/ intraabdominal abscesses REASON FOR THIS EXAMINATION: effusion? Nodular contour of the liver is redemonstrated in keeping with patient's known history of cirrhosis. COMPARISON: MR , and multiple CTs, last one done . There is a small left pleural effusion, which appears new in the interval, with a patchy opacity noted in the retrocardiac region. Patient has known intra-abdominal abscesses. Right sacral sclerotic lesion corresponding to an area of enhancement of the prior MR. Biopsy was recommended as stated on the prior MR report. IMPRESSION: Small left pleural effusion with bibasilar patchy airspace opacities, which could represent infection or atelectasis. The pancreatic cystic lesions are again noted, but evaluated on the current study. Preprocedure non-contrast limited study of the pelvis confirmed the presence of multiple extracolonic fluid collections lying in close proximity to the sigmoid colon. Cirrhosis with splenomegaly, perisplenic varices, and trace ascites. The right PICC has been removed. COMPARISON: Comparison is made to chest PA and lateral radiograph obtained . There are scattered lymph nodes in the retroperitoneum and mesentery, which appear similar compared to prior, and could be reactive. Decrease of left lower lung opacity representing combination of pleural effusion with adjacent atelectasis. Insertion was felt necc. due to sinogram from abscess access showing opacification of the sigmoid colon and rectum indicating persistent bowel perforation. There are three persistent fluid collection in the pelvis, which appear similar in size and distribution compared to prior MR. (Over) 6:01 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval known intra-abdominal abscesses FINAL REPORT (Cont) The most posterior collection measures 2.5 x 2.0, and the more anterior intrapelvic collection measures 2.3 x 2.7. There is a similar appearance of the hypodense lesion in the spleen, evaluated on the current scan. Decreased left lower lung atelectasis and pleural effusion. Decreased left lower lung atelectasis and pleural effusion. Decreased left lower lung atelectasis and pleural effusion. FINDINGS: Left-sided PICC line with tip in azygos vein. Recommend withdrawing 2 to 3 cm to reach left brachiocephalic vein. Recommend withdrawing 2 to 3 cm to reach left brachiocephalic vein. Recommend withdrawing 2 to 3 cm to reach left brachiocephalic vein. Sinus bradycardia. Left-sided PICC line with tip now positioned at upper superior vena cava. s/p PICC line insertion at bedside, however PICC nurse reports line is in azygous vein and needs repositioning. Coronal and sagittal reformations were provided. The patient is status post cholecystectomy. Following this, a dilute intravenous contrast was injected via the needle and the pelvis was rescanned. CT shows persistent abdominal abscesses. Left heart border obscured by left lower lung opacity. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. Clinicalcorrelation is suggested. Cholecystectomy clips are noted in the right upper quadrant of the abdomen. TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling left arm PICC line, and subsequently into the SVC under fluoroscopic guidance. IMPRESSION: Left PICC line with tip at upper SVC. OSSEOUS STRUCTURES: There is a sclerotic lesion in the right sacrum, which was enhancing on prior MR , concerning for neoplastic involvement. Multiple cystic pancreatic lesions appear grossly similar although characterized. Oral contrast is seen all the way down to the rectum. 2.4 x 2.0 right paralabial soft tissue density nodule is again noted, unchanged. TECHNIQUE: CT abdomen and pelvis without IV contrast (unable to obtain IV line), and with oral contrast. PFI REPORT Left PICC line with tip at upper SVC. Delayed R wave progression.Precordial lead T wave abnormalities. A tortuous vessel was opacified, most likely representing the azygos vein, however, subsequently a wire was passed through the PICC line into the brachiocephalic vein into the SVC. The urinary bladder appears tethered at the dome to the area of adjacent pelvic inflammation and fluid collections. 6:01 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval known intra-abdominal abscesses MEDICAL CONDITION: 75F s/p bowel resection c/b recurrent intra-abdominal abscesses p/w fever, hypotension x3d from Heb Reb REASON FOR THIS EXAMINATION: eval known intra-abdominal abscesses No contraindications for IV contrast WET READ: IPf SAT 7:41 PM -persistent rim enhancing fluid collection in the pelvis similar to recent MRI -ongoing sigmoid inflammation -no bowel obstruction FINAL REPORT HISTORY: 75-year-old woman with status post bowel resection in with recurrent intrapelvic abscess, presents with fever, hypotension for three days from rehab. | 10 | [
{
"category": "Radiology",
"chartdate": "2109-09-16 00:00:00.000",
"description": "DRAINAGE HEMATOMA/FLUID",
"row_id": 1153277,
"text": " 12:34 PM\n DRAINAGE HEMATOMA/FLUID; CT GUIDANCE DRAINAGE Clip # \n Reason: ?abscess with possible fistula tract to bowel\n Admitting Diagnosis: ABDOMINAL ABCESS\n ********************************* CPT Codes ********************************\n * DRAINAGE HEMATOMA/FLUID CT GUIDANCE DRAINAGE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with Crohn's disease s/p multiple procedures, most recently\n IR drainage of abdominal abscess in presents with fever, hypotension\n with positive blood cultures. CT shows persistent abdominal abscesses.\n REASON FOR THIS EXAMINATION:\n ?abscess with possible fistula tract to bowel\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED ABSCESS DRAIN\n\n INDICATION: 75-year-old woman with Crohn's disease and recurrent pelvic\n abscesses.\n\n FINDINGS/PROCEDURE:\n\n Following discussion of the risks, benefits and alternatives to the procedure,\n informed written patient consent was obtained. The patient was brought to the\n department and placed supine on the scanner. Preprocedure non-contrast\n limited study of the pelvis confirmed the presence of multiple extracolonic\n fluid collections lying in close proximity to the sigmoid colon.\n\n A preprocedure timeout was performed using three patient identifiers.\n Moderate conscious sedation was provided by the nursing staff for a total\n intraservice time of 45 minutes.\n\n The skin was prepped and draped in the usual sterile fashion. \n 10 cc of 1% lidocaine was infiltrated into the skin and subcutaneous tissues\n for local anesthesia. The needle was passed into the collection and\n its position confirmed using CT fluoroscopy. 4 cc of\n blood-tinged turbid fluid was aspirated and sent for culture and sensitivity.\n Following this, a dilute intravenous contrast was injected via the \n needle and the pelvis was rescanned. This demonstrated contrast opacifying\n the sigmoid colon and rectum and confirmed continued communication between the\n bowel and the pelvic collections. Therefore, we proceeded to insert an 8\n French catheter to JP suction drainage of the collection.\n 30 cc of blood-tinged turbid fluid was aspirated. The \n catheter has been left on a JP bulb drain to improve drainage. There were no\n immediate post-procedure complications.\n\n Dr. , the attending radiologist, was present throughout and\n performed the procedure.\n\n IMPRESSION:\n\n (Over)\n\n 12:34 PM\n DRAINAGE HEMATOMA/FLUID; CT GUIDANCE DRAINAGE Clip # \n Reason: ?abscess with possible fistula tract to bowel\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Technically successful insertion of an 8 French pigtail drain into a\n pelvic collection. Insertion was felt necc. due to sinogram from abscess\n access showing opacification of the sigmoid colon and rectum indicating\n persistent bowel perforation. Dr. informed of the results at 5 p.m.\n on (medical resident).\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-16 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1153328,
"text": " 3:48 PM\n PICC LINE REPLACEMENT Clip # \n Reason: ?repositioning of PICC line\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt: 10\n This is a power pick\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with Crohns disease s/p multiple abdominal procedures\n presents with fevers and hypotension. s/p PICC line insertion at bedside,\n however PICC nurse reports line is in azygous vein and needs repositioning.\n (fyi for scheduling: Patient will be going to IR for abdominal study to\n determine if an abscess has fistula tract to bowel today)\n REASON FOR THIS EXAMINATION:\n ?repositioning of PICC line\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE EXCHANGE\n\n INDICATION: Malposition of indwelling PICC line.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling left arm PICC line, and subsequently into the\n SVC under fluoroscopic guidance. About 10 cc of Optiray IV contrast was\n administered to demonstrate venous anatomy. A tortuous vessel was opacified,\n most likely representing the azygos vein, however, subsequently a wire was\n passed through the PICC line into the brachiocephalic vein into the SVC. The\n old PICC line was then removed and a peel-away sheath was then placed over the\n guidewire. A new double lumen Power PICC line measuring 35.5 cm in length was\n then placed through the peel-away sheath with its tip positioned in the SVC\n under fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a\n new 5 French double lumen PICC line. Final internal length is 35.5 cm, with\n the tip positioned in the SVC. The line is ready to use.\n (Over)\n\n 3:48 PM\n PICC LINE REPLACEMENT Clip # \n Reason: ?repositioning of PICC line\n Admitting Diagnosis: ABDOMINAL ABCESS\n Contrast: OPTIRAY Amt: 10\n This is a power pick\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-14 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1153058,
"text": " 6:01 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval known intra-abdominal abscesses\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75F s/p bowel resection c/b recurrent intra-abdominal abscesses p/w fever,\n hypotension x3d from Heb Reb\n REASON FOR THIS EXAMINATION:\n eval known intra-abdominal abscesses\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SAT 7:41 PM\n -persistent rim enhancing fluid collection in the pelvis similar to recent MRI\n -ongoing sigmoid inflammation\n -no bowel obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman with status post bowel resection in \n with recurrent intrapelvic abscess, presents with fever, hypotension for three\n days from rehab. Patient has known intra-abdominal abscesses.\n\n TECHNIQUE: CT abdomen and pelvis without IV contrast (unable to obtain IV\n line), and with oral contrast. Coronal and sagittal reformations were\n provided.\n\n COMPARISON: MR , and multiple CTs, last one done\n .\n\n FINDINGS: Left trace pleural effusion is noted as well as atelectasis at the\n lung bases.\n\n Nodular contour of the liver is redemonstrated in keeping with patient's known\n history of cirrhosis. Liver lesions seen on prior MR \n evaluated due to lack of IV contrast, A hypodense lesion in the left liver\n lobe is similar to prior and measures 2 cm, (2:10). There is persistent\n splenomegaly as seen on prior. The pancreatic cystic lesions are again noted,\n but evaluated on the current study. The patient is status post\n cholecystectomy. There is no intra- or extra-hepatic biliary duct dilatation.\n There is evidence of perisplenic varices. There is small volume ascites.\n There is a similar appearance of the hypodense lesion in the spleen,\n evaluated on the current scan. There is no free air.\n\n There is no evidence of bowel obstruction. Oral contrast is seen all the way\n down to the rectum. There are scattered lymph nodes in the retroperitoneum\n and mesentery, which appear similar compared to prior, and could be reactive.\n\n CT PELVIS: There is thickening of the sigmoid as described on prior MR\n , and moderate fat stranding, suggesting ongoing inflammation of\n the sigmoid colon. There is tethering of the sigmoid to an adjacent fluid\n collection, (2:63), in a region of previously known fistula, and although no\n direct fistulous tract is demonstrated on the current scan, and persistent\n fistulous tract is likely. There are three persistent fluid collection in the\n pelvis, which appear similar in size and distribution compared to prior MR.\n (Over)\n\n 6:01 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval known intra-abdominal abscesses\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The most posterior collection measures 2.5 x 2.0, and the more anterior\n intrapelvic collection measures 2.3 x 2.7. There is a third smaller collection\n in the anterior abdominal wall at the site of the prior draninage catheter\n measuring 1.2 x 2.1 cm. There is moderate fat stranding in the pelvis in\n keeping with ongoing inflammation. The urinary bladder appears tethered at\n the dome to the area of adjacent pelvic inflammation and fluid collections.\n The patient has a persistent hernia at the left lower abdominal wall with\n small bowel loops and some fluid; however, no evidence of obstruction at this\n level. 2.4 x 2.0 right paralabial soft tissue density nodule is again noted,\n unchanged.\n\n OSSEOUS STRUCTURES: There is a sclerotic lesion in the right sacrum, which\n was enhancing on prior MR , concerning for neoplastic involvement.\n\n IMPRESSION:\n 1. Persistent fluid collections in the pelvis, similar in size and\n distribution compared to most recent MR, with adjacent inflammatory changes in\n the surrounding fat.\n 2. Persistent sigmoid wall thickening, with adjacent fat stranding,\n suggesting ongoing inflammation. While no discrete fistula can be confirmed\n on this study, the tethered appearance of the sigmoid colon to the pelvic\n fluid collections suggests the presence of a fistula.\n 3. No evidence of bowel obstruction with oral contrast reaching the rectum.\n 4. Cirrhosis with splenomegaly, perisplenic varices, and trace ascites.\n Multiple known liver lesions are suboptimally evaluated on non-contrast CT\n scan. Please refer to prior MR for further details.\n 5. Multiple cystic pancreatic lesions appear grossly similar although\n characterized.\n 6. Right sacral sclerotic lesion corresponding to an area of enhancement of\n the prior MR. Biopsy was recommended as stated on the prior MR report.\n 7. Stable large left lower abdominal wall hernia containing loops of small\n bowel and fluid; however, no evidence of obstruction at this level.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1153253,
"text": " 10:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 42 cm Picc placed in left basilic vein, need Picc tip placem\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 42 cm Picc placed in left basilic vein, need Picc tip placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec MON 1:07 PM\n Left-sided PICC line with tip in azygos. Recommend withdrawing 2 to 3 cm to\n reach left brachiocephalic vein. Increased left lower lobe atelectasis and\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with left basilic vein PICC placement, please\n evaluate tip.\n\n TECHNIQUE: Chest portable film obtained.\n\n COMPARISON: Comparison is made to chest PA and lateral radiograph obtained\n .\n\n FINDINGS: Left-sided PICC line with tip in azygos vein. Increased left lower\n lobe atelectasis and effusion, now moderate in size. No pneumothorax.\n Mediastinal, hilar and cardiac silhouettes are unremarkable.\n\n IMPRESSION: Left-sided PICC line with tip in the azygos. Recommend\n withdrawing 2 to 3 cm to reach left brachiocephalic vein. Increased left\n lower lobe atelectasis and effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1153595,
"text": " 9:21 AM\n CHEST (PA & LAT) Clip # \n Reason: effusion? PNA?\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new cough. admitted w/ intraabdominal abscesses\n REASON FOR THIS EXAMINATION:\n effusion? PNA?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PBec WED 11:42 AM\n Left PICC line with tip at upper SVC. Decreased left lower lung atelectasis\n and pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old woman with new cough, currently admitted for\n intra-abdominal abscess, concern for effusion or pneumonia.\n\n TECHNIQUE: Chest PA and lateral radiograph obtained.\n\n COMPARISON: Comparison is made to portable chest film obtained .\n\n FINDINGS: Stable mild right lung base atelectasis. Decrease of left lower\n lung opacity representing combination of pleural effusion with adjacent\n atelectasis. Left-sided PICC line with tip now positioned at upper superior\n vena cava. No pneumothorax. The mediastinal and hilar contours are\n unremarkable. Left heart border obscured by left lower lung opacity.\n\n IMPRESSION: Left PICC line with tip at upper SVC. Decreased left lower lung\n atelectasis and pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1153596,
"text": ", MED SICU-B 9:21 AM\n CHEST (PA & LAT) Clip # \n Reason: effusion? PNA?\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new cough. admitted w/ intraabdominal abscesses\n REASON FOR THIS EXAMINATION:\n effusion? PNA?\n ______________________________________________________________________________\n PFI REPORT\n Left PICC line with tip at upper SVC. Decreased left lower lung atelectasis\n and pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1153254,
"text": ", MED SICU-B 10:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 42 cm Picc placed in left basilic vein, need Picc tip placem\n Admitting Diagnosis: ABDOMINAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 42 cm Picc placed in left basilic vein, need Picc tip placement\n ______________________________________________________________________________\n PFI REPORT\n Left-sided PICC line with tip in azygos. Recommend withdrawing 2 to 3 cm to\n reach left brachiocephalic vein. Increased left lower lobe atelectasis and\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1153041,
"text": " 2:38 PM\n CHEST (PA & LAT) Clip # \n Reason: eval PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with hx fever\n REASON FOR THIS EXAMINATION:\n eval PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n COMPARISON: .\n\n UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The heart remains mildly enlarged\n with a left ventricular predominance. The mediastinal and hilar contours are\n unchanged. The right PICC has been removed. There is a small left pleural\n effusion, which appears new in the interval, with a patchy opacity noted in\n the retrocardiac region. Additionally, within the right lung base, there is\n an ill-defined opacity seen. Pulmonary vascularity is not engorged. There is\n no pneumothorax. Cholecystectomy clips are noted in the right upper quadrant\n of the abdomen. There are no acute osseous findings.\n\n IMPRESSION: Small left pleural effusion with bibasilar patchy airspace\n opacities, which could represent infection or atelectasis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2109-09-15 00:00:00.000",
"description": "Report",
"row_id": 291963,
"text": "Sinus bradycardia. Generalized low voltages. Delayed R wave progression.\nPrecordial lead T wave abnormalities. Findings are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of sinus\nbradycardia and low voltages are now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-09-14 00:00:00.000",
"description": "Report",
"row_id": 291964,
"text": "Sinus rhythm. Poor R wave progression with non-specific T wave inversion in\nleads V1-V3. Clinical correlation is suggested. Compared to the previous\ntracing of the QRS change in lead V4 is probably due to lead\nplacement.\n\n"
}
] |
15,965 | 148,520 | Upon transfer to , the patient underwent cardiac catheterization which showed 2 vessel disease (LAD totally occluded proximally and mid RCA 70% stenosis). LAD was stented with 3.0 x 23 mm Cypher stent, and a jailed diagonal branch was rescued with a 1.5 mm ACE balloon. Final TIMI 2+ flow. The patient was then admitted to the CCU service. 1. CAD - The patient was started on Aspirin, Plavix, Lipitor, Metoprolol, Captopril. She remained on integrilin drip for 18 hours following catheterization and then was continued on heparin drip. She had remained angina-free for the remainder of her hospital stay. She had no new EKG changes and no significant events on telemetry. Beta-blocker and ACE inhibitor doses were gradually maximized based on blood pressure and heart rate. Metoprolol and Capropril were then changed to the corresponding once daily doses of Toprol XL 150 mg po qd and Lisinopril 10 mg po qd on the day of discharge. The patient's blood pressures were checked prior to her discharge and were in 120/80 range. Lipid panel was checked. LDL and total CHOL came back high, 157 and 281, respectively. LFTs were WNL except AST elevation that was thought to be related to release of enzymes from the myocardium. Her right groin site checks revealed no complications. 2. CHF - Echocardiogram revealed EF 35-40% with septal, distal anterior and apikal akinesis. Based on the echo results, it was felt that 8 weeks of oral anticoagulation are indicated for this patient. The patient was started on Coumading 5 mg po qd and was bridged with unfractionated heparin during her hospitalization. On the day of discharge her INR was still subtherapeutic 1.1. She was discharged home with Coumadin and was instructed to have her INR checked in 2 days and Coumadin dose adjusted by Dr. . 3. Disposition and follow up - The patient was discharged home with visiting nurse services who will be following her BP. Follow up appointment with Dr. (her new PCP) was scheduled for . The patient was given a prescription slip to have her INR and K level checked prior to her appointment with Dr. . We emphasized to the patient the importance of follow up for her coumadin dose adjustment. She will also need follow up LFT checks as she was started on Lipitor. The follow up appointment with Dr. , cardiologist in , was also made for the patient. She will need a repeat echocardiogram in one month after discharge. We discusse physical activity limitations with the patient and her daughter over the phone. | Overall left ventricular systolic functionis moderately depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anteroseptal - akinetic; mid anteroseptal -akinetic; basal inferoseptal - hypokinetic; mid inferoseptal - akinetic;anterior apex - akinetic; septal apex- akinetic; apex - akinetic;RIGHT VENTRICLE: The right ventricular wall thickness is normal. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: Physiologic tricuspid regurgitation is seen. Resting regional wall motion abnormalities include septal anddistal anterior and apical akinesis..3.Right ventricular chamber size is normal. /WMA s/p cath w/ LAD stentHeight: (in) 60Weight (lb): 181BSA (m2): 1.79 m2BP (mm Hg): 97/62HR (bpm): 74Status: InpatientDate/Time: at 08:52Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. "O-CV: HR 72-89, NSR with rare PVCs, K 5.1 and Mg 2.4, slightly hemolyzed. Overall left ventricular systolic function is moderatelydepressed. Left anteriorfascicular block. Right ventricular systolic function isnormal.AORTA: The aortic root is normal in diameter. Prior inferior myocardial infarction. The estimatedpulmonary artery systolic pressure is normal.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Image quality was suboptimal.Conclusions:1. Denies chest pain and back pain.MS:A/O/X/3. Left atrial abnormality. Sinus arrhythmiaLeft axis deviation - anterior fascicular blockAnteroseptal infarct - age indeterminatePossible old inferior infarctGeneralized low QRS voltagesSince previous tracing of , no significant change Anterolateral myocardialinfarction with ST-T wave configuration consistent with acute process. Left axis deviation - consider prior inferiormyocardial infarction and left anterior fascicular block. Left axis deviation.Consider prior inferior myocardial infarction and left anterior fascicularblock. Leftaxis deviation - consider prior inferior myocardial infarction and leftanterior fascicular block. Prior anteroseptal andlateral myocardial infarction. The ascending aorta is normal indiameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Ventricular premature beat. Denies nausea. Right ventricular systolicfunction is normal.4.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation.5.The mitral valve leaflets are mildly thickened. Right groin CDI with DSD in place. The left ventricular cavitysize is normal. Mild (1+) mitralregurgitation is seen.6.The estimated pulmonary artery systolic pressure is normal.7..There is no pericardial effusion. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Anterolateral myocardial infarction with ST-T wve configurationconsistent with an acute process. BLEs cool and pale with palpable pulses throughout. Compared to the previous tracing of atrial ectopy is no longer recorded. Denies shortness of breath. The leftventricular cavity size is normal. No BM.ACC: Left AC PIV removed secondary to infiltrated. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Resolved with repositioning.RESP:Breath sounds diminished at bases and occasionally throughout.RR 15-22 and O2Sats 95-97% on 6LNP. At MN even I/O. C/o coccyx discomfort. Rightventricular chamber size is normal. Abd obese and soft with (+) BSs time four quadrants. The left atrium is normal in size.2.Left ventricular wall thicknesses are normal. Clinical correlationis suggested. "O- see flowsheet for all objective data.cv- Tele: SR with occ-freq PVC's- B/P 111-125/59-69- c/o back pain upon adm to CCU- no N/V- no diaphoresis- EKG unchanged- Ntg SL X2& morphine 2mg IV given with relief of pain- tolerated captopril & lopressor- filling pressures high when cathed- PCWP 27- lasix 20mg IV ordered & given- diuresing well- K 4.3- Mg 1.8 Mg sulfate 2gm IV givenHct 41.6 Plts 302 WBC 15.8- CPK 2855 MB 388- arterial & venous sheaths removed from R groin- dsg D&I- (+) palpable DP & PT pulses- integrelin gtt @ 12cc/hr or 2mcq/kg/min.resp- In O2 5L via NC- lung sounds diminished bilaterally- RR 18-22- SpO2 91-95%- sat's improved once diuresed.gi- abd large soft (+) bowel sounds- taking PO liquids with incident-no BM today- glu 277gu- foley draining pale to clear colored urine- I&O essentially equal @ present- BUN 10 Crea .6- post cath hydration D5.45S @ 100cc/hr X2 liters- first liter infusing @ present.neuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.dispo- Full codeIV access- 2 peripheral IV's- one on each arm.A- (+) AMI S/P cardiac cath with PTCA LAD with stent & diag branch rescueP- monitor vs, lung sounds, I&O and labs- repeat blood work @ 2100- EKG with c/o CP- increase ace inhibitor & beta blocker as tolerated-offer emotional support to Pt & family- keep them updated on plan of care. Low limb lead voltage. 2nd PIV in arm remains intact with some old blood at hub portion but flushes with some return.A/P: AMI s/p stent placement to LAD doing fairContinue to titrate BB and ACE per orders.Monitor I/O carefullyFollow CKMBs throughout dayTitrate Heparin per protocol and check PTTsCardiac echo as early at tommorow Left hand 20 guage inserted. Heparin to start at 700 units/hr without bolus. CK 3680(2955). Anterolateral myocardial infarction with ST-T wave configurationconsistent with acute/recent/in evolution process. BPs 118-129/55-61, MAPs 72-89. MB pending(382). Integrillin at 2mcgs/kg/min. Otherwise, no diagnostic interim change. CCU Nursing Progress Note:S-"I feel much better than earlier! to be done in wks.S- "MY back hurts! Since the previous tracing earlier this date no significantchange.TRACING #2 Clinical correlation is suggested. Clinical correlation is suggested. Goal is to keep even. No previoustracing available for comparison.TRACING #1 Asking appropriate questions in regards to medications taken. Heparin to start when Intergrillin discontinued at 0715 AM. No hematoma palpated. HUOs since diuresis, 40cc/hr. Skin warm and dry to touch. Since the previous tracing of further ST-T wave changes suggest evolution pattern of infarction.TRACING #3 Recieving 500cc of post cath fluid and then discontinued at 2200. Breathing unlabored and coordinate.GU/GI: Foley patent and draining yellow to clear yellow urine with diuresis. MAEs on and off of bed. Cooperative and pleasant with care. Given 10mg of Lasix IVP at 2200 with good response. CCU Progress Note:This is a 74 yr old women with no PMHx who presented to OSH with C/O 24hr neck/shoulder/back pain- (+) diaphoresis (+) N/ transferred to for emergent cardiac cath- cath revealved 2VD- PTCA to LAD done with stent placement & diag branch rescue- 70% RCA stenosis ? | 8 | [
{
"category": "Echo",
"chartdate": "2173-08-02 00:00:00.000",
"description": "Report",
"row_id": 76933,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. /WMA s/p cath w/ LAD stent\nHeight: (in) 60\nWeight (lb): 181\nBSA (m2): 1.79 m2\nBP (mm Hg): 97/62\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 08:52\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis moderately depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - akinetic; mid anteroseptal -\nakinetic; basal inferoseptal - hypokinetic; mid inferoseptal - akinetic;\nanterior apex - akinetic; septal apex- akinetic; apex - akinetic;\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Physiologic tricuspid regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Image quality was suboptimal.\n\nConclusions:\n1. The left atrium is normal in size.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is moderately\ndepressed. Resting regional wall motion abnormalities include septal and\ndistal anterior and apical akinesis..\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation.\n5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n6.The estimated pulmonary artery systolic pressure is normal.\n7..There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-04 00:00:00.000",
"description": "Report",
"row_id": 185383,
"text": "Sinus rhythm. Left atrial abnormality. Low limb lead voltage. Left anterior\nfascicular block. Prior inferior myocardial infarction. Prior anteroseptal and\nlateral myocardial infarction. Compared to the previous tracing of \natrial ectopy is no longer recorded. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-03 00:00:00.000",
"description": "Report",
"row_id": 185384,
"text": "Sinus arrhythmia\nLeft axis deviation - anterior fascicular block\nAnteroseptal infarct - age indeterminate\nPossible old inferior infarct\nGeneralized low QRS voltages\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-02 00:00:00.000",
"description": "Report",
"row_id": 185385,
"text": "Sinus rhythm. Anterolateral myocardial infarction with ST-T wave configuration\nconsistent with acute/recent/in evolution process. Left axis deviation.\nConsider prior inferior myocardial infarction and left anterior fascicular\nblock. Clinical correlation is suggested. Since the previous tracing of \nfurther ST-T wave changes suggest evolution pattern of infarction.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2173-07-31 00:00:00.000",
"description": "Report",
"row_id": 185386,
"text": "Sinus rhythm. Anterolateral myocardial infarction with ST-T wve configuration\nconsistent with an acute process. Left axis deviation - consider prior inferior\nmyocardial infarction and left anterior fascicular block. Clinical correlation\nis suggested. Since the previous tracing earlier this date no significant\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2173-07-31 00:00:00.000",
"description": "Report",
"row_id": 185387,
"text": "Sinus rhythm. Ventricular premature beat. Anterolateral myocardial\ninfarction with ST-T wave configuration consistent with acute process. Left\naxis deviation - consider prior inferior myocardial infarction and left\nanterior fascicular block. Clinical correlation is suggested. No previous\ntracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-07-31 00:00:00.000",
"description": "Report",
"row_id": 1470134,
"text": "CCU Progress Note:\n\nThis is a 74 yr old women with no PMHx who presented to OSH with C/O 24hr neck/shoulder/back pain- (+) diaphoresis (+) N/ transferred to for emergent cardiac cath- cath revealved 2VD- PTCA to LAD done with stent placement & diag branch rescue- 70% RCA stenosis ? to be done in wks.\n\nS- \"MY back hurts!\"\n\nO- see flowsheet for all objective data.\n\ncv- Tele: SR with occ-freq PVC's- B/P 111-125/59-69- c/o back pain upon adm to CCU- no N/V- no diaphoresis- EKG unchanged- Ntg SL X2\n& morphine 2mg IV given with relief of pain- tolerated captopril & lopressor- filling pressures high when cathed- PCWP 27- lasix 20mg IV ordered & given- diuresing well- K 4.3- Mg 1.8 Mg sulfate 2gm IV given\nHct 41.6 Plts 302 WBC 15.8- CPK 2855 MB 388- arterial & venous sheaths removed from R groin- dsg D&I- (+) palpable DP & PT pulses- integrelin gtt @ 12cc/hr or 2mcq/kg/min.\n\nresp- In O2 5L via NC- lung sounds diminished bilaterally- RR 18-22- SpO2 91-95%- sat's improved once diuresed.\n\ngi- abd large soft (+) bowel sounds- taking PO liquids with incident-\nno BM today- glu 277\n\ngu- foley draining pale to clear colored urine- I&O essentially equal @ present- BUN 10 Crea .6- post cath hydration D5.45S @ 100cc/hr X2 liters- first liter infusing @ present.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\n\ndispo- Full code\n\nIV access- 2 peripheral IV's- one on each arm.\n\nA- (+) AMI S/P cardiac cath with PTCA LAD with stent & diag branch rescue\n\nP- monitor vs, lung sounds, I&O and labs- repeat blood work @ 2100- EKG with c/o CP- increase ace inhibitor & beta blocker as tolerated-\noffer emotional support to Pt & family- keep them updated on plan of care.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2173-08-01 00:00:00.000",
"description": "Report",
"row_id": 1470135,
"text": "CCU Nursing Progress Note:\nS-\"I feel much better than earlier!\"\n\nO-CV: HR 72-89, NSR with rare PVCs, K 5.1 and Mg 2.4, slightly hemolyzed. BPs 118-129/55-61, MAPs 72-89. Captopril increased to 25mg TID for AM dose. CK 3680(2955). MB pending(382). Integrillin at 2mcgs/kg/min. Heparin to start when Intergrillin discontinued at 0715 AM. Heparin to start at 700 units/hr without bolus. PTT to be done 6-8hrs post start. Right groin CDI with DSD in place. No hematoma palpated. BLEs cool and pale with palpable pulses throughout. Skin warm and dry to touch. Denies chest pain and back pain.\n\nMS:A/O/X/3. Cooperative and pleasant with care. Asking appropriate questions in regards to medications taken. MAEs on and off of bed. C/o coccyx discomfort. Resolved with repositioning.\n\nRESP:Breath sounds diminished at bases and occasionally throughout.RR 15-22 and O2Sats 95-97% on 6LNP. Denies shortness of breath. Breathing unlabored and coordinate.\n\nGU/GI: Foley patent and draining yellow to clear yellow urine with diuresis. Given 10mg of Lasix IVP at 2200 with good response. Goal is to keep even. At MN even I/O. Recieving 500cc of post cath fluid and then discontinued at 2200. HUOs since diuresis, 40cc/hr. Abd obese and soft with (+) BSs time four quadrants. Taking sip of water and ice chips. Denies nausea. No BM.\n\nACC: Left AC PIV removed secondary to infiltrated. Left hand 20 guage inserted. 2nd PIV in arm remains intact with some old blood at hub portion but flushes with some return.\n\nA/P: AMI s/p stent placement to LAD doing fair\n\nContinue to titrate BB and ACE per orders.\nMonitor I/O carefully\nFollow CKMBs throughout day\nTitrate Heparin per protocol and check PTTs\nCardiac echo as early at tommorow\n\n\n"
}
] |
974 | 132,333 | During the hospital course, the patient remained stable. The patient was treated with ibuprofen for his pericarditis. He was evaluated by the Psychiatry Service who recommended holding all of his psychiatric medications while trying to clarify his diagnosis. The patient denied suicidal ideation for the remainder of his hospital course. He was contracted for safety. He was continued on his antiretroviral therapy for his human immunodeficiency virus and Dapsone for prophylaxis. He was thought to have sick euthyroid syndrome with a normal T4 and an elevated thyroid-stimulating hormone. He was screened for a diagnosis program to treat substance abuse as well as his depression. | Trivialmitral regurgitation is seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. BS CLEAR.CARDIAC: HR 76-97 SR, NO ECTOPY. Trivial mitral regurgitation is seen. No SOB, light headedness,pressure, jaw pain assoc w/ CP.ID/GI- Afebrile. Pericardial effusion.Height: (in) 70Weight (lb): 160BSA (m2): 1.90 m2BP (mm Hg): 111/55Status: InpatientDate/Time: at 12:02Test: Portable TTE(Complete)Doppler: Focused pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The mediastinal and hilar contours are unchanged in the interval. Normal appendix. Sinus rhythmNormal ECGSince last ECG, no significant change The leftventricular cavity size is normal. Tx to CCU for R/O MISee Admission FHPA for details.Neuro-A& O x3, tired, cooperative, no slurred speech, MAE, no tremors, no vis/ hallucinations. The left ventricular cavity size is normal. Regional left ventricularwall motion is normal. The mitral valve leaflets arestructurally normal. There is nopericardial effusion. Right ventricular chamber size and free wall motion are normal.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are structurally normal. AP SEMI-UPRIGHT CHEST RADIOGRAPH: The heart size is within normal limits, given technique. The appendix is normal. Overall left ventricular systolic function is normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. IMPRESSION: Stable appearance of the chest. Left ventricular wall thicknesses arenormal. Regional left ventricular wall motion isnormal. CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases are clear. CP- lsft chest, tingling/aching, ^ w/ movement, controlled w/ MSO4 2mg IV q 2h. CT OF THE PELVIS WITH IV CONTRAST: The distal ureters and bladder are normal in appearance. The stomach, small and large bowel loops are normal in appearance. FIRM & DISTENDED. There is a small pericardial effusion. There no ureteral obstruction. BS+. The lungs are clear with no infiltrates or effusions. ABD CT done this pm, prelim read by surgery- no evidence of inflammed appendix. Sinus rhythmST-T wave configuration suggest early repolarization pattern but clinicalcorrelation is suggested for possible pericarditis/injurySince previous tracing of the same date: no significant change No significant retroperitoneal lymphadenopathy. Sinus rhythmST-T wave configuration suggests early repolarization pattern but clinicalcorrelation is suggested for possible pericarditis/injurySince previous tracing of the same date: no significant change No pneumothorax. There are no pleural effusions. Lungs clear, sat 95-96% on RA. The pulmonary vascularity is normal with no evidence of failure. The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys are normal in appearance. BONE WINDOWS: No suspicious lytic or blastic lesions. (#1)CK 3163 WITH MB 67 & TROPONIN 0.5, (#2)CK 1663 WITH MB 35 & TROPONIN <0.3, (#3)CK DUE AT 0800.GI: DENIES NAUSEA. The rectosigmoid colon is unremarkable. Overall left ventricular systolic function is normal(LVEF>55%). PERICARDITIS. MG 1.9. No evidence of cardiac failure or infiltrate. Myocardial infarction. IMPRESSION: No evidence for appendicitis. K 3.6->KCL 40MEQ PO X1. BP 84-114/36-57. Antivirals ordered and approp rx given. No aortic regurgitation is seen. No rib fractures identified. D51/2NS INFUSING AT 100CC/HR X2L(2nd L HANGING). Pt is approp FCCV- 115-130/50-60, HR 80-100 w/ activity. NO STOOL.GU: VOIDING QS CLEAR YELLOW URINE.ID: AFEBRILE.AM LABS TO BE DONE WITH CK AT 0800.PLAN: R/O FOR MI--PROBABLE PERICARDITIS. PATIENT/TEST INFORMATION:Indication: Left ventricular function. NEURO: A&O X3. RR 11-21. RECEIVING MSO4 2MG VP Q2HRS PRN (X3 DURING NOC) & MOTRIN 400MG PO Q8HRS ATC. PLEASANT & COOPERATIVE. Sinus rhythmST-T wave configuration suggests early repolarization pattern but clinicalcorrelation is suggested for possible pericarditis/injurySince previous tracing of : percordial T wave changes are less prominent ABD. VSS, Tx w/ Heparin IV-d/c'd in , , MSO4, levofloxacin, flagyl. On po flagyl, levo flox (1st dose given @12 noon in ED) + BS, firm distended, +/- tend, inconsis exam. Pt c/o CP rad to L arm, and RLQ pain. FINAL REPORT HISTORY: Chest pain. COMPARISON: . ? ? ? Please evaluate. Please evaluate. AIR. SLEEPY BUT EASILY AROUABLE. Transfer to See Transfer note for 7a-3p information.Transfered to . Tolerating cl liqs, crackers.Heme- CD4 count added on . There is no free air or free fluid in the abdomen. STATES HAS NOT SLEPT PAST 2 NOCS & IS TRYING TO CATCH UP.RESP: O2 SATS 94-96% ON RM. TRANSFER TO FLOOR TODAY. Will need assistance upon d/c. There is no free air or free fluid in the pelvis. Both kidneys enhance symmetrically. Serial enzymes #2 due 12MN, lytes, thyroid levels drawn. Sinus tachycardiaST-T wave configuration suggests early repolarization pattern but clinicalcorrelation is suggested for possible pericarditis/injuryNo previous tracing for comparison 10:26 AM CHEST (PORTABLE AP) Clip # Reason: 39 yo man with chest pain. TECHNIQUE: Multiple axial images from the lung bases to the pubic symphysis were obtained following the administration of 150 cc of Optiray. REASON FOR THIS EXAMINATION: 39 yo man with chest pain. 2:40 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: RLQ pain, HIV, concern for appendicitis Field of view: 36 Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 39 year old man with HIV, polysusbtance abuse REASON FOR THIS EXAMINATION: RLQ pain, HIV, concern for appendicitis No contraindications for IV contrast FINAL REPORT HISTORY: 39 year old man with HIV and right lower quadrant pain. | 11 | [
{
"category": "Radiology",
"chartdate": "2200-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 787239,
"text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 39 yo man with chest pain. Please evaluate.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with chest pain.\n REASON FOR THIS EXAMINATION:\n 39 yo man with chest pain. Please evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT CHEST RADIOGRAPH: The heart size is within normal limits,\n given technique. The mediastinal and hilar contours are unchanged in the\n interval. The pulmonary vascularity is normal with no evidence of failure.\n The lungs are clear with no infiltrates or effusions. No rib fractures\n identified. No pneumothorax.\n\n IMPRESSION: Stable appearance of the chest. No evidence of cardiac failure\n or infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-05-05 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 787281,
"text": " 2:40 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: RLQ pain, HIV, concern for appendicitis\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with HIV, polysusbtance abuse\n REASON FOR THIS EXAMINATION:\n RLQ pain, HIV, concern for appendicitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39 year old man with HIV and right lower quadrant pain.\n\n TECHNIQUE: Multiple axial images from the lung bases to the pubic symphysis\n were obtained following the administration of 150 cc of Optiray.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases are clear. There are no\n pleural effusions. There is a small pericardial effusion.\n\n The liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys are\n normal in appearance. Both kidneys enhance symmetrically. There no ureteral\n obstruction. There is no free air or free fluid in the abdomen. No\n significant retroperitoneal lymphadenopathy. The stomach, small and large\n bowel loops are normal in appearance. The appendix is normal.\n\n CT OF THE PELVIS WITH IV CONTRAST: The distal ureters and bladder are normal\n in appearance. The rectosigmoid colon is unremarkable. There is no free air\n or free fluid in the pelvis.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions.\n\n IMPRESSION: No evidence for appendicitis. Normal appendix.\n\n"
},
{
"category": "Echo",
"chartdate": "2200-05-05 00:00:00.000",
"description": "Report",
"row_id": 72899,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. ? Myocardial infarction. ? Pericardial effusion.\nHeight: (in) 70\nWeight (lb): 160\nBSA (m2): 1.90 m2\nBP (mm Hg): 111/55\nStatus: Inpatient\nDate/Time: at 12:02\nTest: Portable TTE(Complete)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Trivial\nmitral regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Regional left ventricular\nwall motion is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. Trivial mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-05 00:00:00.000",
"description": "Report",
"row_id": 1274570,
"text": "CCU Nursing Admission Note-\n39y/o w/ hx CAD, MIx2, polysubstance abuse, + HIV, + HEP C, admiited via ED p being trown out of in (dual diagnosis facility) after using crack cocaine. Pt drank and used crack cocaine cont overnight w/ aquantance, dropped off downtown and took bus to ED. Pt c/o CP rad to L arm, and RLQ pain. VSS, Tx w/ Heparin IV-d/c'd in , , MSO4, levofloxacin, flagyl. Tx to CCU for R/O MI\nSee Admission FHPA for details.\n\nNeuro-\nA& O x3, tired, cooperative, no slurred speech, MAE, no tremors, no vis/ hallucinations. Pt is approp FC\n\nCV- 115-130/50-60, HR 80-100 w/ activity. Serial enzymes #2 due 12MN, lytes, thyroid levels drawn. Lungs clear, sat 95-96% on RA. CP- lsft chest, tingling/aching, ^ w/ movement, controlled w/ MSO4 2mg IV q 2h. No SOB, light headedness,pressure, jaw pain assoc w/ CP.\n\nID/GI- Afebrile. On po flagyl, levo flox (1st dose given @12 noon in ED) + BS, firm distended, +/- tend, inconsis exam. ABD CT done this pm, prelim read by surgery- no evidence of inflammed appendix. Tolerating cl liqs, crackers.\n\nHeme- CD4 count added on . Antivirals ordered and approp rx given.\n\n Pt is homeless, last night thrown out of living situation. Will need assistance upon d/c.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-06 00:00:00.000",
"description": "Report",
"row_id": 1274571,
"text": "NEURO: A&O X3. PLEASANT & COOPERATIVE. SLEEPY BUT EASILY AROUABLE.\n STATES HAS NOT SLEPT PAST 2 NOCS & IS TRYING TO CATCH UP.\nRESP: O2 SATS 94-96% ON RM. AIR. RR 11-21. BS CLEAR.\nCARDIAC: HR 76-97 SR, NO ECTOPY. BP 84-114/36-57. C/O L. CHEST PAIN\n RADIATING TO L. SHOULDER () THAT INCREASES WITH MOVEMENT\n & C&DB. RECEIVING MSO4 2MG VP Q2HRS PRN (X3 DURING NOC) &\n MOTRIN 400MG PO Q8HRS ATC. ? PERICARDITIS. D51/2NS INFUSING\n AT 100CC/HR X2L(2nd L HANGING). K 3.6->KCL 40MEQ PO X1. MG\n 1.9. (#1)CK 3163 WITH MB 67 & TROPONIN 0.5, (#2)CK 1663 WITH\n MB 35 & TROPONIN <0.3, (#3)CK DUE AT 0800.\nGI: DENIES NAUSEA. ABD. FIRM & DISTENDED. BS+. NO STOOL.\nGU: VOIDING QS CLEAR YELLOW URINE.\nID: AFEBRILE.\nAM LABS TO BE DONE WITH CK AT 0800.\nPLAN: R/O FOR MI--PROBABLE PERICARDITIS. TRANSFER TO FLOOR TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-05-06 00:00:00.000",
"description": "Report",
"row_id": 1274572,
"text": "Transfer to \nSee Transfer note for 7a-3p information.\nTransfered to .\n\n"
},
{
"category": "ECG",
"chartdate": "2200-05-05 00:00:00.000",
"description": "Report",
"row_id": 176528,
"text": "Sinus rhythm\nST-T wave configuration suggest early repolarization pattern but clinical\ncorrelation is suggested for possible pericarditis/injury\nSince previous tracing of the same date: no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2200-05-05 00:00:00.000",
"description": "Report",
"row_id": 176529,
"text": "Sinus rhythm\nST-T wave configuration suggests early repolarization pattern but clinical\ncorrelation is suggested for possible pericarditis/injury\nSince previous tracing of the same date: no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2200-05-05 00:00:00.000",
"description": "Report",
"row_id": 176530,
"text": "Sinus tachycardia\nST-T wave configuration suggests early repolarization pattern but clinical\ncorrelation is suggested for possible pericarditis/injury\nNo previous tracing for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2200-05-06 00:00:00.000",
"description": "Report",
"row_id": 176526,
"text": "Sinus rhythm\nNormal ECG\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2200-05-06 00:00:00.000",
"description": "Report",
"row_id": 176527,
"text": "Sinus rhythm\nST-T wave configuration suggests early repolarization pattern but clinical\ncorrelation is suggested for possible pericarditis/injury\nSince previous tracing of : percordial T wave changes are less prominent\n\n"
}
] |
28,675 | 157,426 | He was taken to the operating room on where he underwent a CABG x 3. He was transferred to the ICU in critical but stable condition on neo and propofol. He was transfused for HCT 25. He was extubated later that same day. He was transferred to the floor on POD #2. He had some intermittent atrial fibrillation and his lopressor was increased and he was started on amiodarone. He was transfused 1 unit again for hct 22 with increase to 25. He converted to NSR but continued to have intermittent bouts of afib and was started on coumadin. He was ready for discharge home on POD #6 in NSR. Spoke with at Dr. office who agreed to follow coumadin. | Physiologic mitral regurgitation is seen (within normal limits). Normal ascending aortadiameter. Normaldescending aorta diameter. There isno pericardial effusion.POST-BYPASS: Pt is being A paced, and is on an infusion of phenylephrine1. There is a standard appearance of the cardio mediastinal silohuette following median sternotomy. Normal interatrial septum. see flow sheet for access lines.Resp: Ls clear dim at bases, rr20's, is with non prod cough. Trace AR.MITRAL VALVE: Mild mitral annular calcification. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal aortic arch diameter. Plavix and asa given per pa despite low hct/ oozy chest tubes. Plan to monitor closely.OGT drained minimal bilious. Simple atheroma in aortic arch. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for CABGHeight: (in) 69Weight (lb): 195BSA (m2): 2.05 m2BP (mm Hg): 134/75HR (bpm): 72Status: InpatientDate/Time: at 11:45Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. 7p-7aneuro: a+ox3, mae, follows commands, pain well controlled w/ po percocet q 4hcv: sr 75-85 w/out ectopy until ~0530->afib 110-160, lopressor 10mg iv x1 & 5mg lopressor iv x1 & magnesium 2mg ivpb->afib 110-140 150mg amio bolus given x1; sbp 85-105, neo gtt not restarted, maps>60; ct draining moderate amounts serosanguineous drainage overnoc; max temp 100.3resp: lungs cta, dim to bases, 91-95% on 4L nc, 02 increased to 6L while lying on right side, but returned to 4L once on left side, now maintaining sats >95% on 4L nc, expectorating small amounts thick yellow sputumgi: abdomen soft, hypoactive bowel sounds, fingersticks ssri, tolerating clear liquids overnocgu: foley to gravity draining clear yellow urinelabs: repleted mag/calcium prior to afib, 2mg magnesium sulfate given once in afib; hct dropped from 27 to 24-team awareplan: amio gtt, pulmonary toilet, increase activity as tolerated, po lopressor, transfer to 6 when stable ET tube, left pleural drain, right internal jugular line, and nasogastric tube are in standard placements. Upper denture plate left at bedside.Alert and oriented x 3. There are simple atheroma inthe descending thoracic aorta.5. There are simple atheroma in the aortic arch. STABLE CARDIOMEGALY and parenchymal scarring. Aortic contours are intact post decannulation3. Lungs are grossly clear with minor atelectatic changes of the lung bases. Prominent Eustachian valve (normal variant).LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. PORTABLE SUPINE CHEST, ONE VIEW: Two left chest tubes are in standard position. Bi ventricular function is preserved2. IMPRESSION: Slight improvement in bibasilar atelectasis. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). No MS. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Physiologic TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Neosynephrine to keep sbp >90. Post-operative widening of the cardiomediastinal contours is stable in appearance allowing for differences in technique. Trace aortic regurgitation is seen.6. Thepatient appears to be in sinus rhythm. Right ventricular chamber size and free wall motion are normal.4. The heart size and the cardiomediastinal silhouette is unchanged. ca & magnesium repleted.resp: lungs clear but dim in bases. There is stable appearance of the post-sternotomy wires. P-R interval prolongation.Old inferior wall myocardial infarction. IMPRESSION: AP chest compared to 1:59 a.m.: The enlargement of the postoperative cardiomediastinal silhouette that occurred between 5:50 p.m. on and 1:59 a.m. today is stable. ct drainage>2l sang since or. Sbp 80's on .75mcg of neo, u/o marginal. enc using is, nonproductive cough. Left pleural and at least one midline drain are still in place. ?d/c foley in am. 7a-7pNeuro: Pt a/ox3, mae's follow commands, pt having minimal pain today, percocet with good relief. See flowsheet.Skin: left groin dsg c/d/i, no hematoma. Low blood pressure responsive to volume. On the lateral view, a few small foci of gas are present in the retrosternal region, likely related to recent median sternotomy and coronary bypass surgery procedure. IMPRESSION: Standard postoperative changes of the cardio mediastinum, with no acute cardiopulmonary process. Hct up to 28.5 after blood and again/currently 28.5. Lung volumes are slightly improved, and areas of atelectasis in the left mid and both lower lungs appear minimally improved. related to hypotension. Left pleural and midline drains are still in place. Linear atelectasis in the left lower lobe is new and involving the lateral portion of the lobe with unchanged retrocardiac bibasilar areas of atelectasis. Plan to continue with Neosynephrine to keep sbp >90. see flowsheet.id: tmax 100.4. cefazolin given as ordered.social: no family contact overnight.plan: pain management. Tip of the Swan-Ganz catheter is in the region of the pulmonic valve. Morphine given twice and pain # reduced #. Pt repositioned and reports that he is more comfortable.Glucose to 166. The aortic valve leaflets (3) appear structurally normal with good leafletexcursion. The left atrium is mildly dilated. Resp CarePt from OR s/p CABGX3. He appears comfortable on nasal O2 with sPO2>98%. Chest tubes d/c'd without incident.GI/GU: abd soft, + bs, foley to gravity draining adequate amounts of urineEndo: riss per cvicu protocolSkin: See flowsheetPlan: Rate control with hope to convert to sr, start po amio after drip d/c'd, increasing lopressor dose while maintaining sbp>90. No nose bleeds tonight.Foley draining >100cc/hr. Potassium replacement as noted.Pt c/o sternal incision area discomfort. hct 27.7 & 27.1. aware. Since the previous tracingof inferior Q waves are now more apparent. sat's>95% on 4l nc.gi/gu: abd soft. FINAL REPORT TWO-VIEW CHEST COMPARISON: . Distal extremities warm.Breathsounds clear. Left atrial abnormality. Plan to watch HCT, hourly CT drainage closely. Pt reports frequent L epistaxis. Platelets, FFP, protamine and PEEP used for ^ bleeding. +pp bilat. Drainage at times appeared mostly from patient's L side tubes. Hct 25.0 this am 1 unit prbc's given for low hct, and bleeding overnight from chest tubes. Plan to continue cardiac per fast track policy. Lungs are grossly clear. Labile BP throughout most of the shift. | 15 | [
{
"category": "Radiology",
"chartdate": "2150-11-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990564,
"text": " 5:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate mediastinum for blood\n Admitting Diagnosis: \\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate mediastinum for blood\n ______________________________________________________________________________\n WET READ: AKSb TUE 6:05 PM\n Lines and tubes unchanged. Mediastinum widened, but within expected post-op\n limits and not significantly changed compared to 5 hours prior.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:50 P.M., \n\n HISTORY: Status post CABG, possible mediastinal bleeding.\n\n IMPRESSION: AP chest compared to 12:13 p.m. on :\n\n Bulging contours of the mediastinum at the level of the carina suggest\n increasing mediastinal fluid accumulation, possibly blood. ET tube, left\n pleural drain, right internal jugular line, and nasogastric tube are in\n standard placements. A Swan-Ganz catheter tip projects over the region of the\n pulmonic valve. Lungs are grossly clear. There is no pneumothorax or\n appreciable pleural effusion. Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990616,
"text": " 8:03 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o hemothorax\n Admitting Diagnosis: \\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n r/o hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:27 A.M., :\n\n HISTORY: Otherwise, hemothorax.\n\n IMPRESSION: AP chest compared to 1:59 a.m.:\n\n The enlargement of the postoperative cardiomediastinal silhouette that\n occurred between 5:50 p.m. on and 1:59 a.m. today is stable. As\n before, the differential diagnosis lies between acute cardiac dilatation with\n elevated central venous pressure and hemomediastinum hemopericardium,\n simulating enlargement of the heart. Lungs are low in volume with relatively\n mild left lower lobe atelectasis but clear, with no edema. Left pleural and\n midline drains are still in place. The stomach is moderately distended,\n absent any nasogastric tube. Tip of the Swan-Ganz catheter is in the region\n of the pulmonic valve. No pneumothorax.\n\n and I discussed these findings, at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990822,
"text": " 10:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx s/p ct d/c\n Admitting Diagnosis: \\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval ptx s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after CABG.\n\n Portable AP chest radiograph compared to .\n\n The heart size and the cardiomediastinal silhouette is unchanged. The lung\n volumes remain low also slightly improved compared to the previous study with\n improved ideation of the lung bases. Linear atelectasis in the left lower\n lobe is new and involving the lateral portion of the lobe with unchanged\n retrocardiac bibasilar areas of atelectasis. There is stable appearance of\n the post-sternotomy wires. There is no significant pleural effusion or\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-11-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 991137,
"text": " 5:13 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: \\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n WET READ: JRCi SAT 6:09 PM\n SMALL EFFUSIONS. NO EVIDENCE OF ACUTE CARDIOPULMONARY PROCESS. STABLE\n CARDIOMEGALY and parenchymal scarring. \n\n\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST \n\n COMPARISON: .\n\n INDICATION: Status post CABG.\n\n Post-operative widening of the cardiomediastinal contours is stable in\n appearance allowing for differences in technique. Lung volumes are slightly\n improved, and areas of atelectasis in the left mid and both lower lungs appear\n minimally improved. Small pleural effusions are seen bilaterally. On the\n lateral view, a few small foci of gas are present in the retrosternal region,\n likely related to recent median sternotomy and coronary bypass surgery\n procedure. No apical pneumothorax is identified.\n\n IMPRESSION: Slight improvement in bibasilar atelectasis. Small pleural\n effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-11-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 990503,
"text": " 12:12 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact # if abnormal-will be in\n Admitting Diagnosis: \\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p cabg x3\n REASON FOR THIS EXAMINATION:\n postop film-contact # if abnormal-will be in CVICU approx 12:30\n PM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 67-year-old male status post CABG x3.\n\n COMPARISON: .\n\n PORTABLE SUPINE CHEST, ONE VIEW: Two left chest tubes are in standard\n position. Pulmonary catheter with tip in the proximal main pulmonary artery.\n Tip of NG tube is in stomach. There is a standard appearance of the cardio\n mediastinal silohuette following median sternotomy. Lungs are grossly clear\n with minor atelectatic changes of the lung bases. No pleural effusions.\n\n IMPRESSION: Standard postoperative changes of the cardio mediastinum, with no\n acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 990589,
"text": " 1:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/hi chest tube output-r/o effusion\n Admitting Diagnosis: \\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hi chest tube output-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, , 1:59 A.M.\n\n HISTORY: Increasing chest tube output. Rule out effusion.\n\n IMPRESSION: AP chest compared to earlier on p.m. and 5:50\n p.m.:\n\n Substantial increase in the caliber of the mediastinum, particularly around\n the heart could be due either to fluid or blood accumulation in the\n mediastinum or, alternatively, acute cardiac dilatation and mediastinal\n vascular congestion, coinciding with tracheal extubation. Lungs are lower in\n volume but clear. Small right pleural effusion is new. The stomach is\n distended with air following removal of the nasogastric tube. Left pleural\n and at least one midline drain are still in place. No pneumothorax. Tip of\n the Swan-Ganz line is just beyond the anticipated location of the pulmonic\n valve. Subsequent chest radiograph obtained at 8:27 a.m. and available at the\n time of this dictation, shows no appreciable subsequent change.\n\n"
},
{
"category": "Echo",
"chartdate": "2150-11-03 00:00:00.000",
"description": "Report",
"row_id": 72396,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for CABG\nHeight: (in) 69\nWeight (lb): 195\nBSA (m2): 2.05 m2\nBP (mm Hg): 134/75\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 11:45\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Prominent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mild mitral annular calcification. No MS. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Physiologic TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient. See Conclusions for post-bypass data\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%).\n3. Right ventricular chamber size and free wall motion are normal.\n4. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. Trace aortic regurgitation is seen.\n6. Physiologic mitral regurgitation is seen (within normal limits). There is\nno pericardial effusion.\n\nPOST-BYPASS: Pt is being A paced, and is on an infusion of phenylephrine\n1. Bi ventricular function is preserved\n2. Aortic contours are intact post decannulation\n3. Other findings are unchanged\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-03 00:00:00.000",
"description": "Report",
"row_id": 1635669,
"text": "Op Day CABG\nA paced throughout the shift for slower NSR 70s. Neosynephrine to keep sbp >90. Labile BP throughout most of the shift. Low blood pressure responsive to volume. CI >2.4. Distal extremities warm.\n\nBreathsounds clear. PEEP increased to 10 for CT drainage >100cc hr. Weaned to CPAP later this shift but extubation delayed to get approval from Dr. . Pt extubated without difficulty. Mediastinal and L pleural CT draining >100cc throughout all of the shift. Several phone reports to Dr. for updates on CT drainage amount. Platelets, FFP, protamine and PEEP used for ^ bleeding. Drainage at times appeared mostly from patient's L side tubes. Pt on Plavix through yesterday and reports taking asa for his arthritic neck pain. Hct to 26.8. One unit prbc tonight. Hct up to 28.5 after blood and again/currently 28.5. Plan to monitor closely.\n\nOGT drained minimal bilious. Absent bowel sounds. Pt reports frequent L epistaxis. No nose bleeds tonight.\n\nFoley draining >100cc/hr. Potassium replacement as noted.\n\nPt c/o sternal incision area discomfort. Morphine given twice and pain # reduced #. Pt c/o his chronic neck pain. ASA request denied due to persistent ct drainage. Pt repositioned and reports that he is more comfortable.\n\nGlucose to 166. Insulin gtt per csru glucose protocol.\n\nSternal, mediastinal and L leg ACE wrap dressing d&i. L leg JP draining bloody drainage (55cc this shift).\n\nWife and daughters in till 2100/hr(extubation). Upper denture plate left at bedside.\n\nAlert and oriented x 3. MAE. Plan to watch HCT, hourly CT drainage closely. Plan to continue with Neosynephrine to keep sbp >90.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-04 00:00:00.000",
"description": "Report",
"row_id": 1635670,
"text": "shift update:\n\nneuro: anxious at times, requiring reassurance. oriented x3. awake most of shift. mae. t&r q2-3hrs. c/o neck, back & chest pain 10 out of 10, medicated w/morphine 2mg ivp w/effect, pain out of 10 after morphine.\n\ncv/skin: initially apaced at 90. underlying 80-90's pacer changed to ademand at 60 pacer sensing appropriately but not capturing 100% of time. pacer currently off. increased neo requirements to keep sbp>90. ci>2.5. ct drainage>2l sang since or. hct 27.7 & 27.1. aware. scant drainage from left leg jp. +pp bilat. ca & magnesium repleted.\n\nresp: lungs clear but dim in bases. sat's>95% on 4l nc.\n\ngi/gu: abd soft. +bs. tolerating sips of juice. foley patent w/clear yellow urine. pt c/o constantly feeling the need to urinate & burning sensation->foley flushed w/o difficulty pt reported improvement after flush.\n\nendo: insulin gtt per protocol. see flowsheet.\n\nid: tmax 100.4. cefazolin given as ordered.\n\nsocial: no family contact overnight.\n\nplan: pain management. emotional support. cont to monitor hemodynmics, ct drainage, labs, i&o. neo for bp support. insulin gtt per protocol. ?d/c foley in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-03 00:00:00.000",
"description": "Report",
"row_id": 1635668,
"text": "Resp Care\nPt from OR s/p CABGX3. Current vent settings: SIMV 600 x 16 10P 40%. PEEP increased due to bleeding. Plan to continue cardiac per fast track policy. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-05 00:00:00.000",
"description": "Report",
"row_id": 1635673,
"text": " 7p-7a\nneuro: a+ox3, mae, follows commands, pain well controlled w/ po percocet q 4h\n\ncv: sr 75-85 w/out ectopy until ~0530->afib 110-160, lopressor 10mg iv x1 & 5mg lopressor iv x1 & magnesium 2mg ivpb->afib 110-140 150mg amio bolus given x1; sbp 85-105, neo gtt not restarted, maps>60; ct draining moderate amounts serosanguineous drainage overnoc; max temp 100.3\n\nresp: lungs cta, dim to bases, 91-95% on 4L nc, 02 increased to 6L while lying on right side, but returned to 4L once on left side, now maintaining sats >95% on 4L nc, expectorating small amounts thick yellow sputum\n\ngi: abdomen soft, hypoactive bowel sounds, fingersticks ssri, tolerating clear liquids overnoc\n\ngu: foley to gravity draining clear yellow urine\n\nlabs: repleted mag/calcium prior to afib, 2mg magnesium sulfate given once in afib; hct dropped from 27 to 24-team aware\n\nplan: amio gtt, pulmonary toilet, increase activity as tolerated, po lopressor, transfer to 6 when stable\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-05 00:00:00.000",
"description": "Report",
"row_id": 1635674,
"text": "7a-7p\nNeuro: Pt a/ox3, mae's follow commands, pt having minimal pain today, percocet with good relief. Pt c/o seeing colors and hallucinations ? related to hypotension. Will try tylenol for pain also.\n\nCV: Tele afib 120's today, amio drip started, second 150mg iv amio bolus also given, pt hypotensive sbp dropped to 70's with standing into chair, resolved after 2 minutes in chair, sbp 80's-90, np aware 500ml ns bolus given, sbp still 80's, pt back to bed, another 500ml bolus given sbp 90's throughout day. Amio drip at 0.5mg/min now. 2.5mg iv lopressor given to attempt to convert afib sbp 90's-100's. Pt c/o feeling weak/ dizzy, seeing spots, np aware, pt to remain on bedrest until afib converts to sr. a-line intact/ cortis wnl. 2a/2v wires on a vvi demand rate 60, wires not tested due to heart rate.\n\nResp: ls clear dim at bases, rr20's, sats 97% on 4lnc. enc using is, nonproductive cough. Chest tubes d/c'd without incident.\n\nGI/GU: abd soft, + bs, foley to gravity draining adequate amounts of urine\n\nEndo: riss per cvicu protocol\n\nSkin: See flowsheet\n\nPlan: Rate control with hope to convert to sr, start po amio after drip d/c'd, increasing lopressor dose while maintaining sbp>90.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-04 00:00:00.000",
"description": "Report",
"row_id": 1635671,
"text": "Respiratory Care:\nPatient weaned and extubated per protocol. Noted that he continues to have >50cc/hr chest tube output. He has received blood and recheck HCT=27. He appears comfortable on nasal O2 with sPO2>98%. Ventilator was discontinued and an ambu bag and mask are at the head of his bed.\nPlan to continue monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-11-04 00:00:00.000",
"description": "Report",
"row_id": 1635672,
"text": "7a-7p\nNeuro: Pt a/ox3, mae's, follows commands. Pt c/o pain incisional pain 2 mg iv push morphine/ 2 percocet given also. Pain relieved . Continue percocet efor discomfort every four hours as needed.\n\nCV: tele sr no ectopy. Neo adjusted to keep maps>60. Hct 25.0 this am 1 unit prbc's given for low hct, and bleeding overnight from chest tubes. 20-30cc/hr from chest tube of serosang drainage. Pa pressures 20's/8. Sbp 80's on .75mcg of neo, u/o marginal. Pt also became orthostatic to sbp60's with standing, resolved once in chair with feet up to 90's syst. Pa aware, 500ml ns bolus md . Pa pressure 20's/teens after fluid bolus. CVp 4-10. See flowsheet for drug changes. Palpable pulses, chest tube has no leak or crepitus. 2a/2v wires sense but dont capture despite polarity change. A wires capture in v demand at ma 25. Plavix and asa given per pa despite low hct/ oozy chest tubes. see flow sheet for access lines.\n\nResp: Ls clear dim at bases, rr20's, is with non prod cough. 96% on 4lnc.\n\nGI/GU: foley to gravity draining marginal u/o 30cc/hr. Pa aware. + bs in all four quadrants, tolerating cardiac diet.\n\n\nEndo: insulin gtt weaned per cvicu protocol. See flowsheet.\n\nSkin: left groin dsg c/d/i, no hematoma. Jp bulb in left leg draining sangounous drainage, d/c'd by pa . Dsg changed. Ace wrap intact. See flowsheet for other dsg's.\n\nSocial: wife and children in to visit updated on poc.\n\nPlan: Monitor hemodynamics, wean neo drip as pt tolerates, monitor hct, ? d/c swan line, bs control.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2150-11-03 00:00:00.000",
"description": "Report",
"row_id": 161475,
"text": "Sinus bradycardia. Left atrial abnormality. P-R interval prolongation.\nOld inferior wall myocardial infarction. Since the previous tracing\nof inferior Q waves are now more apparent.\n\n"
}
] |
6,641 | 145,032 | Respiratory status: She has always been in room air with saturations ranging from 88 to 94. She had an arterial blood gas in room air of pH 7.39, pCO2 37, pO2 54, bicarbonate 23 and base deficit of -1. On examination her respirations are comfortable, her respiratory rate in the 40's, lung sounds are clear and equal. | B/P has beenstable via cuff pressures and via UAC - see flow sheet.Echocardiogram has been done - awaiting results form TCH.A: infant is currently stable in roomair, with loud murmur,prostaglandins infusing. Was given Recombivax. A: breathing comforatbly in roomair.P: Continue to moniter.#1 O: Infant remains on Prostaglandins at .01 mcgs/k/minute,infusing via UVC. A: AGA, with cardiacissues. P: Continue to moniter C/V statusclosely. Propgressed to vaginal delkivery. Abd soft and nondistended, infant remains NPO, IVF of NS via UAC, D10TPN/D5W with heparin and Prostaglandins infusing via dbl lumen UVC well, d/s stable, NO VOID since birth, mod mec. 1/2NS infusing via UAC.DLUVC with D10W and D5W infusing, perihperal IV is currentlyheplocked. Parents awar5e of status and plan. Skin pale pink and warm, fair perfusion, tibial pulses nonpalpable, femoral and radial wnl, loud murmur noted, precordium quiet, b/p stable, UAC monitoring, Infant remains on .01mcg/kg/min of Prostaglandin infusion via UVC . A: invovled andinvested parents. They are aware that we are awaiting the echo results andare awaiting transfer of infant to TCH. Clinical, non-invasive monitoring of resp status. A: maintaining blood sugar, awaitingU/O. Awaiting results of echo and awaiting word formTCH when bed is available for transfer to TCH cardiology.#3 O: Remains on TF of 60cc/k/day. Pulmonary blood flow is within normal limits. questions and have been updated at the bedside. P: Continue tomoniter for milestones. Neonatal NP-ProcedureProcedure: UA/UVC placementIndication: continuous blood pressure monitoring, venous accessInfant prep'd for sterility. P: Continue to moniter. Skin w/o leisons. PKU was donein anticipation of transfer to TCH. NPO for now with IV hydration SIngle dose of abx for prophylaxis with line placement. #3.5 fr UAC placed without difficulty and secured at 19cm. HEENT WNL. Temp has beenwarm on open warmer, have weaned temp setting. Attending Addendum NoteHR 130-150'sCBC: hct 41.5 wbc 18.3(58P 3B 23L) plt 306on 60 cc/kg/day NPO for nowno void but large mecoiumalert active in open warmerdstick 63 now 80Imp-stable currentlyplan to transfer to the Cardiac ICUwhen bed is availablewill begin PN Infant has not voided since admisssion and haspassed a couple of meconium stools. transfer to CH. P: COntinue to support and keep parentsupdated on plan of care.#5 O: INfant is alert and active with cares. Suckingoccasionally on her pacifier and have given her sucrose X 2.Anf font soft and flat. Abdomen benign. Anus patent. Spine intact.Initial mean BP 32. Lung soundsare clear and equal. Hips normal. An umbilical venous line reaches the right atrium. Copr nl s1s2 grade 1/6 SEM at MLSB. The bowel gas pattern is normal. Neuro non-focal and age aprpopriate. Awaiting Xray confirmation of placement. Parents in to visit and updated. An umbilical artery line is present. PATIENT/TEST INFORMATION:Indication: Congenital heart disease.Status: InpatientDate/Time: at 11:09Test: Portable TTE (Congenital, complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Conclusions:Pediatric study. #3.5 fr double lumen UVC placed without difficulty and secured at 11cm. Genitalia normal female. Well pefused, saturated to low 90s in RA. Resp rates 40s-50s and infant isbreathing comfortably. Did well in DR. 8,9. Prenatal screens show maternal BT O+, ab-, Hbsag-, RPRNR, RI status.Mother presented in labor this am. Pregnancy apparently otherwise unremarkable. Brought to NICU after visting with parents.On exam slightly pale active infant. Report will be generated by . Comfortable apeparing. 6:45 AM BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # Reason: line placement Admitting Diagnosis: NEWBORN MEDICAL CONDITION: Infant with newly placed lines REASON FOR THIS EXAMINATION: line placement FINAL REPORT This is our initial film on this child with coarctation of the aorta. D-stick 80. RR easy and unlabored, no signs of resp distress, remains on RA, 02 sats pre: 90-95, post 93-96, no desats noted. Mother seen in consultation by Dr . Being given NS bolus of 20 cc/k/d.A- Term infant with unbalanced CAVC raising specter of ductal dependent lesion.P Admit NICU Prostin infusion at 0.01 mg/k/min as per cardiology team. Unable topalpate tibial pulses, femoral and radial pulses are WNL.HR 120s-140s. Parents aware and give their consent for baby girl transfer to Hospital. Skin is warm and pale pink with slightcapillary refill delay to lower extremities. Had a large muscousyspit X 1. NPn days 7am-3pm#2 O: Infant remains in roomair with pre and postductalsats >91%, occasionall drifts to the upper 80s. This line reaches T6. Presently awaiting ambulance for infant's transfer to P6 cardiology floor. The heart is enlarged. "loud" murmur is present. Will start PN tonight.#4 O: Infant's parents in for a couple of visits today.Asking appr. No apnea or bradycardia noted. Cardiologist from TCH in to examine infant, went to speak with parents on postpartum floor. NeonatologyPatient is 2920 gram product of term getsation born to 30 yo G!P0 woman whose pregnancy was complicated by antenatal dx via US of CAVC with right sided prdominace du e to elongated narrow left ventricular outflow tract. NICU Nursing Transfer note:Baby girl and active with handling, sleepy, good cry, sucks on pacifier briefly. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2186-08-11 00:00:00.000",
"description": "Report",
"row_id": 1769714,
"text": "Neonatal NP-Procedure\n\nProcedure: UA/UVC placement\nIndication: continuous blood pressure monitoring, venous access\n\nInfant prep'd for sterility. #3.5 fr UAC placed without difficulty and secured at 19cm. #3.5 fr double lumen UVC placed without difficulty and secured at 11cm. Awaiting Xray confirmation of placement.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-08-11 00:00:00.000",
"description": "Report",
"row_id": 1769715,
"text": "Neonatology\nPatient is 2920 gram product of term getsation born to 30 yo G!P0 woman whose pregnancy was complicated by antenatal dx via US of CAVC with right sided prdominace du e to elongated narrow left ventricular outflow tract. Mother seen in consultation by Dr . Pregnancy apparently otherwise unremarkable. Prenatal screens show maternal BT O+, ab-, Hbsag-, RPRNR, RI status.\n\nMother presented in labor this am. Propgressed to vaginal delkivery. Did well in DR. 8,9. Brought to NICU after visting with parents.\n\nOn exam slightly pale active infant. Well pefused, saturated to low 90s in RA. Comfortable apeparing. Skin w/o leisons. HEENT WNL. Copr nl s1s2 grade 1/6 SEM at MLSB. Abdomen benign. Genitalia normal female. Neuro non-focal and age aprpopriate. Hips normal. Anus patent. Spine intact.\n\nInitial mean BP 32. Being given NS bolus of 20 cc/k/d.\n\nA- Term infant with unbalanced CAVC raising specter of ductal dependent lesion.\nP Admit NICU\n Prostin infusion at 0.01 mg/k/min as per cardiology team.\n Clinical, non-invasive monitoring of resp status.\n NPO for now with IV hydration\n SIngle dose of abx for prophylaxis with line placement.\n transfer to CH.\n Parents awar5e of status and plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-08-11 00:00:00.000",
"description": "Report",
"row_id": 1769716,
"text": "Attending Addendum Note\nHR 130-150's\nCBC: hct 41.5 wbc 18.3(58P 3B 23L) plt 306\non 60 cc/kg/day NPO for now\nno void but large mecoium\nalert active in open warmer\ndstick 63 now 80\n\nImp-stable currently\nplan to transfer to the Cardiac ICU\nwhen bed is available\nwill begin PN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-08-11 00:00:00.000",
"description": "Report",
"row_id": 1769717,
"text": "NPn days 7am-3pm\n\n\n#2 O: Infant remains in roomair with pre and postductal\nsats >91%, occasionall drifts to the upper 80s. Lung sounds\nare clear and equal. Resp rates 40s-50s and infant is\nbreathing comfortably. A: breathing comforatbly in roomair.\nP: Continue to moniter.\n#1 O: Infant remains on Prostaglandins at .01 mcgs/k/minute,\ninfusing via UVC. \"loud\" murmur is present. Unable to\npalpate tibial pulses, femoral and radial pulses are WNL.\nHR 120s-140s. Skin is warm and pale pink with slight\ncapillary refill delay to lower extremities. B/P has been\nstable via cuff pressures and via UAC - see flow sheet.\nEchocardiogram has been done - awaiting results form TCH.\nA: infant is currently stable in roomair, with loud murmur,\nprostaglandins infusing. P: Continue to moniter C/V status\nclosely. Awaiting results of echo and awaiting word form\nTCH when bed is available for transfer to TCH cardiology.\n#3 O: Remains on TF of 60cc/k/day. 1/2NS infusing via UAC.\nDLUVC with D10W and D5W infusing, perihperal IV is currently\nheplocked. Infant has not voided since admisssion and has\npassed a couple of meconium stools. Had a large muscousy\nspit X 1. D-stick 80. A: maintaining blood sugar, awaiting\nU/O. P: Continue to moniter. Will start PN tonight.\n#4 O: Infant's parents in for a couple of visits today.\nAsking appr. questions and have been updated at the bedside.\n They are aware that we are awaiting the echo results and\nare awaiting transfer of infant to TCH. A: invovled and\ninvested parents. P: COntinue to support and keep parents\nupdated on plan of care.\n#5 O: INfant is alert and active with cares. Temp has been\nwarm on open warmer, have weaned temp setting. Sucking\noccasionally on her pacifier and have given her sucrose X 2.\nAnf font soft and flat. Was given Recombivax. PKU was done\nin anticipation of transfer to TCH. A: AGA, with cardiac\nissues. P: Continue tomoniter for milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-08-11 00:00:00.000",
"description": "Report",
"row_id": 1769718,
"text": "NICU Nursing Transfer note:\nBaby girl and active with handling, sleepy, good cry, sucks on pacifier briefly. Skin pale pink and warm, fair perfusion, tibial pulses nonpalpable, femoral and radial wnl, loud murmur noted, precordium quiet, b/p stable, UAC monitoring, Infant remains on .01mcg/kg/min of Prostaglandin infusion via UVC . RR easy and unlabored, no signs of resp distress, remains on RA, 02 sats pre: 90-95, post 93-96, no desats noted. No apnea or bradycardia noted. Abd soft and nondistended, infant remains NPO, IVF of NS via UAC, D10TPN/D5W with heparin and Prostaglandins infusing via dbl lumen UVC well, d/s stable, NO VOID since birth, mod mec. Cardiologist from TCH in to examine infant, went to speak with parents on postpartum floor. Parents in to visit and updated. Presently awaiting ambulance for infant's transfer to P6 cardiology floor. Parents aware and give their consent for baby girl transfer to Hospital.\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-11 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 830695,
"text": " 6:45 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with newly placed lines\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n This is our initial film on this child with coarctation of the aorta.\n\n The heart is enlarged. Pulmonary blood flow is within normal limits. There\n is no evidence of congestive heart failure. An umbilical artery line is\n present. This line reaches T6. An umbilical venous line reaches the right\n atrium. The bowel gas pattern is normal.\n\n"
},
{
"category": "Echo",
"chartdate": "2186-08-11 00:00:00.000",
"description": "Report",
"row_id": 77421,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 11:09\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n"
}
] |
82,551 | 142,414 | P-R interval is longer.Ventricular rate is slower. Poor R wave progression. Non-specific intraventricularconduction delay. Compared to the previous tracingof the ST-T wave changes have resolved. | 1 | [
{
"category": "ECG",
"chartdate": "2107-11-17 00:00:00.000",
"description": "Report",
"row_id": 265262,
"text": "Sinus rhythm with first degree A-V block. Non-specific intraventricular\nconduction delay. Poor R wave progression. Compared to the previous tracing\nof the ST-T wave changes have resolved. P-R interval is longer.\nVentricular rate is slower.\n\n"
}
] |
|
29,884 | 157,976 | 85 year old with severe AS and acute pulmonary edema. . CHF(Acute, diastolic): Likely acute decompensation in the context of severe AS and difficult fluid balance. Patient diuresed gingerly in light of preload dependent AS. Volume overload resolved with PRN lasix. ECho preserved EF and severe EF. Patient was started on 12.5 metoprolol . Patient had left and right heart caths showing branch vessel disease only, no needed for stent. Patient also started on daily ASA. . Aortic stenosis: Patient with known AS, but this is first incident of acute pulmonary edema. Aortic valve area <.8cm2 here. Patient very hesitant to go for surgery, and after much discussion, conclution reached that she be discharged home, and is scheduled for AVR on . . Pulmonary fibrosis: Patient has history of breast Ca, with radiation. PFT's in house demonstarted mild restrictive disease with normal DLCO. She is cleared for surgery from a pulmonary perspective, and can f/u as outpatient. . # HTN: Amlodipine dc/ed and toprol XL continued. . # ARF: pt without evidence of chronic failure on records from PCP, have to presume this is ARF. Likely due to poor forward flow in the context of CHF and severe AS. Patient was diuresed with stabilization of creatinine to 1.1. . # Rhythm: ventricularly paced at heart rate of 80 . # DM2: Glyburide held on floor, on ISS. discharged on glyburide. | Mild (1+) aorticregurgitation is seen. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Normal aortic diameter at the sinus level. Moderate [2+] tricuspid regurgitation is seen. There is moderate symmetric left ventricularhypertrophy. Normal ascending aorta diameter. Moderate mitralannular calcification. Minimal residual interstitial edema persists. Cont with diuresis overnite. Moderate (2+) mitral regurgitation is seen. Moderate PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. There is moderatepulmonary artery systolic hypertension. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. DENIES C/O CHEST PAIN.RESP: ON 3L NC. The tricuspid valve leaflets are mildlythickened. edema, intubated. Shortness of breath.Height: (in) 62Weight (lb): 125BSA (m2): 1.57 m2BP (mm Hg): 150/66HR (bpm): 79Status: InpatientDate/Time: at 10:31Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Heart is upper limits of normal in size, and the aorta is tortuous and calcified. DENIES C/O PAIN.CV: HR 70-80 VPACED RHYTHM. Mild thickening of mitral valve chordae. Right-sided pacemaker is noted. Scattered relative parenchymal lucency in both lungs is mild. Low normalLVEF. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. TURNS WITH MINIMAL ASSIST.CV: HR 60-80 VPACED. Left apical pleural thickening noted. There is no pericardial effusion.IMPRESSION: severe calcific aortic stenosis with moderate concentric leftventricular hypertrophy and low normal ejection fraction GIVEN ATIVAN WITH MINIMAL EFFECT. Intubated. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. The following lung nodules are calcified: 4-mm right upper lobe nodule (4, 66), 2-mm left lower lobe nodule (4, 162). Severe AS(AoVA <0.8cm2). Aortic valvular calcification is severe and mitral annular calcification is moderate. Mild dependent ground-glass opacity is compatible with pulmonary edema. COMPARISONS: Chest radiograph dated . Moderate [2+] TR. Pt requesting sedation, given 1mg ativan IV with good effect. Normal LV cavity size. Normal tricuspidvalve supporting structures. Atheromatous calcification is moderate in the thoracic aorta and extensive in the left anterior descending coronary artery. Repleated K+/Mg+GI/GU- Tol sips of clears, +bs +flatus no bm. A right paratracheal and aortopulmonary window lymph nodes measure up to 9 mm in short axis. diurese. COPIOUS ORAL SECRETIONS.GI: + BOWEL SOUNDS, PASSING GAS, NO BM. The left ventricular cavity size is normal. A catheter or pacing wireis seen in the RA and extending into the RV.LEFT VENTRICLE: Moderate symmetric LVH. There is minimal calcific plaque involving the internal carotid arteries bilaterally. The following nodules are not calcified: Three nodules in the right lower lobe measuring up to 4 mm (4:85, 95, 100), 2-mm right upper lobe nodule (4, 96), two left lower lobe nodules measuring up to 4 mm (4:102, 116). Evidence of prior left mastectomy. INDICATION: Pulmonary edema. NBPs 112-130/47-60s. Additional areas of less severe peripheral fibrosis are noted in the bilateral upper, mid and lower lung zones. creat 1.3Endo: Pt is NIDDM. [Dueto acoustic shadowing, the severity of mitral regurgitation may besignificantly UNDERestimated.] Focal calcifications inaortic root. INDICATION: Aortic stenosis. Calcified tipsof papillary muscles. Extensive left anterior descending coronary artery calcifications. Focal calcifications inascending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. There has been interval extubation. A right-sided pacemaker has two leads, which terminate in the right atrium and right ventricle. + GAG/COUGH. Monitor for resp distress post extubation d/t AS. However, the peak systolic velocities bilaterally are normal, as are the ICA to CCA ratios. TURNS WITH MINIMAL ASSIST. Resp CarePt was trans from EW, remains intubated on CMV as noted on Carevue. Check lytes. In ARF, Cre 1.7 (baseline 1.3) no diuresis. Hemodynamically stable. OGT in place draining bilious material. The left breast soft tissues are absent. FINDINGS: Severe upper lobe pulmonary fibrosis with cicatricial cysts and moderate pleural thickening is compatible with prior left chest radiation. Nasogastric tube is seen with its tip passing below the hemidiaphragm but not included on the current examination. Sedate as needed. Moderate endplate osteophytes are seen at multiple levels in the thoracic spine. Right ventricular chamber size and free wallmotion are normal. Lung volumes are low, likely reflecting restrictive physiology. Lungs diminshed with rales in bases.Neuro: Upon arrival pt was awake and resonding appropriately in conversation. AP PORTABLE CHEST: There are diffuse patchy areas of airsapce opacity in both lungs. No pleural effusion is identified, but there is asymmetrical pleural thickening at the left apex adjacent to the area of fibrosis. Murmur. Moderate (2+) MR. [Due to acoustic shadowing, theseverity of MR may be significantly UNDERestimated. UPDATE PT. UPDATE PT. Scattered mild relative lucency in both lungs may be secondary to a perfusion abnormality such as pulmonary hypertension or air trapping. Extubated today w/o complications, plan for poss AVR on thurs. LUNGS CLEAR. LUNGS CLEAR. Preoperative assessment. Sinus rhythm with atrial sensed and ventricular paced rhythm. A two-lead pacer is noted with leads overlying the right atrium and right ventricle. The mitral valve leaflets are mildly thickened. Additional subpleural pulmonary fibrosis is moderate in the remainder of the left upper lobe and mild in the left lower lobe and right lung. Nursing Note 7a-7pNeuro- A+Ox3, cooperative no sedation given. Severe aortic valvular calcification with associated left ventricular chamber enlargement. Pulmonary fibrosis is severe in the left apex and compatible with known prior chest radiation, and mild-to-moderate in the remainder of the lung parenchyma. Tissue Doppler imagingsuggests an increased left ventricular filling pressure (PCWP>18mmHg). ENCOURAGE C&DB. IMPRESSION: 1. GIVEN FENT IN DIVIDED DOSES FOR SEDATION WITH GOOD EFFECT. PATIENT/TEST INFORMATION:Indication: Left ventricular function. NURSING PROGRESS NOTE 7P-7AS: INTUBATEDO: NEURO: PT. I/O(-) 500CC.GI: + BOWEL SOUNDS. Predominantly dependent ground-glass opacity in the lower lobes is also mild. REASON FOR THIS EXAMINATION: please assess interval change/ FINAL REPORT EXAMINATION: AP chest. | 17 | [
{
"category": "Radiology",
"chartdate": "2140-10-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 982065,
"text": " 3:15 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: RESPIRATORY ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman aortic stenosis transferred here s/p pulm edema, with AS,\n now planned for AVR tomorrow\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST :\n\n COMPARISON: and .\n\n INDICATION: Aortic stenosis. Preoperative assessment.\n\n There has been interval extubation. Permanent pacemaker remains in standard\n position with leads in the right atrium and right ventricle. Heart is upper\n limits of normal in size, and the aorta is tortuous and calcified.\n\n Extensive bilateral interstitial pulmonary fibrosis is present, with\n peripheral predominance. Upper, mid and lower lung zones are involved, but\n left apex is most severely affected. Overall, left lung is involved greater\n than right. Lung volumes are low, likely reflecting restrictive physiology.\n No pleural effusion is identified, but there is asymmetrical pleural\n thickening at the left apex adjacent to the area of fibrosis.\n\n IMPRESSION:\n\n Extensive pulmonary fibrosis with most marked abnormalities at left apex.\n\n Suspect chronic lung disease such as idiopathic pulmonary fibrosis with\n superimposed scarring from prior granulomatous disease at left apex.\n\n Findings have been communicated to Dr. by telephone on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-09 00:00:00.000",
"description": "TEETH (PANOREX FOR DENTAL)",
"row_id": 981677,
"text": " 1:03 PM\n TEETH (PANOREX FOR DENTAL) Clip # \n Reason: preop for AVR\n Admitting Diagnosis: RESPIRATORY ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe AS\n REASON FOR THIS EXAMINATION:\n preop for AVR\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Severe aortic stenosis. Evaluate for dental disease prior\n to surgery.\n\n TEETH, PANOREX VIEWS.\n\n Extensive dental work is being performed with the root canals and fillings.\n\n No evidence of apical abscess or erosion seen in the maxilla. Area of lucency\n is present under the right second incisor of the maxilla, and this could\n represent an area of infection at the apex of this tooth.\n\n IMPRESSION: Potential apical infection of right second incisor.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-12 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 982044,
"text": " 1:31 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: preop eval for AVR\n Admitting Diagnosis: RESPIRATORY ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with severe AS\n\n REASON FOR THIS EXAMINATION:\n preop eval for AVR\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID STUDY\n\n HISTORY: Preop for valve replacement.\n\n There is minimal calcific plaque involving the internal carotid arteries\n bilaterally. However, the peak systolic velocities bilaterally are normal, as\n are the ICA to CCA ratios. There is also normal antegrade flow involving both\n vertebral arteries.\n\n IMPRESSION: Minimal bilateral ICA plaque, no appreciable ICA or CCA stenosis\n identified, however.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-12 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 982094,
"text": " 6:28 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval severity of fibrosis\n Admitting Diagnosis: RESPIRATORY ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with pulmonary fibrosis on CXR and history of breast cancer\n REASON FOR THIS EXAMINATION:\n eval severity of fibrosis\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n WET READ: BTCa WED 11:20 PM\n PRELIMINARY REPORT: Severe pulmonary fibrosis with associated traction\n bronchiectasis involving the left upper lobe. Additional areas of less severe\n peripheral fibrosis are noted in the bilateral upper, mid and lower lung\n zones. Mosaic ground glass opacity at the bases likely represents air\n trapping. No suspicious pulmonary nodules, consolidation or effusion\n identified. Left apical pleural thickening noted. Evidence of prior left\n mastectomy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old woman with pulmonary fibrosis on chest x-ray and a\n history of breast cancer status post left mastectomy and chest radiation;\n evaluate for pulmonary fibrosis.\n\n COMPARISONS: Chest radiograph dated .\n\n TECHNIQUE: MDCT images of the chest were obtained without intravenous\n contrast and utilizing a 1.25 mm slices and soft tissue and lung algorithms.\n Coronal reformations were essential to interpretation.\n\n FINDINGS: Severe upper lobe pulmonary fibrosis with cicatricial cysts and\n moderate pleural thickening is compatible with prior left chest radiation.\n Additional subpleural pulmonary fibrosis is moderate in the remainder of the\n left upper lobe and mild in the left lower lobe and right lung. Scattered\n relative parenchymal lucency in both lungs is mild. Predominantly dependent\n ground-glass opacity in the lower lobes is also mild.\n\n The following lung nodules are calcified: 4-mm right upper lobe nodule (4,\n 66), 2-mm left lower lobe nodule (4, 162). The following nodules are not\n calcified: Three nodules in the right lower lobe measuring up to 4 mm (4:85,\n 95, 100), 2-mm right upper lobe nodule (4, 96), two left lower lobe nodules\n measuring up to 4 mm (4:102, 116).\n\n A right-sided pacemaker has two leads, which terminate in the right atrium and\n right ventricle. The left breast soft tissues are absent. Atheromatous\n calcification is moderate in the thoracic aorta and extensive in the left\n anterior descending coronary artery. Aortic valvular calcification is severe\n and mitral annular calcification is moderate. The left ventricular chamber is\n enlarged. There is no pleural or pericardial effusion. A right paratracheal\n and aortopulmonary window lymph nodes measure up to 9 mm in short axis.\n\n (Over)\n\n 6:28 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval severity of fibrosis\n Admitting Diagnosis: RESPIRATORY ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Limited images of the upper abdomen are insufficient for diagnosis given the\n lack of intravenous contrast. However, no definite abnormalities are\n identified. There are no findings suspicious for malignancy in the imaged\n bones. Moderate endplate osteophytes are seen at multiple levels in the\n thoracic spine.\n\n IMPRESSION:\n 1. Pulmonary fibrosis is severe in the left apex and compatible with known\n prior chest radiation, and mild-to-moderate in the remainder of the lung\n parenchyma.\n\n 2. Mild dependent ground-glass opacity is compatible with pulmonary edema.\n\n 3. Scattered mild relative lucency in both lungs may be secondary to a\n perfusion abnormality such as pulmonary hypertension or air trapping.\n\n 4. Severe aortic valvular calcification with associated left ventricular\n chamber enlargement.\n\n 5. Multiple calcified and noncalcified pulmonary nodules measuring up to 4 mm\n in diameter. If the patient has no known malignancy or risk factors for lung\n cancer, no additional followup is required.\n\n 6. Extensive left anterior descending coronary artery calcifications.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981429,
"text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EValuate for infiltrate/tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n EValuate for infiltrate/tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Respiratory failure.\n\n COMPARISON: None.\n\n AP PORTABLE CHEST: There are diffuse patchy areas of airsapce opacity in both\n lungs. This may represent pulmonary edema, hemorrhage or infection. The heart\n is not enlarged. No pneumothorax is identified. A two-lead pacer is noted\n with leads overlying the right atrium and right ventricle. An endotracheal\n tube is noted with its tip 3 cm above the carina. An endogastric tube courses\n down esophagus and stomach and its tip is not well visualized.\n\n IMPRESSION: Diffuse bilateral airspace opacities may represent pulmonary\n edema, hemorrhage, or infectuous process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981570,
"text": " 7:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess interval change/\n Admitting Diagnosis: RESPIRATORY ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman aortic stenosis transferred here with flash pulm. edema,\n intubated.\n REASON FOR THIS EXAMINATION:\n please assess interval change/\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Pulmonary edema. Intubated.\n\n A single AP view of the chest is obtained at 09:22 hours and compared\n with the prior morning's radiograph. The patient remains intubated with the\n tip of the ET tube approximately 3 cm above the carina. There has been an\n improvement in the appearance of the diffuse bilateral interstitial and\n alveolar opacities since the prior examination consistent with improvement in\n pulmonary edema. Right-sided pacemaker is noted. Nasogastric tube is seen\n with its tip passing below the hemidiaphragm but not included on the current\n examination. Visualized bowel gas pattern is unremarkable.\n\n IMPRESSION:\n\n Improvement in the appearance of pulmonary edema since the prior day's\n examination. Minimal residual interstitial edema persists.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-08 00:00:00.000",
"description": "Report",
"row_id": 1648290,
"text": "Nursing Note 7a-7p\nNeuro- A+Ox3, cooperative no sedation given. MAE in bed, no c/o sob/c-pain.\n Pt was placed on a PS trial 40% 5/0 for approx 2.5 hrs. Tol well w/ no signs of flashing. ABG wnls, extubated w/o complications to 40% face tent. Placed on 3L nc @ 6pm, tol well w/ sats >96%.\nCV- V-paced 70-80, no vea. NBPs 112-130/47-60s. Placed on NTG gtt when extubated @ 0.25mcg/kg/min x 1hr. This per Dr in hopes to work as a preload reducer & prevent her flashing post extubation. Repleated K+/Mg+\nGI/GU- Tol sips of clears, +bs +flatus no bm. Foley draining approx 20-30cc/hr cyu. In ARF, Cre 1.7 (baseline 1.3) no diuresis. LOS balance -1130, 24hr -270.\nID- Tmax 100.9 po-> 99.6\nEndo- All sugars below RISS.\nA/P- 85yo female intubated @ OSH for resp distress, tnsf to . Known severe AS. Extubated today w/o complications, plan for poss AVR on thurs. Monitor for resp distress post extubation d/t AS. ? diurese.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-09 00:00:00.000",
"description": "Report",
"row_id": 1648291,
"text": "NURSING PROGRESS NOTE 7P-7A\nS: I SLEPT OFF AND ON\"\n\nO: NEURO: PLEASANT AND COOPERATIVE WITH CARE. SLEPT IN LONG NAPS OVERNIGHT. TURNS WITH MINIMAL ASSIST. DENIES C/O PAIN.\n\nCV: HR 70-80 VPACED RHYTHM. NO VEA NOTED. BP 122-134/56. DENIES C/O CHEST PAIN.\n\nRESP: ON 3L NC. O2 SAT 96%. WEAK, NON PRODUCTIVE COUGH. LUNGS CLEAR. DENIES C/O SOB.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE IN FAIR AMTS. GIVEN 20 MG IV LASIX WITH FAIR DIURESIS. I/O(-) 500CC.\n\nGI: + BOWEL SOUNDS. PASSING GAS. NO BM OVERNIGHT. FEELS HUNGRY. TAKING SIPS OF JUICE WELL.\n\nENDO: BLOOD GLUCOSE IN GOOD CONTROL, NO NEED FOR SSRI.\n\nA: ADMITTED WITH RESP DISTRESS REQUIRING INTUBATION, AORTIC STENOSIS, NEEDS AVR.\n\nP: CONT TO MONITOR I/O, LYTES REPLETE AS NEEDED. ENCOURAGE C&DB. OOB TODAY. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-07 00:00:00.000",
"description": "Report",
"row_id": 1648285,
"text": "Nursing Progress Note\n\nO: Please see FHP and flow sheet for further objective data. 85yo women with known AS transferred to ED here after acute episode of shortness of breath with desaturation into 70's requiring intubation at OSH. Tx'd with lasix and nitro. Tele AV paced. SBP 90's-120's. To receive additional lasix 60mg IV this pm. Other cardiac meds on hold.\n\nResp: Pt received intubated A/C 50% 450 X 20 8. ABG's 7.49 38 207 30. rate decreased to 15 and peep down to 5. O2 sats 98-100%. Lungs diminshed with rales in bases.\n\nNeuro: Upon arrival pt was awake and resonding appropriately in conversation. Able to follow commands. Pt requesting sedation, given 1mg ativan IV with good effect. Both wrists in soft restraints to protect ETT.\n\nGI/GU: Pt is NPO. OGT in place draining bilious material. Abd is soft nontender. Foley is draining CYU. creat 1.3\n\nEndo: Pt is NIDDM. RISSC.\n\nSocial: Pt is normally very active and independent lives alone. Has 2 sons. Pt is full code. Family will discuss possiblity of AVR once extubated.\n\nA&P:85yo women with known AS with sudden onset of SOB requiring intubation. Hemodynamically stable. Cont with diuresis overnite. Check lytes. Sedate as needed. Attempt to wean with possible extubation in am. Keep family updated on POC\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-07 00:00:00.000",
"description": "Report",
"row_id": 1648286,
"text": "Resp Care\nPt was trans from EW, remains intubated on CMV as noted on Carevue. Plan to continue with current tx ?? OR early next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-08 00:00:00.000",
"description": "Report",
"row_id": 1648287,
"text": "NURSING PROGRESS NOTE 7P-7A\nS: INTUBATED\n\nO: NEURO: PT. AWAKE, ALERT. RESTLESS, PULLING AT LINES. WRIST RESTRAINTS ON FOR PT. SAFETY. GIVEN ATIVAN WITH MINIMAL EFFECT. GIVEN FENT IN DIVIDED DOSES FOR SEDATION WITH GOOD EFFECT. MOVING ALL EXTREMITIES. TURNS WITH MINIMAL ASSIST.\n\nCV: HR 60-80 VPACED. BP 92/43-124/48. DENIES CP.\n\nRESP: VENT SETTINGS 40% FIO2, RATE 16, TV 450 PEEP 5, AC. SUCTIONING FOR THICK TAN SPUTUM. LUNGS CLEAR. + GAG/COUGH. RSBI 85. COPIOUS ORAL SECRETIONS.\n\nGI: + BOWEL SOUNDS, PASSING GAS, NO BM. OGT IN PLACE, DRAINING BILIOUS MATERIAL.\n\nGU: FOLEY DRAINING SMALL AMTS OF CLEAR YELLOW URINE. ~50 CC/HR.\n\nENDO: NO SSRI COVERAGE REQUIRED. BLOOD GLUCOSE IN GOOD CONTROL.\n\nID: AFEBRILE, GIVEN FLU VACCINE.\n\nA: ADMIT WITH RESP DISTRESS, NEEDS AVR.\n\nP: WEAN TO POSSIBLE EXTUBATION, FOLLOW LABS, O2 SAT, I/O. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-08 00:00:00.000",
"description": "Report",
"row_id": 1648288,
"text": "Respiratory Care:\nPatient remaims on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 85 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-08 00:00:00.000",
"description": "Report",
"row_id": 1648289,
"text": "Resp Care\n\nPt weaned and extubated without incident. Cuff leak present prior and no stridor noted after.\n"
},
{
"category": "Echo",
"chartdate": "2140-10-07 00:00:00.000",
"description": "Report",
"row_id": 85632,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Murmur. Shortness of breath.\nHeight: (in) 62\nWeight (lb): 125\nBSA (m2): 1.57 m2\nBP (mm Hg): 150/66\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Low normal\nLVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(AoVA <0.8cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. Moderate (2+) MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is moderate symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets are severely thickened/deformed.\nThere is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due\nto acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: severe calcific aortic stenosis with moderate concentric left\nventricular hypertrophy and low normal ejection fraction\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-08 00:00:00.000",
"description": "Report",
"row_id": 220681,
"text": "Sinus rhythm with atrial sensing and ventricular pacing. Compared to the\nprior tracing there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-07 00:00:00.000",
"description": "Report",
"row_id": 220682,
"text": "Sinus rhythm with atrial sensing and ventricular pacing. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Report",
"row_id": 220680,
"text": "Sinus rhythm with atrial sensed and ventricular paced rhythm. Since previous\ntracing of no significant change.\n\n"
}
] |
71,143 | 163,828 | 86F with hx of pancreatic CA s/p biliary stenting presenting with ascending cholangitis. . #: Septic Shock: Pt with fever, leukocytosis, increased LFTs in setting of dilated CBD, thus infected source likely biliary, consistent with ascending cholangitis. Patient received IVF, but remained hypotensive so was started on Levophed. CVL placed in ED. Initial lactate 2.2, trended down to 1.8. Patient underwent ERCP with replacement of her temporary biliary stent with a permanent stent. Frank pus was drained from the CBD. With decompression of CBD, sepsis resolved and patient was weaned off pressors. Pt was covered with Zosyn, Vanco initially. Cultures remained no growth to date. She was weaned to Zosyn alone successfully, which was transitioned to Augmentin several days prior to discharge to complete a total of ten days of antibiotics. . #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB in setting of a stent 1.4cm in the CBD. Ultrasound revealing dilated intrahepatic ducts at 4mm and radiographic findings suggestive of small stones and sluge in the GB. No evidence of acute cholecystitis. Treatment for her infection occurred as per above. . # Gap Metabolic Acidosis: Bicarb of 17 on initial labs with gap of 14. Lactate slightly elevated at 2.2. Diarrhea (Non-Gap) may also be contributing to decreased bicarb. Patient received large amount NS, and hyperchloremic metabolic acidosis was also a contributor to her acid-base picture. Anion gap improved over 24 hours. . # DMII/Hypoglycemia: Pt hypoglycemic to 56 while in ED, received 1 Amp of D50. DDx included sepsis, decreased PO in setting of regular insulin dosing. Patient was re-started on her home Lasix when transferred to the general medicine floor, which she tolerated well. . #: ARF: Cr 1.7 at presentation from baseline 1.0 to 1.4. Pt with 300 UOP at OSH. BUN at 29 up from 12. DDx Pre-renal from hypoperfusion in the setting of septic shock, less likely post-renal, intrinsic. Improved with IVF hydration to a baseline of 1.2 prior to discharge. . # Myositis: Pt was on long term steroids and methotrexate. Pt currently on 10mg prednisone. AM cortisol was wnl. She was given stress dose steroids which were weaned back to her baseline of prednisone 10mg daily and she remained hemodynamically stable. She should resume her Methotrexate as an outpatient. . #Oncology: Patient without a tissue diagnosis, and interested in knowing her options. She was seen by oncology in the ICU. She underwent CT A/P with contrast to discern if mass had grown or spread. She obtained follow up in oncology clinic for further assessment. Rad onc was also consulted for potential palliative XRT in the future. CA19-9 was pending at discharge. She was noted to have a right adnexal mass on abdominal CT; follow-up pelvic ultrasound was non-diagnostic. This should be further discussed at her Oncology follow-up appointment. | WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. WBC 25, TB 4.9, Cr 1.7, Lactate 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated intrahepatic duct. Upon arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the pt was subsequently transferred to for presumed ascending cholangitis. Upon arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the pt was subsequently transferred to for presumed ascending cholangitis. Upon arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the pt was subsequently transferred to for presumed ascending cholangitis. Upon arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the pt was subsequently transferred to for presumed ascending cholangitis. Upon arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the pt was subsequently transferred to for presumed ascending cholangitis. Upon arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L, FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and the pt was subsequently transferred to for presumed ascending cholangitis. Fluid-filled rectum with little-to-no formed stool seen in the colon; trace peritoneal fluid adjacent to right colon. Fluid-filled rectum with little-to-no formed stool seen in the colon; trace peritoneal fluid adjacent to right colon. CT ABDOMEN WITHOUT AND WITH IV CONTRAST: At the lung bases, there are moderate pleural effusions bilaterally with mild associated atelectasis. Peripancreatic vessels are normally opacified. Peripancreatic vessels are normally opacified. Initial image demonstrates a previously placed pancreatic stent, which per report appeared clogged. Peripancreatic arteries and veins are normally opacified. There is a small hiatal hernia. ERCP in AM for stent replacement. However, the right ovary demonstrates a 2.0 x 1.0 cm cyst. Mild degenerative changes are noted, consisting primarily of bulky osteophytosis. Moderate bilateral pleural effusions. Moderate bilateral pleural effusions. Moderate bilateral pleural effusions. Surrounding the stent at its proximal end, above the level of the pancreas, there is a circumferential rim of poorly defined, abnormal soft tissue density material. Pneumobilia c/w prior stent and sphincterotomy. Pneumobilia c/w prior stent and sphincterotomy. Fibroid uterus with calcified fibroids, compatible with degenerating fibroids. Pneumobilia consistent with presence of stent and sphincterotomy. 88F w/ pancreatic CA and recent stent placement in . 88F w/ pancreatic CA and recent stent placement in . FINDINGS: There is a small left pleural effusion. CHEST RADIOGRAPH, PORTABLE AP VIEW: A right IJ line was repositioned, now the tip ends at the superior cavoatrial junction. Sinus rhythm at upper limits of normal rate with sinus arrhythmia. Hypodense renal lesions are noted bilaterally. The cardiac silhouette, hilar, and mediastinal contours appear normal. There is a late transitionwith tiny R waves in the anterior leads consistent with possible prior anteriormyocardial infarction. Abnormal soft tissue density involving the CBD to the level of the pancreatic head, surrounding the CBD stent and contacting but not encasing or narrowing the main vein and common hepatic artery. The patient was not tender over the gallbladder. Right upper quadrant ultrasound of . There is minimal bibasilar lung atelectasis, unchanged. FINDINGS: There is slight opacity obscuring the left hemidiaphragm, likely atelectasis. Fluid-filled rectum with little to no formed stool seen in the remainder of the colon. Hepatic (Over) 4:39 PM CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # Reason: please do CT abd/pelvis to assess for extension of her pancr Admitting Diagnosis: ASCENDING CHOLANGITIS FINAL REPORT (Cont) vasculature appears within normal limits. | 32 | [
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 716942,
"text": "88F w/ pancreatic CA and recent stent placement in . presented to\n Hospital with fever 104 and weakness x3days.\n Neuro: alert and oriented x3, afebrile. No c/o pain.\n Resp: LSC, O2 sat 99% on 2L NC. Strong cough, no c/o increased WOB or\n SOB.\n CV: NSR 80s, BP 100s MAP >60 off levophed, 1L NSx4 given in ED, NS\n L# given on arrival. CVP 7-9.\n GI/GU: foley in place and draining clear yellow urine. +BS, no c/o\n N/V/D. ERCP in AM for stent replacement. DM1, BS in ED was 56, 1amp D50\n given. BS on arrival 170.\n Access: TL CVC, PIV x2.\n"
},
{
"category": "Physician ",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 717230,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Post-ERCP recs:\n NPO overnight\n Clear liquids in AM if pain free, no fevers\n Needs oncology follow-up\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:50 AM\n Piperacillin - 02:44 PM\n Piperacillin/Tazobactam (Zosyn) - 05:38 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96.1\n HR: 65 (59 - 71) bpm\n BP: 149/58(79) {92/44(56) - 156/75(91)} mmHg\n RR: 17 (13 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 7 (-1 - 9)mmHg\n Total In:\n 4,519 mL\n 847 mL\n PO:\n TF:\n IVF:\n 4,519 mL\n 847 mL\n Blood products:\n Total out:\n 1,865 mL\n 440 mL\n Urine:\n 1,865 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,654 mL\n 407 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///15/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Abd: Tenderness LUQ>RUQ\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : , No(t) Bronchial: , No(t) Wheezes\n : , No(t) Diminished: , No(t) Absent : )\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 135 K/uL\n 9.1 g/dL\n 131 mg/dL\n 1.3 mg/dL\n 15 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.4 %\n 22.1 K/uL\n [image002.jpg]\n 05:54 AM\n 06:00 PM\n 06:03 PM\n 05:24 AM\n WBC\n 28.6\n 20.6\n 22.1\n Hct\n 27.8\n 28.2\n 28.4\n Plt\n 153\n 147\n 135\n Cr\n 1.6\n 1.3\n 1.3\n Glucose\n 120\n 129\n 131\n Other labs: PT / PTT / INR:14.1/27.3/1.2, CK / CKMB / Troponin-T:266//,\n ALT / AST:129/60, Alk Phos / T Bili:147/1.9, Amylase / Lipase:80/54,\n Differential-Neuts:95.5 %, Lymph:2.1 %, Mono:2.1 %, Eos:0.1 %, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:217 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 86F with hx of pancreatic CA s/p biliary stenting presenting with\n ascending cholangitis. S/P ERCP revision of stent.\n .\n #: Septic Shock: Resolved with decompression of CBD, broad spectrum\n ABX. As per ERCP frank puss drained\n - BP- excellent to elevated\n - Transfuse to 21\n - Continue Zosyn, vanc (enterrococcus)\n - Follow-Up BCx here and at OSH\n .\n #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB\n in setting of a stent 1.4cm in the CBD. ERCP drained frank pus, patient\n improved greatly clinically with ABX and ERCP drainage.\n - IV Zosyn for broad spectrum GNR coverage, vanc for enterococcus.\n - Clears ADAT\n .\n # Gap Metabolic Acidosis: Gap closing from 14-> 12, low bicarb with\n elevated chloride most likely secondary to NS resuscitation.\n - Trend bicarb, gap\n - IVF PRN (LR)\n .\n #: : Cr 1.7 from baseline 1.0 to 1.7 now down to 1.3 today. DDx\n Pre-renal from hypoperfusion in the setting of septic shock, as\n improved with IVF, resolution of shock.\n - IVF\n - Avoid Nephrotoxins\n - Trend\n .\n # Myositis: Pt on long term steroids and methotrexate. Pt currently on\n 10mg prednisone.\n - Check CPK\n - Check am Cortisol given long term steroids\n .\n #Oncology: Patient without a tissue diagnosis, and interested in\n knowing her options.\n -needs either floor onc consult or outpatient onc follow-up\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:46 AM\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer: Ranitidine\n VAP:\n Comments:\n Communication: patient, SON : MD\n Code status: Full code\n Disposition: Call out\n ------ Protected Section ------\n ICU Attending:\n My earlier note was lost by the Metavision system.\n I interviewed and examined the patient at approximately 10 AM today.\n Details of recent history and data are outlined above by Dr.\n .\n Patient continues to have abdominal pain, but is generally feeling\n better following ERCP and stent placement. No dyspnea. No\n lightheadedness.\n On exam, the patient was awake and alert and oriented, and comfortable\n appearing. Mucus membranes were slightly dry. Chest revealed\n symmetrical movment with rare rales. PMI was not displaced. S1 and S2\n were soft. No gallop. Abdominal exam notable for both LUQ and RUQ\n tenderness, greater on left than right. Abdominal sounds present. There\n was trace peripheral edema.\n Labs notable for a metabolic acidosis, improving LFTs, and persistent\n anemia.\n IMP/Plan:\n CHOLANGITIS\n PANCREATIC MASS\n ANEMIA\n METABOLIC ACIDOSIS\n Patient continues on antibiotics for cholangitis. Symptoms and labs\n improving post stent placement. Hemodynamically stable.\n Metabolic acidosis likely combination of anion gap (lactate and renal\n failure) and non-gap (due to fluid resuscitation with NS). Renal\n function beginning to improve. If patient needs additional lV fluid,\n would use Lactated Ringers.\n Hct stable. Not at transfusion threshold.\n Time: 25 mins.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:13 ------\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 717231,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n .H/O cancer (Malignant Neoplasm), Cholangiocarcinoma / Gallbladder\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 717167,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Post-ERCP recs:\n NPO overnight\n Clear liquids in AM if pain free, no fevers\n Needs oncology follow-up\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:50 AM\n Piperacillin - 02:44 PM\n Piperacillin/Tazobactam (Zosyn) - 05:38 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96.1\n HR: 65 (59 - 71) bpm\n BP: 149/58(79) {92/44(56) - 156/75(91)} mmHg\n RR: 17 (13 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 7 (-1 - 9)mmHg\n Total In:\n 4,519 mL\n 847 mL\n PO:\n TF:\n IVF:\n 4,519 mL\n 847 mL\n Blood products:\n Total out:\n 1,865 mL\n 440 mL\n Urine:\n 1,865 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,654 mL\n 407 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///15/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 135 K/uL\n 9.1 g/dL\n 131 mg/dL\n 1.3 mg/dL\n 15 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.4 %\n 22.1 K/uL\n [image002.jpg]\n 05:54 AM\n 06:00 PM\n 06:03 PM\n 05:24 AM\n WBC\n 28.6\n 20.6\n 22.1\n Hct\n 27.8\n 28.2\n 28.4\n Plt\n 153\n 147\n 135\n Cr\n 1.6\n 1.3\n 1.3\n Glucose\n 120\n 129\n 131\n Other labs: PT / PTT / INR:14.1/27.3/1.2, CK / CKMB / Troponin-T:266//,\n ALT / AST:129/60, Alk Phos / T Bili:147/1.9, Amylase / Lipase:80/54,\n Differential-Neuts:95.5 %, Lymph:2.1 %, Mono:2.1 %, Eos:0.1 %, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:217 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 86F with hx of pancreatic CA s/p biliary stenting presenting with\n ascending cholangitis. S/P ERCP revision of stent.\n .\n #: Septic Shock: Resolved with decompression of CBD, broad spectrum\n ABX. As per ERCP frank puss drained\n - BP- excellent to elevated\n - Transfuse to 21\n - Continue Zosyn, vanc (enterrococcus)\n - Follow-Up BCx here and at OSH\n .\n #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB\n in setting of a stent 1.4cm in the CBD. ERCP drained frank pus, patient\n improved greatly clinically with ABX and ERCP drainage.\n - IV Zosyn for broad spectrum GNR coverage, vanc for enterococcus.\n - Clears ADAT\n .\n # Gap Metabolic Acidosis: Gap closing from 14-> 12, low bicarb with\n elevated chloride most likely secondary to NS resuscitation.\n - Trend bicarb, gap\n - IVF PRN (LR)\n .\n #: : Cr 1.7 from baseline 1.0 to 1.7 now down to 1.3 today. DDx\n Pre-renal from hypoperfusion in the setting of septic shock, as\n improved with IVF, resolution of shock.\n - IVF\n - Avoid Nephrotoxins\n - Trend\n .\n # Myositis: Pt on long term steroids and methotrexate. Pt currently on\n 10mg prednisone.\n - Check CPK\n - Check am Cortisol given long term steroids\n .\n #Oncology: Patient without a tissue diagnosis, and interested in\n knowing her options.\n -needs either floor onc consult or outpatient onc follow-up\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:46 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Call out\n"
},
{
"category": "Physician ",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 717200,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Post-ERCP recs:\n NPO overnight\n Clear liquids in AM if pain free, no fevers\n Needs oncology follow-up\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:50 AM\n Piperacillin - 02:44 PM\n Piperacillin/Tazobactam (Zosyn) - 05:38 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96.1\n HR: 65 (59 - 71) bpm\n BP: 149/58(79) {92/44(56) - 156/75(91)} mmHg\n RR: 17 (13 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 7 (-1 - 9)mmHg\n Total In:\n 4,519 mL\n 847 mL\n PO:\n TF:\n IVF:\n 4,519 mL\n 847 mL\n Blood products:\n Total out:\n 1,865 mL\n 440 mL\n Urine:\n 1,865 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,654 mL\n 407 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///15/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Abd: Tenderness LUQ>RUQ\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : , No(t) Bronchial: , No(t) Wheezes\n : , No(t) Diminished: , No(t) Absent : )\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 135 K/uL\n 9.1 g/dL\n 131 mg/dL\n 1.3 mg/dL\n 15 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.4 %\n 22.1 K/uL\n [image002.jpg]\n 05:54 AM\n 06:00 PM\n 06:03 PM\n 05:24 AM\n WBC\n 28.6\n 20.6\n 22.1\n Hct\n 27.8\n 28.2\n 28.4\n Plt\n 153\n 147\n 135\n Cr\n 1.6\n 1.3\n 1.3\n Glucose\n 120\n 129\n 131\n Other labs: PT / PTT / INR:14.1/27.3/1.2, CK / CKMB / Troponin-T:266//,\n ALT / AST:129/60, Alk Phos / T Bili:147/1.9, Amylase / Lipase:80/54,\n Differential-Neuts:95.5 %, Lymph:2.1 %, Mono:2.1 %, Eos:0.1 %, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:217 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 86F with hx of pancreatic CA s/p biliary stenting presenting with\n ascending cholangitis. S/P ERCP revision of stent.\n .\n #: Septic Shock: Resolved with decompression of CBD, broad spectrum\n ABX. As per ERCP frank puss drained\n - BP- excellent to elevated\n - Transfuse to 21\n - Continue Zosyn, vanc (enterrococcus)\n - Follow-Up BCx here and at OSH\n .\n #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB\n in setting of a stent 1.4cm in the CBD. ERCP drained frank pus, patient\n improved greatly clinically with ABX and ERCP drainage.\n - IV Zosyn for broad spectrum GNR coverage, vanc for enterococcus.\n - Clears ADAT\n .\n # Gap Metabolic Acidosis: Gap closing from 14-> 12, low bicarb with\n elevated chloride most likely secondary to NS resuscitation.\n - Trend bicarb, gap\n - IVF PRN (LR)\n .\n #: : Cr 1.7 from baseline 1.0 to 1.7 now down to 1.3 today. DDx\n Pre-renal from hypoperfusion in the setting of septic shock, as\n improved with IVF, resolution of shock.\n - IVF\n - Avoid Nephrotoxins\n - Trend\n .\n # Myositis: Pt on long term steroids and methotrexate. Pt currently on\n 10mg prednisone.\n - Check CPK\n - Check am Cortisol given long term steroids\n .\n #Oncology: Patient without a tissue diagnosis, and interested in\n knowing her options.\n -needs either floor onc consult or outpatient onc follow-up\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:46 AM\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer: Ranitidine\n VAP:\n Comments:\n Communication: patient, SON : MD\n Code status: Full code\n Disposition: Call out\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 716998,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 717064,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 717065,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n ERCP done stent removed frank pus noted sent for tests new\n metal sstent placed.\n .H/O cancer (Malignant Neoplasm), Cholangiocarcinoma / Gallbladder\n Assessment:\n Pt denies pain or nausea but states that belly does not feel good .\n belly soft ,pos bs passing flatus s/b team and ERCP team.\n Temp 97.8 po sr in 60-70\ns no ectopy noted. Bp initially high 90\ns cvp\n 4-6. current 110-120/70.\n c/o of headache resolved with tylenol.\n Action:\n Continue to monitor for pain.\n Response:\n Plan:\n . Give dexometomidate and propofol for procedure recovered in unit\n given started vancomycin and continued on Zosyn.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 717066,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n ERCP done stent removed frank pus noted sent for tests new\n metal stent placed. Given dexanetomidine 25 and propofo l 120 mcgl for\n procedure by anaes thesia also some neo. recovered in unit pt\n tolerated procedure well and remained stable throughout recovery.please\n see aneas tesi note for further details.\n .H/O cancer (Malignant Neoplasm), Cholangiocarcinoma / Gallbladder\n Assessment:\n Pt denies pain or nausea but states that belly does not feel good .\n belly soft ,pos bs passing flatus s/b team and ERCP team.\n Very fiesty aoox3 mae to command very involved in care.\n Temp 97.8 po sr in 60-70\ns no ectopy noted. Bp initially high 90\ns cvp\n 4-6. current 110-120/70.\n u/o @ 100 mls/hr. clear yellow urine.\n c/o of headache resolved with tylenol.\n Action:\n Continue to monitor for pain.\n Monitored hemodynamics\n Repleted lytes as ordered.\n Antibiotics as ordered.\n Running 100 mls ns /hr pt npo except meds may have some icechips\n Bs 150 no coverage given as pt npo.\n Wbc down to 20.8 from 28 this am. Cr stable .\n Response:\n Pt remain stable with good urine output. and appears comfortable\n sleeping in short naps.\n Plan:\n Continue to monitor hemo dynamics\n Labs as ordered.\n Poss start clears in am .\n Of note pt cvp line disconected at transducer found large amount of\n blood and clots in bed. Team aware . hct sent on finding was 28.2\n increased slightly for 27.9. pt aware of blood loss and awre of results\n of hct.\n"
},
{
"category": "Physician ",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 716962,
"text": "Chief Complaint: Septic Shock\n HPI:\n 86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n .\n Upon arrival to the floor the pt is resting comfortably. She states she\n feels improved. She denies headache, shaking chills, chest pain,\n shortness of breath. She reports mild right upper quadrant pain and\n yellowing of the eyes.\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 06:09 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Prednisone 10mg PO Daily\n Methotrexate 15mg PO Friday\n Aspirin 81mg PO Daily\n Hydrochlorothiazide 25mg PO Daily\n Lisinopril 20mg PO QHS\n Folic Acid 1mg PO Daily\n Fosamax 70mg PO once a week.\n Insulin Glargine 100 unit/mL Solution Sig: Four (4) units\n Subcutaneous After breakfast.\n Calcium 600 + D(3)\n Ergocalciferol (Vitamin D2) Oral\n Multi-Vitamin HP/Minerals Capsule Oral\n Omega-3 Fatty Acids Oral\n Past medical history:\n Family history:\n Social History:\n # IDDM2 for five years\n # Necrotizing Myositis s/p statin 3 years ago; continues with\n methotrexate\n and prednisone taper\n # Hypertension\n # Anxiety\n Occupation: Former Professor\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in . No history of smoking, drinking or\n recreational drug use.\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Seizure\n Flowsheet Data as of 06:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 77 (77 - 85) bpm\n BP: 94/49(59) {94/49(59) - 161/52(82)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (8 - 13)mmHg\n Total In:\n 2,107 mL\n PO:\n TF:\n IVF:\n 2,107 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,907 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : , No(t) Bronchial: , No(t) Wheezes\n : , No(t) Diminished: , No(t) Absent : )\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 153 K/uL\n 9.1 g/dL\n 120 mg/dL\n 1.6 mg/dL\n 25 mg/dL\n 18 mEq/L\n 110 mEq/L\n 3.3 mEq/L\n 138 mEq/L\n 27.8 %\n 28.6 K/uL\n [image002.jpg]\n \n 2:33 A1/8/ 05:54 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 28.6\n Hct\n 27.8\n Plt\n 153\n Cr\n 1.6\n Glucose\n 120\n Other labs: PT / PTT / INR:15.0//1.3, CK / CKMB / Troponin-T:266//, ALT\n / AST:156/106, Alk Phos / T Bili:136/4.3, Amylase / Lipase:56/18,\n Lactic Acid:1.8 mmol/L, Ca++:6.3 mg/dL, Mg++:1.5 mg/dL, PO4:3.0 mg/dL\n CXR: No acute cardiopulmonary process (my read)\n .\n ECG: Sinus Arrhythmia, Rate 99, normal axis, normal intervals, No ST-T\n changes.\n .\n RUQ U/S:\n Stent in the CBD, which measures 1.4cm. intrahepatic ducts are dilated\n to 4mm. Small stones and sluge in the GB, which is slightly distended,\n but no wall thickening or peri-gallbladder fluid.\n Assessment and Plan\n 86F with hx of pancreatic CA s/p biliary stenting presenting with\n ascending cholangitis.\n .\n #: Septic Shock: Pt with fever, leukocytosis, increased LFTs in setting\n of dilated CBD, thus infected source likely biliary, now on 5th liter\n of NS requiring pressors. Initial lactate 2.2 down to 1.8. CVL placed\n in ED.\n - Maintain CVP 8-12\n - Maps >65 with IVF, Levophed as needed\n - Consider A-Line\n - Check Sv02\n - Maintain UOP 30cc/hr with NS IVF Bolus PRN\n - Maintain HCT>30\n - Continue Zosyn\n - Follow-Up BCx here and at OSH\n - Follow-Up ERCP recs and consider ERCP in AM\n - Check cortisol, consider stress dose steroids given chronic steroid\n use.\n .\n #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB\n in setting of a stent 1.4cm in the CBD. Ultrasound revealing dilated\n intrahepatic ducts at 4mm and radiographic findings suggestive of small\n stones and sluge in the GB. No evidence of acute cholecystitis.\n - Sepsis management as above\n - Currently covering with IV Zosyn for broad spectrum GNR coverage.\n .\n # Gap Metabolic Acidosis: Bicarb of 17 on initial labs with gap of 14.\n Lactate slightly elevated at 2.2. Diarrhea (Non-Gap) may also be\n contributing to decreased bicarb.\n - ABG to confirm acid-base status\n - Trend bicarb, gap\n - IVF PRN\n .\n # Hypoglycemia: Pt hypoglycemic to 56 while in ED, received 1 Amp of\n D50. DDx includes sepsis, decreased PO in setting of regular insulin\n dosing.\n - QIDFS with HISS\n #: : Cr 1.7 from baseline 1.0 to 1.4. Pt with 300 UOP at OSH. BUN at\n 29 up from 12. DDx Pre-renal from hypoperfusion in the setting of\n septic shock, less likely post-renal, intrinsic.\n - IVF\n - Consider urine lytes\n - renally dose meds\n - Avoid Nephrotoxins\n .\n # Myositis: Pt on long term steroids and methotrexate. Pt currently on\n 10mg prednisone.\n - Check CPK\n - Check am Cortisol given long term steroids\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:46 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 716963,
"text": "88F w/ pancreatic CA and recent stent placement in . presented to\n Hospital with fever 104 and weakness x3days.\n Neuro: alert and oriented x3, afebrile. No c/o pain.\n Resp: LSC, O2 sat 99% on 2L NC. Strong cough, no c/o increased WOB or\n SOB.\n CV: NSR 80s, BP 100s MAP >60 off levophed, 1L NSx4 given in ED, NS\n L# given on arrival. CVP 7-9.\n GI/GU: foley in place and draining clear yellow urine. +BS, no c/o\n N/V/D. ERCP in AM for stent replacement. DM1, BS in ED was 56, 1amp D50\n given. BS on arrival 170, no coverage given since pt is NPO.\n Access: TL CVC, needs to be pulled back and recked, PIV x2.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 717055,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 717058,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n"
},
{
"category": "Physician ",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 716965,
"text": "Chief Complaint: Septic Shock\n HPI:\n 86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n .\n Upon arrival to the floor the pt is resting comfortably. She states she\n feels improved. She denies headache, shaking chills, chest pain,\n shortness of breath. She reports mild right upper quadrant pain and\n yellowing of the eyes.\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 06:09 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Prednisone 10mg PO Daily\n Methotrexate 15mg PO Friday\n Aspirin 81mg PO Daily\n Hydrochlorothiazide 25mg PO Daily\n Lisinopril 20mg PO QHS\n Folic Acid 1mg PO Daily\n Fosamax 70mg PO once a week.\n Insulin Glargine 100 unit/mL Solution Sig: Four (4) units\n Subcutaneous After breakfast.\n Calcium 600 + D(3)\n Ergocalciferol (Vitamin D2) Oral\n Multi-Vitamin HP/Minerals Capsule Oral\n Omega-3 Fatty Acids Oral\n Past medical history:\n Family history:\n Social History:\n # IDDM2 for five years\n # Necrotizing Myositis s/p statin 3 years ago; continues with\n methotrexate\n and prednisone taper\n # Hypertension\n # Anxiety\n Occupation: Former Professor\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in . No history of smoking, drinking or\n recreational drug use.\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Seizure\n Flowsheet Data as of 06:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 77 (77 - 85) bpm\n BP: 94/49(59) {94/49(59) - 161/52(82)} mmHg\n RR: 16 (14 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (8 - 13)mmHg\n Total In:\n 2,107 mL\n PO:\n TF:\n IVF:\n 2,107 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,907 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///18/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : , Crackles : , No(t) Bronchial: , No(t) Wheezes\n : , No(t) Diminished: , No(t) Absent : )\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 153 K/uL\n 9.1 g/dL\n 120 mg/dL\n 1.6 mg/dL\n 25 mg/dL\n 18 mEq/L\n 110 mEq/L\n 3.3 mEq/L\n 138 mEq/L\n 27.8 %\n 28.6 K/uL\n [image002.jpg]\n \n 2:33 A1/8/ 05:54 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 28.6\n Hct\n 27.8\n Plt\n 153\n Cr\n 1.6\n Glucose\n 120\n Other labs: PT / PTT / INR:15.0//1.3, CK / CKMB / Troponin-T:266//, ALT\n / AST:156/106, Alk Phos / T Bili:136/4.3, Amylase / Lipase:56/18,\n Lactic Acid:1.8 mmol/L, Ca++:6.3 mg/dL, Mg++:1.5 mg/dL, PO4:3.0 mg/dL\n CXR: No acute cardiopulmonary process (my read)\n .\n ECG: Sinus Arrhythmia, Rate 99, normal axis, normal intervals, No ST-T\n changes.\n .\n RUQ U/S:\n Stent in the CBD, which measures 1.4cm. intrahepatic ducts are dilated\n to 4mm. Small stones and sluge in the GB, which is slightly distended,\n but no wall thickening or peri-gallbladder fluid.\n Assessment and Plan\n 86F with hx of pancreatic CA s/p biliary stenting presenting with\n ascending cholangitis.\n .\n #: Septic Shock: Pt with fever, leukocytosis, increased LFTs in setting\n of dilated CBD, thus infected source likely biliary, now on 5th liter\n of NS requiring pressors. Initial lactate 2.2 down to 1.8. CVL placed\n in ED.\n - Maintain CVP 8-12\n - Maps >65 with IVF, Levophed as needed\n - Consider A-Line\n - Check Sv02\n - Maintain UOP 30cc/hr with NS IVF Bolus PRN\n - Maintain HCT>30\n - Continue Zosyn\n - Follow-Up BCx here and at OSH\n - Follow-Up ERCP recs and consider ERCP in AM\n - Check cortisol, consider stress dose steroids given chronic steroid\n use.\n .\n #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB\n in setting of a stent 1.4cm in the CBD. Ultrasound revealing dilated\n intrahepatic ducts at 4mm and radiographic findings suggestive of small\n stones and sluge in the GB. No evidence of acute cholecystitis.\n - Sepsis management as above\n - Currently covering with IV Zosyn for broad spectrum GNR coverage.\n .\n # Gap Metabolic Acidosis: Bicarb of 17 on initial labs with gap of 14.\n Lactate slightly elevated at 2.2. Diarrhea (Non-Gap) may also be\n contributing to decreased bicarb.\n - ABG to confirm acid-base status\n - Trend bicarb, gap\n - IVF PRN\n .\n # Hypoglycemia: Pt hypoglycemic to 56 while in ED, received 1 Amp of\n D50. DDx includes sepsis, decreased PO in setting of regular insulin\n dosing.\n - QIDFS with HISS\n #: : Cr 1.7 from baseline 1.0 to 1.4. Pt with 300 UOP at OSH. BUN at\n 29 up from 12. DDx Pre-renal from hypoperfusion in the setting of\n septic shock, less likely post-renal, intrinsic.\n - IVF\n - Consider urine lytes\n - renally dose meds\n - Avoid Nephrotoxins\n .\n # Myositis: Pt on long term steroids and methotrexate. Pt currently on\n 10mg prednisone.\n - Check CPK\n - Check am Cortisol given long term steroids\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:46 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Overnight Intensivist Addendum\n I saw and examined the patient, and was physically present with Dr.\n for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points.\n Briefly, 86 y/o recently diagnosed pancreatic cancer, s/p CBD stent\n here with septic shock.\n 2 days of emesis, diarrhea, shaking chills, then confusion, brought\n into hospital where she was noted to have a T104.9,\n leukocytosis, ARF, acidosis. Given a dose of Zosyn and sent to \n for further evaluation. Here, initially normotensive, then dropped her\n SBP to 70, underwent RIJ CVL placement and started on levophed.\n Currently reports she feels significantly improved since the ED.\n PMHx reviewed, notable for necrotizing myositis s/p statin use 3 y/ago,\n on methotrexate and a very slow prednisone taper\n All, Meds, Social, reviewed as per resident note. Fam hx NC for\n pancreatitic or liver dz.\n VS T97.8 P80\ns BP 94/59-108/49, CVP 8. Total in ~6L IVF (from ED to\n current) ~?300cc urine (~100 in past ~1.5hr). Sat 98% on 2L NC.\n Exam notable for mild abd tenderness RUQ. Awake, alert, ungs clear, RRR\n S1 S2, no edema.\n Labs notable for lactate 2.2 -> 1.8\n WBC 25, Hct 30, INR 1.3. Chem with bicarb 19, gap 14, Cr 1.7 (baseline\n 1.0-1.2), Bili 4.9, Alk Phos 169.\n CXR, EKG reviewed. CVL in RA.\n 86 y/o pancreatic ca here with septic shock, ARF. Agree with plan as\n above to continue on sepsis protocol with IVF / pressors; we will check\n a central venous gas. Likely source is biliary, and will need ERCP\n this AM and coverage with Zosyn. Given chronic prednisone use and\n shock would give stress dose steroids. CVL will be pulled back to\n SVC/RA junction.\n Remainder of plan as above.\n Pt is critically ill. CC time 40 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 07:03 AM ------\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 717146,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n Upon arrival initial vitals 100.8 137/92 98 18 98% on RA. Looked well\n appearing. Clear lungs. RUQ tenderness. WBC 25, TB 4.9, Cr 1.7, Lactate\n 2.2, UA neg, RUQ revealed stent remains in CBD and a dilated\n intrahepatic duct. The pt was noted to be hypoglycemic and subsequently\n received an Amp D50, KCL. ERCP consulted (pending). Subsequently the pt\n SBP dropped to 70, received 4L of NS, 40meq KCl, Foley with 200cc UOP.\n Morphine 2mg IV x1, RIJ placed. Prior to transfer to the floor vitals\n 82 108/47 98% RA on .12 of Levophed.\n ERCP done stent removed frank pus noted sent for tests new\n metal stent placed. Given dexanetomidine 25 and propofo l 120 mcgl for\n procedure by anaes thesia also some neo. recovered in unit pt\n tolerated procedure well and remained stable throughout recovery.please\n see aneas tesi note for further details.\n .H/O cancer (Malignant Neoplasm), Cholangiocarcinoma / Gallbladder\n Assessment:\n Pt dx with pancreatic ca. mild compaints of right upper and lower quad\n pain. Bs pos in all quads. No stool this shift and pt is passing\n flatus.\n Action:\n pt is on antibiotics\n Response:\n Pt is anxious to speak to the oncology people as she would like to know\n more about her pancreatic ca. pt hemodynamics have been stable\n throughout the shift\n Plan:\n Pt will be monitored for increased temps and wbc\ns. is taking ice chips\n and sips with no problems noted and will advance today. be called\n out to the floor. Current plan is for oncology to follow pt on out\n patient status.\n"
},
{
"category": "Physician ",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 717154,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Post-ERCP recs:\n NPO overnight\n Clear liquids in AM if pain free, no fevers\n Needs oncology follow-up\n Allergies:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 10:50 AM\n Piperacillin - 02:44 PM\n Piperacillin/Tazobactam (Zosyn) - 05:38 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 05:38 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.6\nC (96.1\n HR: 65 (59 - 71) bpm\n BP: 149/58(79) {92/44(56) - 156/75(91)} mmHg\n RR: 17 (13 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SB (Sinus Bradycardia)\n CVP: 7 (-1 - 9)mmHg\n Total In:\n 4,519 mL\n 847 mL\n PO:\n TF:\n IVF:\n 4,519 mL\n 847 mL\n Blood products:\n Total out:\n 1,865 mL\n 440 mL\n Urine:\n 1,865 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,654 mL\n 407 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///15/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 135 K/uL\n 9.1 g/dL\n 131 mg/dL\n 1.3 mg/dL\n 15 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 116 mEq/L\n 143 mEq/L\n 28.4 %\n 22.1 K/uL\n [image002.jpg]\n 05:54 AM\n 06:00 PM\n 06:03 PM\n 05:24 AM\n WBC\n 28.6\n 20.6\n 22.1\n Hct\n 27.8\n 28.2\n 28.4\n Plt\n 153\n 147\n 135\n Cr\n 1.6\n 1.3\n 1.3\n Glucose\n 120\n 129\n 131\n Other labs: PT / PTT / INR:14.1/27.3/1.2, CK / CKMB / Troponin-T:266//,\n ALT / AST:129/60, Alk Phos / T Bili:147/1.9, Amylase / Lipase:80/54,\n Differential-Neuts:95.5 %, Lymph:2.1 %, Mono:2.1 %, Eos:0.1 %, Lactic\n Acid:1.8 mmol/L, Albumin:2.7 g/dL, LDH:217 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 86F with hx of pancreatic CA s/p biliary stenting presenting with\n ascending cholangitis.\n .\n #: Septic Shock: Resolved with decompression of CBD, broad spectrum\n ABX. As per ERCP frank puss drained\n - Maintain CVP 8-12\n - Maps >65 with IVF, Levophed as needed\n - Consider A-Line\n - Check Sv02\n - Maintain UOP 30cc/hr with NS IVF Bolus PRN\n - Maintain HCT>30\n - Continue Zosyn\n - Follow-Up BCx here and at OSH\n - Follow-Up ERCP recs and consider ERCP in AM\n - Check cortisol, consider stress dose steroids given chronic steroid\n use.\n .\n #: Ascending Cholangitis: Pt with elevated transaminases, Alk Phos, TB\n in setting of a stent 1.4cm in the CBD. Ultrasound revealing dilated\n intrahepatic ducts at 4mm and radiographic findings suggestive of small\n stones and sluge in the GB. No evidence of acute cholecystitis.\n - Sepsis management as above\n - Currently covering with IV Zosyn for broad spectrum GNR coverage.\n .\n # Gap Metabolic Acidosis: Bicarb of 17 on initial labs with gap of 14.\n Lactate slightly elevated at 2.2. Diarrhea (Non-Gap) may also be\n contributing to decreased bicarb.\n - ABG to confirm acid-base status\n - Trend bicarb, gap\n - IVF PRN\n .\n # Hypoglycemia: Pt hypoglycemic to 56 while in ED, received 1 Amp of\n D50. DDx includes sepsis, decreased PO in setting of regular insulin\n dosing.\n - QIDFS with HISS\n #: : Cr 1.7 from baseline 1.0 to 1.4. Pt with 300 UOP at OSH. BUN at\n 29 up from 12. DDx Pre-renal from hypoperfusion in the setting of\n septic shock, less likely post-renal, intrinsic.\n - IVF\n - Consider urine lytes\n - renally dose meds\n - Avoid Nephrotoxins\n .\n # Myositis: Pt on long term steroids and methotrexate. Pt currently on\n 10mg prednisone.\n - Check CPK\n - Check am Cortisol given long term steroids\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:45 AM\n 20 Gauge - 04:46 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 716940,
"text": "88F w/ pancreatic CA and recent stent placement in . presented to\n Hospital with fever 104 and weakness x3days.\n Neuro: alert and oriented x3, afebrile. No c/o pain.\n Resp: LSC, O2 sat 99% on 2L NC. Strong cough, no c/o increased WOB or\n SOB.\n CV: NSR 80s, BP 100s MAP >60 off levophed, 1L NSx4 given in ED, NS L#5\n given on arrival.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 717247,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n On ERCP wsa done, a stent was removed with frank pus noted, this\n was sent for tests and a new metal stent was placed.\n .H/O cancer (Malignant Neoplasm), Cholangiocarcinoma / Gallbladder\n Assessment:\n Pt states that she still has some abd pain with palpation though much\n improved from yesterday, afebrile, WBC 22K, BP 150-160s\n Action:\n Started on clears and advanced to full liquids, OOB to a chair, conts\n on abx\n Response:\n Tolerating food, afebrile, BP up\n Plan:\n Follow labs, pt is very interested in knowing everything about her\n cancer, onc to be following, advance diet as she tolerates, restart her\n BP meds when able.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ASCENDING CHOLANGITIS\n Code status:\n Full code\n Height:\n Admission weight:\n 60.1 kg\n Daily weight:\n Allergies/Reactions:\n Lipitor (Oral) (Atorvastatin Calcium)\n Unknown;\n Corgard (Oral) (Nadolol)\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: CAD\n Additional history: pancreatic CA, declined whipple.\n # IDDM2 for five years\n # Necrotizing Myositis s/p statin 3 years ago; continues with\n methotrexate\n and prednisone taper\n # Hypertension\n # Anxiety\n Surgery / Procedure and date: stent placement \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:154\n D:90\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 30 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,417 mL\n 24h total out:\n 910 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 05:24 AM\n Potassium:\n 3.8 mEq/L\n 05:24 AM\n Chloride:\n 116 mEq/L\n 05:24 AM\n CO2:\n 15 mEq/L\n 05:24 AM\n BUN:\n 23 mg/dL\n 05:24 AM\n Creatinine:\n 1.3 mg/dL\n 05:24 AM\n Glucose:\n 131 mg/dL\n 05:24 AM\n Hematocrit:\n 28.4 %\n 05:24 AM\n Finger Stick Glucose:\n 228\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 716953,
"text": "88F w/ pancreatic CA and recent stent placement in . presented to\n Hospital with fever 104 and weakness x3days.\n Neuro: alert and oriented x3, afebrile. No c/o pain.\n Resp: LSC, O2 sat 99% on 2L NC. Strong cough, no c/o increased WOB or\n SOB.\n CV: NSR 80s, BP 100s MAP >60 off levophed, 1L NSx4 given in ED, NS\n L# given on arrival. CVP 7-9.\n GI/GU: foley in place and draining clear yellow urine. +BS, no c/o\n N/V/D. ERCP in AM for stent replacement. DM1, BS in ED was 56, 1amp D50\n given. BS on arrival 170.\n Access: TL CVC, needs to be pulled back and recked, PIV x2.\n"
},
{
"category": "Nursing",
"chartdate": "2106-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 717232,
"text": "86F with hx of newly diagnosed pancreatic CA, s/p palliative CBD stent\n presents with persistent vomitting, diarrhea, fevers. The pt reports\n her symptoms began at 2am Tuesday night during which she had episodes\n of emesis, diarrhea and shaking chills. These symptoms continued into\n Wednesday where she reported decreased PO. Per the pt, on Thursday she\n developed confusion and subsequently was brought to an OSH ED. Upon\n arrival to the OSH, initial vitals 100.3 tm 104.9, 165/68 92 16 96%2L,\n FS 110, the pt received a dose of Zosyn 3.375mg, KCL 20meq, 1L NS, and\n the pt was subsequently transferred to for presumed ascending\n cholangitis.\n .\n On ERCP wsa done, a stent was removed with frank pus noted, this\n was sent for tests and a new metal stent was placed.\n .H/O cancer (Malignant Neoplasm), Cholangiocarcinoma / Gallbladder\n Assessment:\n Pt states that she still has some abd pain with palpation though much\n improved from yesterday, afebrile, WBC 22K, BP 150-160s\n Action:\n Started on clears and advanced to full liquids, OOB to a chair, conts\n on abx\n Response:\n Tolerating food, afebrile, BP up\n Plan:\n Follow labs, pt is very interested in knowing everything about her\n cancer, onc to be following, advance diet as she tolerates, restart her\n BP meds when able.\n"
},
{
"category": "ECG",
"chartdate": "2106-12-02 00:00:00.000",
"description": "Report",
"row_id": 239919,
"text": "Sinus bradycardia. Possible prior anterior myocardial infarction.\nQ-T interval prolongation. Compared to the previous tracing of \nthe rate has increased. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-11-29 00:00:00.000",
"description": "Report",
"row_id": 239920,
"text": "Sinus bradycardia. The Q-T interval is prolonged. There is a late transition\nwith tiny R waves in the anterior leads consistent with possible prior anterior\nmyocardial infarction. Non-specific ST-T wave changes. Low voltage in the\nprecordial leads. Compared to the previous tracing the rate is slower and\nthe Q-T interval is longer.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-11-25 00:00:00.000",
"description": "Report",
"row_id": 239921,
"text": "Sinus rhythm at upper limits of normal rate with sinus arrhythmia. Borderline\nlow voltage. Q waves in leads V1-V2. Consider septal myocardial infarction.\nSince the previous tracing of the rate is faster.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1115714,
"text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for volume overload\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with pancreatic cancer and sepsis\n REASON FOR THIS EXAMINATION:\n evaluate for volume overload\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Pancreatic cancer and sepsis.\n\n FINDINGS: There is a small left pleural effusion. Patchy alveolar infiltrate\n in the left lower lung that is increased compared to the prior study. Right\n IJ line is unchanged. There is a new stent in the right upper quadrant.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-26 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1115640,
"text": " 3:14 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: ercp films \n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with pancreatic cancer and intra-pancreatic bile duct\n stricture who had a previously placed plastic biliary stent.... comes in with\n cholangitis. ERCP -> removed plastic stent, inserted a metal stent\n REASON FOR THIS EXAMINATION:\n ercp films \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known pancreatic cancer with previously placed CBD stent. Now\n with cholangitis\n\n FINDINGS: Seven fluoroscopic ERCP images are included. Initial image\n demonstrates a previously placed pancreatic stent, which per report appeared\n clogged. This stent was removed with, per report, drainage of pus and sludge.\n Subsequent images demonstrate cannulation of the common bile duct. Contrast\n injection demonstrates a stricture at the lower third of the common bile duct\n with moderate postobstructive dilation. A metal biliary stent was placed.\n There are degenerative changes of the thoracic and lumbar spine.\n\n For further details, please see the endoscopy report in the online medical\n record.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1115530,
"text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? line placement\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with new R IJ\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n WET READ: JMGw 3:32 AM\n right IJ line tip in the right atrium. withdrawal by 4.5 cm would put it into\n the low svc. otherwise stable appearance to chest compared to study 4 hours\n prior\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with new right IJ. Line placement.\n\n COMPARISON: Chest radiograph .\n\n CHEST RADIOGRAPH PORTABLE AP VIEW: A new right IJ line tip ends in the right\n atrium. Recommended withdrawal by 4.5 cm. The lungs are clear and well\n expanded. There is no pneumothorax or pleural effusion. The\n cardiomediastinal silhouette, hilar contours and pulmonary vasculature are\n normal.\n\n IMPRESSION: New right IJ line tip ends in the right atrium. Withdrawal by\n 4.5 cm is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1115564,
"text": " 7:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for line placement\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with presumed pancreatic cancer s/p biliary stenting with\n sepsis, right IJ pulled back\n REASON FOR THIS EXAMINATION:\n please eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with presumed pancreatic cancer status post\n biliary stenting with sepsis, right IJ pulled back, please evaluate for line.\n\n COMPARISON: Chest radiograph at 03:08 a.m.\n\n CHEST RADIOGRAPH, PORTABLE AP VIEW: A right IJ line was repositioned, now\n the tip ends at the superior cavoatrial junction. There is no pneumothorax or\n pleural effusion. There is minimal bibasilar lung atelectasis, unchanged.\n The cardiomediastinal silhouette, hilar contours, and pulmonary vasculature\n are normal.\n\n IMPRESSION:\n\n Right IJ line tip ends in the cavoatrial junction. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-29 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1116077,
"text": " 4:39 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: please do CT abd/pelvis to assess for extension of her pancr\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with pancreatic mass of unclear pathology.\n REASON FOR THIS EXAMINATION:\n please do CT abd/pelvis to assess for extension of her pancreatic mass/cancer.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc MON 7:05 PM\n 1. No pancreatic or peri-pancreatic mass visualized. Conceivably, the presence\n of a large metallic CBD stent could have compressed a small mass. The\n pancreatic duct is 4mm, normal in caliber, and there is no parenchymal\n atrophy. Peripancreatic vessels are normally opacified.\n 2. Pneumobilia c/w prior stent and sphincterotomy.\n 3. Moderate bilateral pleural effusions.\n 4. Fluid-filled rectum with little-to-no formed stool seen in the colon;\n trace peritoneal fluid adjacent to right colon. However, no bowel wall\n thickening. Normal appendix.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old woman with pancreatic mass of unclear pathology.\n\n COMPARISON: ERCP exams performed and . Right upper\n quadrant ultrasound of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis before and after administration of intravenous contrast material.\n Post-contrast images were obtained in arterial and venous phases. Multiplanar\n reformatted images were generated.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: At the lung bases, there are\n moderate pleural effusions bilaterally with mild associated atelectasis.\n Otherwise, lungs are clear without consolidation. The heart size is normal\n without pericardial effusion.\n\n In the abdomen, a large caliber metallic stent is present in the CBD,\n extending into the duodenum. Surrounding the stent at its proximal end, above\n the level of the pancreas, there is a circumferential rim of poorly defined,\n abnormal soft tissue density material. This abnormal material contacts the\n vein and common hepatic artery, but does not encase or narrow these\n vessels. The celiac and superior mesenteric arteries are not involved. The\n pancreatic parenchyma at the level of the stent is normally enhancing, without\n focal lesions identified within the pancreatic head. Pancreatic parenchyma\n demonstrates no atrophy. The pancreatic duct is mildly dilated, measuring up\n to 4 mm. to the level of the metal stent with no obvious obstructing mass.\n Peripancreatic arteries and veins are normally opacified. There is no\n peripancreatic lymphadenopathy.\n\n Within the liver, there is a mild degree of pneumobilia, consistent with stent\n placement and sphincterotomy. No focal liver lesions are identified. Hepatic\n (Over)\n\n 4:39 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: please do CT abd/pelvis to assess for extension of her pancr\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vasculature appears within normal limits. The spleen, adrenal glands, stomach\n and duodenum are unremarkable. There is a small hiatal hernia. The kidneys\n enhance and excrete contrast symmetrically without hydronephrosis or renal\n stones. Hypodense renal lesions are noted bilaterally. The largest, at the\n interpolar region of the left kidney measures up to 19 mm and has attenuation\n characteristics consistent with a simple cyst. A smaller hypodense lesion at\n the interpolar region of the right kidney is too small to accurately\n characterize. The abdominal aorta demonstrates atherosclerotic calcification,\n but is normal in caliber and all branches are patent. There is no free air or\n free fluid in the abdomen.\n\n CT PELVIS WITH IV CONTRAST: Loops of large and small bowel demonstrate little\n to no formed stool within the colon. The rectum is filled with fluid density\n material. There is a small amount of simple fluid tracking along the right\n colon. However, there is no bowel wall thickening, and the colon is not\n distended with fluid. Loops of small bowel are normal in caliber. The\n appendix is normal.\n\n The urinary bladder is distended. The uterus contains a large calcified\n fibroid at the fundus. There are no adnexal masses. However, the right ovary\n demonstrates a 2.0 x 1.0 cm cyst. There is a small amount of simple fluid in\n the left cul-de-sac near the rectum. There is no pelvic or inguinal\n lymphadenopathy by size criteria.\n\n OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesion. Mild\n degenerative changes are noted, consisting primarily of bulky osteophytosis.\n\n IMPRESSION:\n\n 1. Abnormal soft tissue density involving the CBD to the level of the\n pancreatic head, surrounding the CBD stent and contacting but not encasing or\n narrowing the main vein and common hepatic artery. There is no\n evidence of mass within the pancreatic head. Given that prior cytology was\n suspicious for adenocarcinoma, findings are consistent with\n cholangiocarcinoma, although the imaging appearance would also support\n inflammatory changes.\n\n 2. Pneumobilia consistent with presence of stent and sphincterotomy.\n\n 3. Moderate bilateral pleural effusions.\n\n 4. Fluid-filled rectum with little to no formed stool seen in the remainder\n of the colon. Trace peritoneal fluid adjacent to the right colon and adjacent\n to the rectum. However, there is no bowel wall thickening. The appendix is\n normal.\n\n (Over)\n\n 4:39 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: please do CT abd/pelvis to assess for extension of her pancr\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. 1 x 2 cm right ovarian cyst which is unusual in a postmenopausal woman.\n Followup ultrasound is recommended.\n\n 6. Fibroid uterus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-12-01 00:00:00.000",
"description": "PELVIS, NON-OBSTETRIC",
"row_id": 1116427,
"text": " 3:01 PM\n PELVIS, NON-OBSTETRIC; PELVIS U.S., TRANSVAGINAL Clip # \n Reason: MASS ON CT PLEASE CHARACTERIZE\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with Right ovarian mass noted on CT\n REASON FOR THIS EXAMINATION:\n please characterize\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Right adnexal mass seen on prior CT from .\n\n TECHNIQUE: Transabdominal and transvaginal ultrasound images of the pelvis\n with the latter for better visualization of pelvic organs were submitted for\n interpretation.\n\n COMPARISON: CT abdomen and pelvis from .\n\n FINDINGS: Uterus measures 5.3 x 3.1 x 3.5 cm and contains a 1.7-cm calcified\n fibroid, also seen on prior CT. Endometrium is difficult to visualize;\n however, there is no definite endometrial thickening. A questionable\n hyperechoic structure in the right adnexa may represent the right ovary, this\n measures up to 1.6 cm. The left adnexa is not visualized. The exam could not\n be continued due to patient's discomfort. Trace amount of pelvic fluid.\n\n IMPRESSION:\n 1. Fibroid uterus with calcified fibroids, compatible with degenerating\n fibroids.\n 2. Right adnexa is not well evaluated due to overlying bowel gas and\n discontinuation of the exam due to patient discomfort. Comparison with prior\n imaging (if available) or an MRI can be obtained for further evaluation of\n right adnexal mass.\n 3. Trace pelvic fluid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-29 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 1116078,
"text": ", P. MED 5S 4:39 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n Reason: please do CT abd/pelvis to assess for extension of her pancr\n Admitting Diagnosis: ASCENDING CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with pancreatic mass of unclear pathology.\n REASON FOR THIS EXAMINATION:\n please do CT abd/pelvis to assess for extension of her pancreatic mass/cancer.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No pancreatic or peri-pancreatic mass visualized. Conceivably, the presence\n of a large metallic CBD stent could have compressed a small mass. The\n pancreatic duct is 4mm, normal in caliber, and there is no parenchymal\n atrophy. Peripancreatic vessels are normally opacified.\n 2. Pneumobilia c/w prior stent and sphincterotomy.\n 3. Moderate bilateral pleural effusions.\n 4. Fluid-filled rectum with little-to-no formed stool seen in the colon;\n trace peritoneal fluid adjacent to right colon. However, no bowel wall\n thickening. Normal appendix.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1115520,
"text": " 11:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with fever\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with fever. Evaluate for pneumonia.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n COMPARISON: None.\n\n FINDINGS: There is slight opacity obscuring the left hemidiaphragm, likely\n atelectasis. Otherwise, the lungs appear clear. The cardiac silhouette,\n hilar, and mediastinal contours appear normal. The aorta is calcified and\n tortuous. There are degenerative changes of the thoracic spine, and\n glenohumeral joints. A stent projects over the right upper quadrant, likely\n in the CBD.\n\n IMPRESSION: Left basilar atelectasis, unlikely pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-11-25 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1115521,
"text": " 11:46 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: FEVER. EVAL FOR BILIARY DIL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with hx biliary stent with fevers\n REASON FOR THIS EXAMINATION:\n eval biliary dilatation\n ______________________________________________________________________________\n WET READ: JMGw 12:21 AM\n stent in the CBD, which measures 1.4cm. intrahepatic ducts are dilated to\n 4mm. small stones and sluge in the GB, which is slightly distended, but no\n wall thickening or peri-gallbladder fluid.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 86-year-old woman with history of biliary stent and fevers.\n Evaluate for biliary dilation.\n\n LIVER ULTRASOUND\n\n COMPARISON: ERCP performed on .\n\n FINDINGS: The liver parenchyma appears normal without masses or lesions.\n There is normal hepatopetal flow within the main portal vein. There is a\n stent within the CBD. The CBD is dilated measuring up to 1.4 cm, measured at\n the level of the porta hepatis. There is intrahepatic biliary ductal dilation\n measuring approximately 4 mm. Within the gallbladder are small stones, and\n sludge. The gallbladder is slightly distended, but there is no apparent wall\n thickening, or pericholecystic fluid. The patient was not tender over the\n liver or gallbladder. There is no free fluid in the upper abdomen. The CBD\n at the level of the pancreas measures 2 mm. No pancreatic mass is identified.\n\n IMPRESSION:\n\n 1. Stent within the CBD, measuring 1.4 cm. Intrahepatic biliary ductal\n dilation to 4 mm.\n\n 2. Stones and sludge within a slightly distended gallbladder, but no wall\n thickening, or pericholecystic fluid. The patient was not tender over the\n gallbladder.\n\n 3. If there is concern for a pancreatic mass, CTA would be recommended.\n\n"
}
] |
94,817 | 108,338 | Primary Reason for Hospitalization: 43 year old woman with decompensated alcoholic cirrhosis/hepatitis complicated by ascites, encephalopathy and a history of SBP and HRS with known grade 3 esophageal varices on subtherapeutic nadolol presenting with dyspnea, with course complicated by esophageal variceal bleed. | Allowing for low lung volumes, the cardiac, mediastinal and hilar contours appear unchanged. Non-specific air-fluid levels in the epigastric region. Low lung volumes with minor basilar atelectasis. Ascites.Conclusions:Extremely limited image quality. Otherwise, the exam is unchanged with minimal left basilar atelectasis. Lungs are low in volume aside from mild left basal atelectasis clear. FINDINGS: The lung volumes are low. No significant difference compared withprevious tracing.TRACING #2 Cardiomediastinal and hilar contours are unremarkable. Hepatopulmonary syndromeWeight (lb): 152BP (mm Hg): 97/54HR (bpm): 103Status: InpatientDate/Time: at 12:02Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. IMPRESSION: No evidence of acute disease. Streaky minor opacities in the lower lungs suggest minor atelectasis. ET tube in standard placement. Cardiomediastinal silhouette is normal. There is no appreciable pleural effusion. Normal tracing. Normal tracing. FINDINGS: The right jugular venous catheter has been withdrawn, the tip is now terminating in the upper right atrium. No pneumothorax. Overall normal LVEF (>55%).RIGHT VENTRICLE: RV not well seen.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. IMPRESSION: Right internal jugular venous catheter now terminates in upper right atrium. TECHNIQUE: Chest, PA and lateral. No pleural effusion or pneumothorax. Sinus rhythm. Sinus rhythm. Otherwise, the lungs appear clear. Views of the upper abdomen are limited but show air-fluid levels within the bowel of the epigastric region. Overall left ventricularsystolic function appears grossly normal (LVEF>55%). The bony structures are unremarkable. PA pressure could not bedetermined due to extremely suboptimal image quality. There are no pleural effusions or pneumothorax. ?CHF. pleural effusion? No previous tracing available for comparison.TRACING #1 Due to suboptimal technical quality, a focalwall motion abnormality cannot be fully excluded. IMPRESSION: AP chest compared to : New right internal jugular line ends in the right atrium would need to be withdrawn 5.5 cm to place it in the low SVC. Evaluate right IJ line. Recommend withdrawal 1-2 cm to terminate in cavoatrial junction. REASON FOR THIS EXAMINATION: {See Clinical Indication Field} No contraindications for IV contrast FINAL REPORT CHEST RADIOGRAPHS HISTORY: Ascites and liver disease, presenting with dyspnea. 2:48 PM CHEST PORT. Dr. was paged. COMPARISONS: . ? PATIENT/TEST INFORMATION:Indication: Dyspnea. 8:18 AM CHEST PORT. 1:26 PM CHEST (PA & LAT) Clip # Reason: {See Clinical Indication Field} MEDICAL CONDITION: History: 43F with liver disease and ascites w/ dysnpeaClinical Question: pna? LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: eval placement of R IJ line which we pulled back Admitting Diagnosis: DYSPNEA MEDICAL CONDITION: 43 year old woman with placement of R IJ line which we pulled back REASON FOR THIS EXAMINATION: eval placement of R IJ line which we pulled back FINAL REPORT INDICATION: Right internal jugular line pulled back, please evaluate for new position. COMPARISON: Comparison is made to chest radiograph performed the same day six hours earlier. | 6 | [
{
"category": "Echo",
"chartdate": "2133-01-16 00:00:00.000",
"description": "Report",
"row_id": 88225,
"text": "PATIENT/TEST INFORMATION:\nIndication: Dyspnea. ?CHF. ? Hepatopulmonary syndrome\nWeight (lb): 152\nBP (mm Hg): 97/54\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 12:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Ascites.\n\nConclusions:\nExtremely limited image quality. Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Overall left ventricular\nsystolic function appears grossly normal (LVEF>55%). PA pressure could not be\ndetermined due to extremely suboptimal image quality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1230374,
"text": " 2:48 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval placement of R IJ line which we pulled back\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with placement of R IJ line which we pulled back\n REASON FOR THIS EXAMINATION:\n eval placement of R IJ line which we pulled back\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right internal jugular line pulled back, please evaluate for new\n position.\n\n COMPARISON: Comparison is made to chest radiograph performed the same day six\n hours earlier.\n\n FINDINGS: The right jugular venous catheter has been withdrawn, the tip is\n now terminating in the upper right atrium. Otherwise, the exam is unchanged\n with minimal left basilar atelectasis. Cardiomediastinal and hilar contours\n are unremarkable. No pleural effusion or pneumothorax.\n\n IMPRESSION: Right internal jugular venous catheter now terminates in upper\n right atrium. Recommend withdrawal 1-2 cm to terminate in cavoatrial junction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1230214,
"text": " 1:26 PM\n CHEST (PA & LAT) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 43F with liver disease and ascites w/ dysnpeaClinical Question: pna?\n pleural effusion?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHS\n\n HISTORY: Ascites and liver disease, presenting with dyspnea.\n\n COMPARISONS: .\n\n TECHNIQUE: Chest, PA and lateral.\n\n FINDINGS: The lung volumes are low. Allowing for low lung volumes, the\n cardiac, mediastinal and hilar contours appear unchanged. Streaky minor\n opacities in the lower lungs suggest minor atelectasis. Otherwise, the lungs\n appear clear. There are no pleural effusions or pneumothorax. The bony\n structures are unremarkable. Views of the upper abdomen are limited but show\n air-fluid levels within the bowel of the epigastric region.\n\n IMPRESSION: No evidence of acute disease. Low lung volumes with minor\n basilar atelectasis. Non-specific air-fluid levels in the epigastric region.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-01-15 00:00:00.000",
"description": "Report",
"row_id": 234749,
"text": "Sinus rhythm. Normal tracing. No significant difference compared with\nprevious tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2133-01-15 00:00:00.000",
"description": "Report",
"row_id": 234750,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-01-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1230313,
"text": " 8:18 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please evaluate RIJ\n Admitting Diagnosis: DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman s/p central line placement\n REASON FOR THIS EXAMINATION:\n please evaluate RIJ\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:07 A.M., \n\n HISTORY: 43-year-old woman central venous line placed. Evaluate right IJ\n line.\n\n IMPRESSION: AP chest compared to :\n\n New right internal jugular line ends in the right atrium would need to be\n withdrawn 5.5 cm to place it in the low SVC.\n\n Dr. was paged.\n\n Lungs are low in volume aside from mild left basal atelectasis clear. There\n is no appreciable pleural effusion. Cardiomediastinal silhouette is normal.\n ET tube in standard placement. No pneumothorax.\n\n"
}
] |
26,847 | 171,054 | ASSESSMENT AND PLAN: Patient is a 82 yo female with a h/o diastolic CHF, AFib, CAD who presents with progressive SOB and found to have a CHF exacerbation likely secondary to AFib with RVR. . # Dyspnea: History and presentation suggests that she likely had flash pulmonary edema causing her respiratory distress. Patient was transferred to the MICU on arrival, where she was placed on BIPAP. The patient was placed on a nitroglycerine drip and was given Lasix. The patient diuresed significantly, and her O2 requirement decreased to 2L. The patient was thus transferred to the floor. She was placed back on her home dose of Lasix 40 mg PO daily, and her O2 requirement decreased. The patient was ruled out for influenza, and her blood cultures did not show any growth. It was thought that the etiology of this patient's flash pulmonary edema was AFib with RVR. The patient was rate controlled for this condition and did not have any further episodes of dyspnea. . # Leukocytosis: The patient had a leukocytosis of 28.3 on admission. Blood cultures, urine cultures, sputum cultures, and influenza cultures were drawn, which did not show any obvious source of underlying infection. It was thought that this leukocytosis was a stress reaction; thus, the patient was not started on antibiotics. Her leukocytosis decreased with oxygenation and adequate diuresis, and the patient remained afebrile during this admission. . # Atrial Fibrillation: Patient was found to be in AFib with RVR on admission. She was continued on her home dose of beta blocker and verapamil, and her pulse decreased appropriately. The patient continued to be adequately beta-blocked on this admission. She was monitored on telemetry, and her Coumadin was continued, and did not have any acute events during this admission. . # Coronary Artery Disease: The patient has a h/o MI. She denies any chest pain on this admission, but it was thought that cardiac ischemia may have been the etiology of her flash pulmonary edema. The patient's cardiac troponins were checked, and they were negative x4. She was continued on her home doses of Metoprolol, Statin, ACE inhibitor, and ASA. . # COPD: The patient was continued on her home dose of Fluticasone, Spiriva, and nebulizations as needed. . # Anxiety: The patient was continued on her home dose of Alprazolam as needed. . # Urinary Tract Infection: The patient's U/A on admission showed small blood and 500+ protein. The patient's urine culture grew out Gram positive bacteria, consistent with Lactobacillus or alpha streptococcus. The patient was not started on antibiotics for her asymptomatic bacteriuria. . # Code: DNR/DNI per patient. . | Response: CK 71, Tropnonin < 0.01. Response: CK 71, Tropnonin < 0.01. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. # FEN: clears for now while still tachypnic. # FEN: clears for now while still tachypnic. # FEN: clears for now while still tachypnic. CAD: h/o MI , had PCI at 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic EF 3. atrial fibrillation on coumadin 4. CAD: h/o MI , had PCI at 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic EF 3. atrial fibrillation on coumadin 4. CAD: h/o MI , had PCI at 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic EF 3. atrial fibrillation on coumadin 4. Nasal aspirate sent today and is still PND. Nasal aspirate sent today and is still PND. WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86 N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2 . WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86 N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2 . WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86 N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2 . If still tachycardic, will titrate up prn -continue coumadin. If still tachycardic, will titrate up prn -continue coumadin. If still tachycardic, will titrate up prn -continue coumadin. Labs / Radiology Trop-T: <0.01 CK: 39 MB: Notdone . Labs / Radiology Trop-T: <0.01 CK: 39 MB: Notdone . Labs / Radiology Trop-T: <0.01 CK: 39 MB: Notdone . Her chest xray and lung exam suggest she is still fluid overloaded but she is currently off of BIPAP and on NC. Her chest xray and lung exam suggest she is still fluid overloaded but she is currently off of BIPAP and on NC. Her chest xray and lung exam suggest she is still fluid overloaded but she is currently off of BIPAP and on NC. # COPD: continue fluticasone, spiriva, and nebs prn . # COPD: continue fluticasone, spiriva, and nebs prn . # COPD: continue fluticasone, spiriva, and nebs prn . Ca: 9.4 Mg: 2.0 P: 4.6 . Ca: 9.4 Mg: 2.0 P: 4.6 . Ca: 9.4 Mg: 2.0 P: 4.6 . .H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia) Assessment: Pt cont off nitro gtt, does not c/o SOB or chest pain. Possible LLL opacity on CXR concerning for PNA; however pt is afebrile, no cough, likely residual fluid. # FEN: clears for now while still tachypnic. # FEN: clears for now while still tachypnic. # FEN: clears for now while still tachypnic. If still tachycardic, will titrate up prn -continue coumadin. If still tachycardic, will titrate up prn -continue coumadin. If still tachycardic, will titrate up prn -continue coumadin. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. # PPx: Anticoagulated on Coumadin (supratherapeutic). CAD: h/o MI , had PCI at 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic EF 3. atrial fibrillation on coumadin 4. CAD: h/o MI , had PCI at 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic EF 3. atrial fibrillation on coumadin 4. Chief Complaint: dyspnea HPI: PCP: . Chief Complaint: dyspnea HPI: PCP: . # COPD: continue fluticasone, spiriva, and nebs prn . # COPD: continue fluticasone, spiriva, and nebs prn . # COPD: continue fluticasone, spiriva, and nebs prn . # COPD: continue fluticasone, spiriva, and nebs prn . On exampatient with -basilar crackles noted and absence of significant wheezing. # Code: DNR/DNI per patient. # Code: DNR/DNI per patient. # Code: DNR/DNI per patient. # Code: DNR/DNI per patient. # anxiety: continue prn alprazolam . # anxiety: continue prn alprazolam . # anxiety: continue prn alprazolam . # anxiety: continue prn alprazolam . Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction (pseudonormal left ventricular inflow Doppler spectrum). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction (pseudonormal left ventricular inflow Doppler spectrum). Labs / Radiology Trop-T: <0.01 CK: 39 MB: Notdone . Labs / Radiology Trop-T: <0.01 CK: 39 MB: Notdone . Her chest xray and lung exam suggest she is still fluid overloaded but she is currently off of BIPAP and on NC. Her chest xray and lung exam suggest she is still fluid overloaded but she is currently off of BIPAP and on NC. Her chest xray and lung exam suggest she is still fluid overloaded but she is currently off of BIPAP and on NC. Left ventricularhypertrophy. # Dispo: ICU for now . # Dispo: ICU for now . # Dispo: ICU for now . | 23 | [
{
"category": "Nursing",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 351755,
"text": ".H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypomagnesemia (Low magneseium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 351756,
"text": "82 y/o female with grade II diastolic CHF, CAD, Atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV Lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BiPAP and placed on 6L NC as her respiratory status improved.\n Events: Arrived to MICU on 6L NC, Nitro gtt, able to engage in\n conversation w/ mild dyspnea RR 20-low 30\nI feel much better, I\n fine now\n. Given additional 80mg IV Lasix w/ good response- sat 92-92%\n no change post Lasix , crackles 2/3 up back but visibly less dyspnea.\n Nitro gtt titrated off w/ addition of home PO medications- BP goal\n 120-130/ Tolerating clear liquids and ordered dinner. ? Additional\n Lasix and electrolyte repletion.\n .H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n No CP- ROMI, CK and trop neg to date\n Action:\n CK and trop,\n Response:\n No change, CH 60, trop negative\n Plan:\n 3^rd set due @ 2200, hx CAD s/p MI monitor for CP\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypomagnesemia (Low magneseium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 351757,
"text": "82 y/o female with grade II diastolic CHF, CAD, Atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV Lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BiPAP and placed on 6L NC as her respiratory status improved.\n Events: Arrived to MICU on 6L NC, alert oriented, HOH, on Nitro gtt,\n able to engage in conversation w/ mild dyspnea RR 20-low 30\nI feel\n much better, I\nm fine now\n. Given additional 80mg IV Lasix w/ good\n response- sat 92-92% no change post Lasix , crackles 2/3 up back but\n visibly less dyspnea. Nitro gtt titrated off w/ addition of home PO\n medications- BP goal 120-130/ Tolerating clear liquids and ordered\n dinner. ? Additional Lasix and electrolyte repletion.\n .H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n No CP- ROMI, CK and trop neg to date\n Action:\n CK and trop,\n Response:\n No change, CH 60, trop negative\n Plan:\n 3^rd set due @ 2200, hx CAD s/p MI monitor for CP\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n Crackles 2/3 up bilat lungs,\n Action:\n 1000ml fluid restriction, 80mg IV Lasix,\n Response:\n Initial UOP >400cc then tapering to 22 cc/hr pale urine, sat 94%-\n unable to titrate down O2 @ this time, weaned of Nitro gtt and BP W/I\n goal range\n Plan:\n Restarting Verapemil, Metoprolol,- likely further diuresis\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n K 3.6\n Action:\n 20meq PO KCL ordered- deffering to dinner to take\n Response:\n Due for 2200 lytes? Add on K\n Plan:\n Cont monitor s/s hypokalemia, repletion PRN\n Hypomagnesemia (Low magneseium)\n Assessment:\n Mg 1.7\n Action:\n Ordered 2mg Magnesium Sulfate\n Response:\n Plan:\n Cont monitoring and repletion PRN\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 351832,
"text": "CHF exacerbation.\n Am woke up acutely SOB w/ mild inc in symptoms over 24 hrs. Woke up in\n AM \"couldn't catch my breath\", no fevers, N/V, sick contacts called\n EMS. In ambulance given 2 tab SL NTG, 80mg IV LAsix. On arrival to ED\n placed on NRB w/ ast 80%, diuresised total 680cc to Lasix, and placed\n on BIPAP, Nitro gtt. Able to wean to 6L NC w/ sat 90-95%- decreasing w/\n talking and activity prior to arrival. Arrival to MICU able to engage\n in conversation w/ mild SOB \"much better\" on Nitro gtt @ 5.7cc/hr.\n Nitro gtt cont to be off. Last echo showed EF of 60%.\n Code: DNR/DNI. Droplet precautions because pt is being ruled out for\n flu. MRSA screen also sent today. Nasal aspirate sent today and is\n still PND. At home pt is on coumadin for her A-fib.\n .H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Pt cont off nitro gtt, does not c/o SOB or chest pain. HR 50-70. BP\n 120-150/70-80.\n Action:\n Pt cont on here home medication, did decrease her lopressor dose today\n from 100 mg to 50mg. cardiac enzymes from last night negative.\n Response:\n Pt without c/o chest pain or SOB\n Plan:\n Cont to monitor for SOB, chest pain, cont. on cardiac diet and fluid\n restrictions.\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n A-fib/A-flutter, HR 50-70. pt with very little pedal edema, which seems\n to decreased. Nitro gtt remains off. Still some crackles heard in\n upper lobes, but is better than this AM. Pt weaned down to 2L NC O2\n sats in Mid 90\ns, weight this AM 64.5\n Action:\n Pt lopressor dose decreased from 100mg to 50mg. did get lasix 40 mg\n today.\n Response:\n Pt put out about 400ml over 4 hr after lasix was given, otherwise UO is\n about 30-40 ml/hr\n Plan:\n Daily weights, pt on fluid restriction of 1 Liter per day.\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n AM lab K level 3.8\n Action:\n Gave Oral Potassium 20mg.\n Response:\n Rechecked labs at 1500 which are still PND\n Plan:\n Cont to monitor electrolytes while pt is getting lasix.\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 351754,
"text": "82 y/o female with grade II diastolic CHF, CAD, Atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV Lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BiPAP and placed on 6L NC as her respiratory status improved.\n Events: Arrived to MICU on 6L NC, Nitro gtt, able to engage in\n conversation w/ mild dyspnea RR 20-low 30\nI feel much better, I\n fine now\n. Given additional 80mg IV Lasix w/ good response- sat 92-92%\n no change post Lasix , crackles 2/3 up back but visibly less dyspnea.\n Nitro gtt titrated off w/ addition of home PO medications- BP goal\n 120-130/ Tolerating clear liquids and ordered dinner. ? Additional\n Lasix and electrolyte repletion.\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 351836,
"text": "CHF exacerbation.\n Am woke up acutely SOB w/ mild inc in symptoms over 24 hrs. Woke up in\n AM \"couldn't catch my breath\", no fevers, N/V, sick contacts called\n EMS. In ambulance given 2 tab SL NTG, 80mg IV LAsix. On arrival to ED\n placed on NRB w/ ast 80%, diuresised total 680cc to Lasix, and placed\n on BIPAP, Nitro gtt. Able to wean to 6L NC w/ sat 90-95%- decreasing w/\n talking and activity prior to arrival. Arrival to MICU able to engage\n in conversation w/ mild SOB \"much better\" on Nitro gtt @ 5.7cc/hr.\n Nitro gtt cont to be off. Last echo showed EF of 60%.\n Code: DNR/DNI. Droplet precautions because pt is being ruled out for\n flu. MRSA screen also sent today. Nasal aspirate sent today and is\n still PND. At home pt is on coumadin for her A-fib.\n .H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Pt cont off nitro gtt, does not c/o SOB or chest pain. HR 50-70. BP\n 120-150/70-80.\n Action:\n Pt cont on here home medication, did decrease her lopressor dose today\n from 100 mg to 50mg. cardiac enzymes from last night negative.\n Response:\n Pt without c/o chest pain or SOB\n Plan:\n Cont to monitor for SOB, chest pain, cont. on cardiac diet and fluid\n restrictions.\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n A-fib/A-flutter, HR 50-70. pt with very little pedal edema, which seems\n to decreased. Nitro gtt remains off. Still some crackles heard in\n upper lobes, but is better than this AM. Pt weaned down to 2L NC O2\n sats in Mid 90\ns, weight this AM 64.5\n Action:\n Pt lopressor dose decreased from 100mg to 50mg. did get lasix 40 mg\n today.\n Response:\n Pt put out about 400ml over 4 hr after lasix was given, otherwise UO is\n about 30-40 ml/hr\n Plan:\n Daily weights, pt on fluid restriction of 1 Liter per day.\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n AM lab K level 3.8\n Action:\n Gave Oral Potassium 20mg.\n Response:\n Rechecked labs at 1500 which are still PND\n Plan:\n Cont to monitor electrolytes while pt is getting lasix.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE\n Code status:\n Full code\n Height:\n 59 Inch\n Admission weight:\n 65.1 kg\n Daily weight:\n 64.5 kg\n Allergies/Reactions:\n Ambien (Oral) (Zolpidem Tartrate)\n Confusion/Delir\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CAD, CHF, Hypertension, MI\n Additional history: AFib on Coumadin, CAD with h/o MI ', CHF, Afib on\n Coumadin,\n HTN, Basal cell ca, and anxiety\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:125\n D:61\n Temperature:\n 96.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n A Flut (Atrial Flutter)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 508 mL\n 24h total out:\n 1,830 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 04:06 AM\n Potassium:\n 3.8 mEq/L\n 04:06 AM\n Chloride:\n 103 mEq/L\n 04:06 AM\n CO2:\n 31 mEq/L\n 04:06 AM\n BUN:\n 16 mg/dL\n 04:06 AM\n Creatinine:\n 0.9 mg/dL\n 04:06 AM\n Glucose:\n 105 mg/dL\n 04:06 AM\n Hematocrit:\n 36.1 %\n 04:06 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 6\n Transferred to: CC7\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Nursing 1900-0700",
"row_id": 351787,
"text": ".H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n No chest pain noted or stated by the pt. Assumed care of pt off of\n nitro GTT. Hr from 60-70\ns A-flutter with rare PVC. BP 110-120/60\n Action:\n Assessing for chest pain or discomfort often. Pt received her home BP\n medications this evening with no difficulty. CE drawn at 2200.\n Response:\n CK 71, Tropnonin < 0.01.\n Plan:\n Continue with home regimen of BP medications. Monitor pt for chest pain\n and discomfort.\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n Bilateral upper lobes clear with fine crackles bilaterally\n ways up\n the lung fields. Assumed care of pt with 6L NC. Pt does have 2+ pedal\n edema.\n Action:\n Pt received 80mg of IV lasix. NC titrated down to 3L NC.\n Response:\n Pt initially responded to the lasix with 500cc of urine output for the\n first hr. Subsequent hrs urine output has diminished. Pt now on 3L NC\n SpO2 = 93-96%. Pt states no SOB or DOE. Daily weight today 65.7kg, as\n of 0530 pt is negative 1,012.\n Plan:\n Pt requires reinforcement in regards to fluid intake and her\n restrictions. Daily weights, pt is on a 1L fluid restriction. Lasix IV\n PRN.\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n Am potassium 3.8\n Action:\n Potassium to be repleted\n Response:\n Labs to be drawn later in the day to evaluate treatment for\n hypokalemia.\n Plan:\n Labs to be drawn later in the day to monitor electrolytes.\n Hypomagnesemia (Low magneseium)\n Assessment:\n Assumed care of pt with a Mg of 1.7\n Action:\n Pt received 2gms of magnesium IV at 2230.\n Response:\n AM magnesium 2.5\n Plan:\n Monitor Magnesium and replete PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 351720,
"text": "82 YOF\n Events:\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Nursing 1900-0700",
"row_id": 351773,
"text": ".H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n No chest pain noted or stated by the pt. Assumed care of pt off of\n nitro GTT. Hr from 60-70\ns A-flutter with rare PVC. BP 110-120/60\n Action:\n Assessing for chest pain or discomfort often. Pt received her home BP\n medications this evening with no difficulty. CE drawn at 2200.\n Response:\n CK 71, Tropnonin < 0.01.\n Plan:\n Continue with home regimen of BP medications. Monitor pt for chest pain\n and discomfort.\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n Bilateral upper lobes clear with fine crackles bilaterally\n ways up\n the lung fields. Assumed care of pt with 6L NC. Pt does have 2+ pedal\n edema.\n Action:\n Pt received 80mg of IV lasix. NC titrated down to 4L NC.\n Response:\n Pt initially responded to the lasix with 500cc of urine output for the\n first hr. Subsequent hrs urine output has diminished. On 4L NC SpO2 =\n 93-96%. Pt states no SOB or DOE.\n Plan:\n Pt requires reinforcement in regards to fluid intake and her\n restrictions. Daily weights, pt is on a 1L fluid restriction. Lasix IV\n PRN.\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypomagnesemia (Low magneseium)\n Assessment:\n Assumed care of pt with a Mg of 1.7\n Action:\n Pt received 2gms of magnesium IV at 2230.\n Response:\n Waiting results from AM labs to evaluate treatment.\n Plan:\n Monitor Magnesium and replete PRN.\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 351736,
"text": "Chief Complaint: dyspnea\n HPI:\n PCP: . \n 82 y/o female with grade II diastolic CHF, CAD, atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BIPAP and placed on 6L NC as her respiratory status improved.\n .\n Currently, pt reports marked improvement in her breathing. Denies CP,\n palpitations, nausea/vomiting. +constipation. No dysuria, hematuria.\n +chronic bilateral lower extremity pain but no change recently.\n .\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per sheets:\n 1. Metoprolol Tartrate 100 mg PO BID\n 2. Verapamil 80 mg PO TID\n 3. Alprazolam 0.25 mg PO once a day as needed for anxiety\n 4. Warfarin 2.5 mg PO Q4PM\n 5. Lasix 40 mg PO once a day\n 6. Quinapril 20 mg PO BID\n 7. Aspirin 325 mg PO once a day\n 8. Atorvastatin 40 mg PO DAILY\n 9. Fluticasone two puffs \n 10. Tiotropium Bromide one cap IH daily\n 11. Xopenex PRN\n Past medical history:\n Family history:\n Social History:\n per OMR and patient:\n 1. CAD: h/o MI , had PCI at \n 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic\n EF\n 3. atrial fibrillation on coumadin\n 4. HTN\n 5. Cystic carcinoma: s/p resection, cystoscopy shows no\n recurrence\n 6. Basal cell CA: left nasal ala, s/p Mohs' resection\n 7. Anxiety\n 8. COPD\n CAD: father died of MI at 62yo; mother had MI.\n Lives in senior housing in (independent living) has 2 children;\n smoked >60 pack-years, quit 2 years ago; denies any alcohol or drug\n use\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n VS: BP 156/83, HR 105, RR 32, O2sat 93% on 6L NC\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 2/3 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n Trop-T: <0.01 CK: 39 MB: Notdone\n .\n 142 103 18 246* AGap=15\n --------------<\n 3.7 28 0.9\n estGFR: 60\n .\n Ca: 9.4 Mg: 2.0 P: 4.6\n .\n proBNP: 1853*\n .\n WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86\n N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2\n .\n PT: 28.1 PTT: 29.7 INR: 2.8*\n U/A:\n Color Yellow Appear Clear SpecGr 1.012 pH 6.5 Urobil Neg Bili\n Neg Leuk Neg Bld Sm Nitr Neg Prot 500 Glu Neg Ket Neg RBC 0-2\n WBC Bact Occ Yeast Rare Epi \n .\n UCX and BCX pending\n \n 2:33 A\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n EKG: atrial fibrillation with rate around 100. nl axis. poor baseline\n but no obvious ST changes.\n .\n CXR: my read: bilateral infiltrates right greater than left suggestive\n of fluid overload.\n Echo :\n The left atrium is dilated. The right atrium is moderately dilated.\n There is mild symmetric left ventricular hypertrophy. The left\n ventricular cavity size is normal. Overall left ventricular systolic\n function is normal (LVEF 60%). Tissue Doppler imaging suggests an\n increased left ventricular filling pressure (PCWP>18mmHg). Transmitral\n Doppler and tissue velocity imaging are consistent with Grade II\n (moderate) LV diastolic dysfunction (pseudonormal left ventricular\n inflow Doppler spectrum). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. [Due to acoustic shadowing, the severity of\n mitral regurgitation may be significantly UNDERestimated.] The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion. There is an anterior space which most likely\n represents a fat pad. Compared with the findings of the prior report\n (images unavailable for review) of , the findings are\n similar. The left ventricle is hypertrophic and displays reduced\n diastolic compliance.\n Assessment and Plan:\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea: History and presentation suggests that she likely had flash\n pulmonary edema causing her respiratory distress. Her chest xray and\n lung exam suggest she is still fluid overloaded but she is currently\n off of BIPAP and on NC. Other DDX includes pneumonia hidden under fluid\n on CXR but no fevers, cough or sputum production. She does have a\n leukocytosis and lymphocytosis. This is concerning for possible\n influenza. Also AMI (unlikely but will rule out) and PE (unlikely given\n she is therapeutic on coumadin), COPD (presumed diagnosis since last\n admission but currently no wheezing on exam).\n -given another 80mg IV furosemide x1\n -monitor I/O and likely will give more furosemide later today. Goal\n negative as possible.\n -nitro gtt to keep SBP between 100-130 and ween to off as quickly as\n possible\n -Ween oxygen prn and if worsens, will use BIPAP\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP (see below)\n -monitor on tele\n -EKG in AM\n -continue to cycle CE\n .\n # acute on chronic diastolic CHF exacerbation: hyperdynamic EF with\n grade II diastolic dysfunction.\n -diurese as above\n -fluid restrict to 1L per day\n -low salt diet\n .\n # leukocytosis: As above, could be stress reaction but lymphocytosis is\n concerning for possible viral infection.\n -nasal aspirate for respiratory viruses and influenza\n .\n # HTN: try to ween nitro gtt and continue home regimen.\n .\n # atrial fibrillation: currently tachycardic but has not received\n morning medications.\n -give metoprolol and verapamil per home regimen. If still tachycardic,\n will titrate up prn\n -continue coumadin. Currently therapeutic.\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: clears for now while still tachypnic. Advance as tolerated.\n Monitor lytes.\n .\n # PPx: continue coumadin for DVT ppx. Currently therapeutic. Bowel\n regimen. No GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: ICU for now\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition: clear liquids for now and advance\n Glycemic Control:\n Lines: PIVs\n Prophylaxis:\n DVT: on coumadin\n Stress ulcer: n/a\n VAP: n/a\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 351739,
"text": "Chief Complaint: dyspnea\n HPI:\n PCP: . \n 82 y/o female with grade II diastolic CHF, CAD, atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BIPAP and placed on 6L NC as her respiratory status improved.\n .\n Currently, pt reports marked improvement in her breathing. Denies CP,\n palpitations, nausea/vomiting. +constipation. No dysuria, hematuria.\n +chronic bilateral lower extremity pain but no change recently.\n .\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per sheets:\n 1. Metoprolol Tartrate 100 mg PO BID\n 2. Verapamil 80 mg PO TID\n 3. Alprazolam 0.25 mg PO once a day as needed for anxiety\n 4. Warfarin 2.5 mg PO Q4PM\n 5. Lasix 40 mg PO once a day\n 6. Quinapril 20 mg PO BID\n 7. Aspirin 325 mg PO once a day\n 8. Atorvastatin 40 mg PO DAILY\n 9. Fluticasone two puffs \n 10. Tiotropium Bromide one cap IH daily\n 11. Xopenex PRN\n Past medical history:\n Family history:\n Social History:\n per OMR and patient:\n 1. CAD: h/o MI , had PCI at \n 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic\n EF\n 3. atrial fibrillation on coumadin\n 4. HTN\n 5. Cystic carcinoma: s/p resection, cystoscopy shows no\n recurrence\n 6. Basal cell CA: left nasal ala, s/p Mohs' resection\n 7. Anxiety\n 8. COPD\n CAD: father died of MI at 62yo; mother had MI.\n Lives in senior housing in (independent living) has 2 children;\n smoked >60 pack-years, quit 2 years ago; denies any alcohol or drug\n use\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n VS: BP 156/83, HR 105, RR 32, O2sat 93% on 6L NC\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 2/3 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n Trop-T: <0.01 CK: 39 MB: Notdone\n .\n 142 103 18 246* AGap=15\n --------------<\n 3.7 28 0.9\n estGFR: 60\n .\n Ca: 9.4 Mg: 2.0 P: 4.6\n .\n proBNP: 1853*\n .\n WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86\n N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2\n .\n PT: 28.1 PTT: 29.7 INR: 2.8*\n U/A:\n Color Yellow Appear Clear SpecGr 1.012 pH 6.5 Urobil Neg Bili\n Neg Leuk Neg Bld Sm Nitr Neg Prot 500 Glu Neg Ket Neg RBC 0-2\n WBC Bact Occ Yeast Rare Epi \n .\n UCX and BCX pending\n \n 2:33 A\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n EKG: atrial fibrillation with rate around 100. nl axis. poor baseline\n but no obvious ST changes.\n .\n CXR: my read: bilateral infiltrates right greater than left suggestive\n of fluid overload.\n Echo :\n The left atrium is dilated. The right atrium is moderately dilated.\n There is mild symmetric left ventricular hypertrophy. The left\n ventricular cavity size is normal. Overall left ventricular systolic\n function is normal (LVEF 60%). Tissue Doppler imaging suggests an\n increased left ventricular filling pressure (PCWP>18mmHg). Transmitral\n Doppler and tissue velocity imaging are consistent with Grade II\n (moderate) LV diastolic dysfunction (pseudonormal left ventricular\n inflow Doppler spectrum). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. [Due to acoustic shadowing, the severity of\n mitral regurgitation may be significantly UNDERestimated.] The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion. There is an anterior space which most likely\n represents a fat pad. Compared with the findings of the prior report\n (images unavailable for review) of , the findings are\n similar. The left ventricle is hypertrophic and displays reduced\n diastolic compliance.\n Assessment and Plan:\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea: History and presentation suggests that she likely had flash\n pulmonary edema causing her respiratory distress. Her chest xray and\n lung exam suggest she is still fluid overloaded but she is currently\n off of BIPAP and on NC. Other DDX includes pneumonia hidden under fluid\n on CXR but no fevers, cough or sputum production. She does have a\n leukocytosis and lymphocytosis. This is concerning for possible\n influenza. Also AMI (unlikely but will rule out) and PE (unlikely given\n she is therapeutic on coumadin), COPD (presumed diagnosis since last\n admission but currently no wheezing on exam).\n -given another 80mg IV furosemide x1\n -monitor I/O and likely will give more furosemide later today. Goal\n negative as possible.\n -nitro gtt to keep SBP between 100-130 and ween to off as quickly as\n possible\n -Ween oxygen prn and if worsens, will use BIPAP\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP (see below)\n -monitor on tele\n -EKG in AM\n -continue to cycle CE\n .\n # acute on chronic diastolic CHF exacerbation: hyperdynamic EF with\n grade II diastolic dysfunction.\n -diurese as above\n -fluid restrict to 1L per day\n -low salt diet\n .\n # leukocytosis: As above, could be stress reaction but lymphocytosis is\n concerning for possible viral infection.\n -nasal aspirate for respiratory viruses and influenza\n .\n # HTN: try to ween nitro gtt and continue home regimen.\n .\n # atrial fibrillation: currently tachycardic but has not received\n morning medications.\n -give metoprolol and verapamil per home regimen. If still tachycardic,\n will titrate up prn\n -continue coumadin. Currently therapeutic.\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: clears for now while still tachypnic. Advance as tolerated.\n Monitor lytes.\n .\n # PPx: continue coumadin for DVT ppx. Currently therapeutic. Bowel\n regimen. No GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: ICU for now\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition: clear liquids for now and advance\n Glycemic Control:\n Lines: PIVs\n Prophylaxis:\n DVT: on coumadin\n Stress ulcer: n/a\n VAP: n/a\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 351742,
"text": "Chief Complaint: dyspnea\n HPI:\n PCP: . \n 82 y/o female with grade II diastolic CHF, CAD, atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BIPAP and placed on 6L NC as her respiratory status improved.\n .\n Currently, pt reports marked improvement in her breathing. Denies CP,\n palpitations, nausea/vomiting. +constipation. No dysuria, hematuria.\n +chronic bilateral lower extremity pain but no change recently.\n .\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per sheets:\n 1. Metoprolol Tartrate 100 mg PO BID\n 2. Verapamil 80 mg PO TID\n 3. Alprazolam 0.25 mg PO once a day as needed for anxiety\n 4. Warfarin 2.5 mg PO Q4PM\n 5. Lasix 40 mg PO once a day\n 6. Quinapril 20 mg PO BID\n 7. Aspirin 325 mg PO once a day\n 8. Atorvastatin 40 mg PO DAILY\n 9. Fluticasone two puffs \n 10. Tiotropium Bromide one cap IH daily\n 11. Xopenex PRN\n Past medical history:\n Family history:\n Social History:\n per OMR and patient:\n 1. CAD: h/o MI , had PCI at \n 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic\n EF\n 3. atrial fibrillation on coumadin\n 4. HTN\n 5. Cystic carcinoma: s/p resection, cystoscopy shows no\n recurrence\n 6. Basal cell CA: left nasal ala, s/p Mohs' resection\n 7. Anxiety\n 8. COPD\n CAD: father died of MI at 62yo; mother had MI.\n Lives in senior housing in (independent living) has 2 children;\n smoked >60 pack-years, quit 2 years ago; denies any alcohol or drug\n use\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n VS: BP 156/83, HR 105, RR 32, O2sat 93% on 6L NC\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 2/3 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n Trop-T: <0.01 CK: 39 MB: Notdone\n .\n 142 103 18 246* AGap=15\n --------------<\n 3.7 28 0.9\n estGFR: 60\n .\n Ca: 9.4 Mg: 2.0 P: 4.6\n .\n proBNP: 1853*\n .\n WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86\n N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2\n .\n PT: 28.1 PTT: 29.7 INR: 2.8*\n U/A:\n Color Yellow Appear Clear SpecGr 1.012 pH 6.5 Urobil Neg Bili\n Neg Leuk Neg Bld Sm Nitr Neg Prot 500 Glu Neg Ket Neg RBC 0-2\n WBC Bact Occ Yeast Rare Epi \n .\n UCX and BCX pending\n \n 2:33 A\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n EKG: atrial fibrillation with rate around 100. nl axis. poor baseline\n but no obvious ST changes.\n .\n CXR: my read: bilateral infiltrates right greater than left suggestive\n of fluid overload.\n Echo :\n The left atrium is dilated. The right atrium is moderately dilated.\n There is mild symmetric left ventricular hypertrophy. The left\n ventricular cavity size is normal. Overall left ventricular systolic\n function is normal (LVEF 60%). Tissue Doppler imaging suggests an\n increased left ventricular filling pressure (PCWP>18mmHg). Transmitral\n Doppler and tissue velocity imaging are consistent with Grade II\n (moderate) LV diastolic dysfunction (pseudonormal left ventricular\n inflow Doppler spectrum). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. [Due to acoustic shadowing, the severity of\n mitral regurgitation may be significantly UNDERestimated.] The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion. There is an anterior space which most likely\n represents a fat pad. Compared with the findings of the prior report\n (images unavailable for review) of , the findings are\n similar. The left ventricle is hypertrophic and displays reduced\n diastolic compliance.\n Assessment and Plan:\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea: History and presentation suggests that she likely had flash\n pulmonary edema causing her respiratory distress. Her chest xray and\n lung exam suggest she is still fluid overloaded but she is currently\n off of BIPAP and on NC. Other DDX includes pneumonia hidden under fluid\n on CXR but no fevers, cough or sputum production. She does have a\n leukocytosis and lymphocytosis. This is concerning for possible\n influenza. Also AMI (unlikely but will rule out) and PE (unlikely given\n she is therapeutic on coumadin), COPD (presumed diagnosis since last\n admission but currently no wheezing on exam).\n -given another 80mg IV furosemide x1\n -monitor I/O and likely will give more furosemide later today. Goal\n negative as possible.\n -nitro gtt to keep SBP between 100-130 and ween to off as quickly as\n possible\n -Ween oxygen prn and if worsens, will use BIPAP\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP (see below)\n -monitor on tele\n -EKG in AM\n -continue to cycle CE\n .\n # acute on chronic diastolic CHF exacerbation: hyperdynamic EF with\n grade II diastolic dysfunction.\n -diurese as above\n -fluid restrict to 1L per day\n -low salt diet\n .\n # leukocytosis: As above, could be stress reaction but lymphocytosis is\n concerning for possible viral infection.\n -nasal aspirate for respiratory viruses and influenza\n .\n # HTN: try to ween nitro gtt and continue home regimen.\n .\n # atrial fibrillation: currently tachycardic but has not received\n morning medications.\n -give metoprolol and verapamil per home regimen. If still tachycardic,\n will titrate up prn\n -continue coumadin. Currently therapeutic.\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: clears for now while still tachypnic. Advance as tolerated.\n Monitor lytes.\n .\n # PPx: continue coumadin for DVT ppx. Currently therapeutic. Bowel\n regimen. No GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: ICU for now\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition: clear liquids for now and advance\n Glycemic Control:\n Lines: PIVs\n Prophylaxis:\n DVT: on coumadin\n Stress ulcer: n/a\n VAP: n/a\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now\n ------ Protected Section ------\n I was physically present with the resident team on this date and was\n present for the evaluation and history and review of systems and\n examination and agree with the findings. I would add the following\n Patient is an 82 yo male with a history of atrial fibrillation\n ------ Protected Section Addendum Entered By: , MD\n on: 17:49 ------\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 351745,
"text": "Chief Complaint: dyspnea\n HPI:\n PCP: . \n 82 y/o female with grade II diastolic CHF, CAD, atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BIPAP and placed on 6L NC as her respiratory status improved.\n .\n Currently, pt reports marked improvement in her breathing. Denies CP,\n palpitations, nausea/vomiting. +constipation. No dysuria, hematuria.\n +chronic bilateral lower extremity pain but no change recently.\n .\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per sheets:\n 1. Metoprolol Tartrate 100 mg PO BID\n 2. Verapamil 80 mg PO TID\n 3. Alprazolam 0.25 mg PO once a day as needed for anxiety\n 4. Warfarin 2.5 mg PO Q4PM\n 5. Lasix 40 mg PO once a day\n 6. Quinapril 20 mg PO BID\n 7. Aspirin 325 mg PO once a day\n 8. Atorvastatin 40 mg PO DAILY\n 9. Fluticasone two puffs \n 10. Tiotropium Bromide one cap IH daily\n 11. Xopenex PRN\n Past medical history:\n Family history:\n Social History:\n per OMR and patient:\n 1. CAD: h/o MI , had PCI at \n 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic\n EF\n 3. atrial fibrillation on coumadin\n 4. HTN\n 5. Cystic carcinoma: s/p resection, cystoscopy shows no\n recurrence\n 6. Basal cell CA: left nasal ala, s/p Mohs' resection\n 7. Anxiety\n 8. COPD\n CAD: father died of MI at 62yo; mother had MI.\n Lives in senior housing in (independent living) has 2 children;\n smoked >60 pack-years, quit 2 years ago; denies any alcohol or drug\n use\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n VS: BP 156/83, HR 105, RR 32, O2sat 93% on 6L NC\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 2/3 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n Trop-T: <0.01 CK: 39 MB: Notdone\n .\n 142 103 18 246* AGap=15\n --------------<\n 3.7 28 0.9\n estGFR: 60\n .\n Ca: 9.4 Mg: 2.0 P: 4.6\n .\n proBNP: 1853*\n .\n WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86\n N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2\n .\n PT: 28.1 PTT: 29.7 INR: 2.8*\n U/A:\n Color Yellow Appear Clear SpecGr 1.012 pH 6.5 Urobil Neg Bili\n Neg Leuk Neg Bld Sm Nitr Neg Prot 500 Glu Neg Ket Neg RBC 0-2\n WBC Bact Occ Yeast Rare Epi \n .\n UCX and BCX pending\n \n 2:33 A\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n EKG: atrial fibrillation with rate around 100. nl axis. poor baseline\n but no obvious ST changes.\n .\n CXR: my read: bilateral infiltrates right greater than left suggestive\n of fluid overload.\n Echo :\n The left atrium is dilated. The right atrium is moderately dilated.\n There is mild symmetric left ventricular hypertrophy. The left\n ventricular cavity size is normal. Overall left ventricular systolic\n function is normal (LVEF 60%). Tissue Doppler imaging suggests an\n increased left ventricular filling pressure (PCWP>18mmHg). Transmitral\n Doppler and tissue velocity imaging are consistent with Grade II\n (moderate) LV diastolic dysfunction (pseudonormal left ventricular\n inflow Doppler spectrum). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. [Due to acoustic shadowing, the severity of\n mitral regurgitation may be significantly UNDERestimated.] The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion. There is an anterior space which most likely\n represents a fat pad. Compared with the findings of the prior report\n (images unavailable for review) of , the findings are\n similar. The left ventricle is hypertrophic and displays reduced\n diastolic compliance.\n Assessment and Plan:\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea: History and presentation suggests that she likely had flash\n pulmonary edema causing her respiratory distress. Her chest xray and\n lung exam suggest she is still fluid overloaded but she is currently\n off of BIPAP and on NC. Other DDX includes pneumonia hidden under fluid\n on CXR but no fevers, cough or sputum production. She does have a\n leukocytosis and lymphocytosis. This is concerning for possible\n influenza. Also AMI (unlikely but will rule out) and PE (unlikely given\n she is therapeutic on coumadin), COPD (presumed diagnosis since last\n admission but currently no wheezing on exam).\n -given another 80mg IV furosemide x1\n -monitor I/O and likely will give more furosemide later today. Goal\n negative as possible.\n -nitro gtt to keep SBP between 100-130 and ween to off as quickly as\n possible\n -Ween oxygen prn and if worsens, will use BIPAP\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP (see below)\n -monitor on tele\n -EKG in AM\n -continue to cycle CE\n .\n # acute on chronic diastolic CHF exacerbation: hyperdynamic EF with\n grade II diastolic dysfunction.\n -diurese as above\n -fluid restrict to 1L per day\n -low salt diet\n .\n # leukocytosis: As above, could be stress reaction but lymphocytosis is\n concerning for possible viral infection.\n -nasal aspirate for respiratory viruses and influenza\n .\n # HTN: try to ween nitro gtt and continue home regimen.\n .\n # atrial fibrillation: currently tachycardic but has not received\n morning medications.\n -give metoprolol and verapamil per home regimen. If still tachycardic,\n will titrate up prn\n -continue coumadin. Currently therapeutic.\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: clears for now while still tachypnic. Advance as tolerated.\n Monitor lytes.\n .\n # PPx: continue coumadin for DVT ppx. Currently therapeutic. Bowel\n regimen. No GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: ICU for now\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition: clear liquids for now and advance\n Glycemic Control:\n Lines: PIVs\n Prophylaxis:\n DVT: on coumadin\n Stress ulcer: n/a\n VAP: n/a\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now\n ------ Protected Section ------\n I was physically present with the resident team on this date and was\n present for the evaluation and history and review of systems and\n examination and agree with the findings. I would add the following\n Patient is an 82 yo male with a history of atrial fibrillation\n ------ Protected Section Addendum Entered By: , MD\n on: 17:49 ------\n ------ Protected Section Addendum Entered By: , MD\n on: 17:58 ------\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 351746,
"text": "Chief Complaint: dyspnea\n HPI:\n PCP: . \n 82 y/o female with grade II diastolic CHF, CAD, atrial fibrillation\n who presents with increasing shortness of breath. She reports that in\n the middle of night to early morning she began to notice she could not\n longer lie flat in bed. Her breathing was becoming more labored. Denies\n any chest pain, palpitations, nausea, vomiting. No cough recently, no\n fevers, chills. She lives in , but no known sick\n contacts around recently that she is aware of. She has chronic lower\n extremity edema but does not feel it has been worse recently.\n .\n EMS noted her oxygen saturation was in the high 80s on a NRB. They gave\n her 2 NTG SL and 80mg IV lasix. In the ED, her vital signs were T 99.6,\n HR 119, BP 198/92, RR 34, O2sat 60% on NRB. She was placed on BIPAP and\n her saturation improved to 92%. She was placed on a nitro gtt. CXR\n suggested pulmonary edema. Prior to coming to the floor she was taken\n off BIPAP and placed on 6L NC as her respiratory status improved.\n .\n Currently, pt reports marked improvement in her breathing. Denies CP,\n palpitations, nausea/vomiting. +constipation. No dysuria, hematuria.\n +chronic bilateral lower extremity pain but no change recently.\n .\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n per sheets:\n 1. Metoprolol Tartrate 100 mg PO BID\n 2. Verapamil 80 mg PO TID\n 3. Alprazolam 0.25 mg PO once a day as needed for anxiety\n 4. Warfarin 2.5 mg PO Q4PM\n 5. Lasix 40 mg PO once a day\n 6. Quinapril 20 mg PO BID\n 7. Aspirin 325 mg PO once a day\n 8. Atorvastatin 40 mg PO DAILY\n 9. Fluticasone two puffs \n 10. Tiotropium Bromide one cap IH daily\n 11. Xopenex PRN\n Past medical history:\n Family history:\n Social History:\n per OMR and patient:\n 1. CAD: h/o MI , had PCI at \n 2. diastolic CHF with grade II dysfunction and normal to hyperdynamic\n EF\n 3. atrial fibrillation on coumadin\n 4. HTN\n 5. Cystic carcinoma: s/p resection, cystoscopy shows no\n recurrence\n 6. Basal cell CA: left nasal ala, s/p Mohs' resection\n 7. Anxiety\n 8. COPD\n CAD: father died of MI at 62yo; mother had MI.\n Lives in senior housing in (independent living) has 2 children;\n smoked >60 pack-years, quit 2 years ago; denies any alcohol or drug\n use\n Review of systems:\n Flowsheet Data as of\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Respiratory\n Physical Examination\n VS: BP 156/83, HR 105, RR 32, O2sat 93% on 6L NC\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 2/3 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n Trop-T: <0.01 CK: 39 MB: Notdone\n .\n 142 103 18 246* AGap=15\n --------------<\n 3.7 28 0.9\n estGFR: 60\n .\n Ca: 9.4 Mg: 2.0 P: 4.6\n .\n proBNP: 1853*\n .\n WBC 28.3* Hgb 14.3 HCT 43.4 PLT 380 MCV 86\n N:49.4 L:47.2* M:2.5 E:0.7 Bas:0.2\n .\n PT: 28.1 PTT: 29.7 INR: 2.8*\n U/A:\n Color Yellow Appear Clear SpecGr 1.012 pH 6.5 Urobil Neg Bili\n Neg Leuk Neg Bld Sm Nitr Neg Prot 500 Glu Neg Ket Neg RBC 0-2\n WBC Bact Occ Yeast Rare Epi \n .\n UCX and BCX pending\n \n 2:33 A\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n Hct\n Plt\n Cr\n TropT\n TC02\n Glucose\n Imaging:\n Microbiology:\n EKG: atrial fibrillation with rate around 100. nl axis. poor baseline\n but no obvious ST changes.\n .\n CXR: my read: bilateral infiltrates right greater than left suggestive\n of fluid overload.\n Echo :\n The left atrium is dilated. The right atrium is moderately dilated.\n There is mild symmetric left ventricular hypertrophy. The left\n ventricular cavity size is normal. Overall left ventricular systolic\n function is normal (LVEF 60%). Tissue Doppler imaging suggests an\n increased left ventricular filling pressure (PCWP>18mmHg). Transmitral\n Doppler and tissue velocity imaging are consistent with Grade II\n (moderate) LV diastolic dysfunction (pseudonormal left ventricular\n inflow Doppler spectrum). There is no ventricular septal defect. Right\n ventricular chamber size and free wall motion are normal. The aortic\n valve leaflets (3) are mildly thickened but aortic stenosis is not\n present. No aortic regurgitation is seen. The mitral valve leaflets are\n mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\n regurgitation is seen. [Due to acoustic shadowing, the severity of\n mitral regurgitation may be significantly UNDERestimated.] The\n estimated pulmonary artery systolic pressure is normal. There is no\n pericardial effusion. There is an anterior space which most likely\n represents a fat pad. Compared with the findings of the prior report\n (images unavailable for review) of , the findings are\n similar. The left ventricle is hypertrophic and displays reduced\n diastolic compliance.\n Assessment and Plan:\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea: History and presentation suggests that she likely had flash\n pulmonary edema causing her respiratory distress. Her chest xray and\n lung exam suggest she is still fluid overloaded but she is currently\n off of BIPAP and on NC. Other DDX includes pneumonia hidden under fluid\n on CXR but no fevers, cough or sputum production. She does have a\n leukocytosis and lymphocytosis. This is concerning for possible\n influenza. Also AMI (unlikely but will rule out) and PE (unlikely given\n she is therapeutic on coumadin), COPD (presumed diagnosis since last\n admission but currently no wheezing on exam).\n -given another 80mg IV furosemide x1\n -monitor I/O and likely will give more furosemide later today. Goal\n negative as possible.\n -nitro gtt to keep SBP between 100-130 and ween to off as quickly as\n possible\n -Ween oxygen prn and if worsens, will use BIPAP\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP (see below)\n -monitor on tele\n -EKG in AM\n -continue to cycle CE\n .\n # acute on chronic diastolic CHF exacerbation: hyperdynamic EF with\n grade II diastolic dysfunction.\n -diurese as above\n -fluid restrict to 1L per day\n -low salt diet\n .\n # leukocytosis: As above, could be stress reaction but lymphocytosis is\n concerning for possible viral infection.\n -nasal aspirate for respiratory viruses and influenza\n .\n # HTN: try to ween nitro gtt and continue home regimen.\n .\n # atrial fibrillation: currently tachycardic but has not received\n morning medications.\n -give metoprolol and verapamil per home regimen. If still tachycardic,\n will titrate up prn\n -continue coumadin. Currently therapeutic.\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: clears for now while still tachypnic. Advance as tolerated.\n Monitor lytes.\n .\n # PPx: continue coumadin for DVT ppx. Currently therapeutic. Bowel\n regimen. No GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: ICU for now\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition: clear liquids for now and advance\n Glycemic Control:\n Lines: PIVs\n Prophylaxis:\n DVT: on coumadin\n Stress ulcer: n/a\n VAP: n/a\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now\n ------ Protected Section ------\n I was physically present with the resident team on this date and was\n present for the evaluation and history and review of systems and\n examination and agree with the findings. I would add the following\n Patient is an 82 yo male with a history of atrial fibrillation\n ------ Protected Section Addendum Entered By: , MD\n on: 17:49 ------\n ------ Protected Section Addendum Entered By: , MD\n on: 17:58 ------\n Addendum modified with premature signature above\nto revise\n Patient is 82 yo female with history of atrial fibrillation who\n experienced worsening dyspnea presenting as orthopnea and EMS\n called\npatient had saturations of 88% on NRB mask en route to ED and in\n ED patient had significant hypertension, tachypnea and placed on BIPAP\n and TNG with rapid improvement of respiratory status with diuresis\n effected with Lasix. Now in ICU patient endorses significant\n improvement in respiratory distress.\n On exam\npatient with -basilar crackles noted and absence of\n significant wheezing. She has peripheral edema (trace) but with\n patient review of history she notes no significant change in her\n peripheral edema.\n Will\n -Continue with afterload reduction and rate control with patient having\n excellent control at current with SBP=124 and HR-54 in atrial\n fibrillation.\n -Maintain negative fluid balance as tolerated\n -Wean TNG\n -Will rule out influenza given leukocytosis and lymphocyte predominance\n and presentation with respiratory distress\n -Additional issues to be treated as defined in the resident note above.\n Critical Care Time: 35 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:08 ------\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 351814,
"text": "Chief Complaint: Pulmonary Edema\n Congestive Heart Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n NASAL SWAB - At 04:38 AM\n screening for MRSA\n History obtained from Medical records\n Allergies:\n Ambien (Oral) (Zolpidem Tartrate)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Dyspnea, much improved\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.8\nC (96.5\n HR: 69 (52 - 102) bpm\n BP: 133/56(76) {112/49(68) - 157/83(103)} mmHg\n RR: 25 (17 - 38) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 64.5 kg (admission): 65.1 kg\n Height: 59 Inch\n Total In:\n 844 mL\n 208 mL\n PO:\n 800 mL\n 180 mL\n TF:\n IVF:\n 44 mL\n 28 mL\n Blood products:\n Total out:\n 1,660 mL\n 1,260 mL\n Urine:\n 1,540 mL\n 1,260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -816 mL\n -1,052 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n General Appearance: Thin\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Crackles : , Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.2 g/dL\n 246 K/uL\n 105 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 103 mEq/L\n 143 mEq/L\n 36.1 %\n 11.4 K/uL\n [image002.jpg]\n 03:14 PM\n 10:19 PM\n 04:06 AM\n WBC\n 11.4\n Hct\n 36.1\n Plt\n 246\n Cr\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n Glucose\n 103\n 105\n Other labs: PT / PTT / INR:32.7/36.2/3.4, CK / CKMB /\n Troponin-T:71//<0.01, Ca++:8.7 mg/dL, Mg++:2.5 mg/dL, PO4:3.1 mg/dL\n Imaging: CXr--Cardiomegaly, improved bilateral infiltrates and most\n dramatic on right side. Persistent small effusions.\n Assessment and Plan\n 82 yo female with known history of CHF now admit with exacerbation and\n presenting with hypoxemic respiratory compromise now with reasonable\n response to diuresis.\n 1)Congestive Heart Failure--Chronic Systolic with Acute exacerbation-\n -Continue with standing Lasix and will move to po for goal continued\n negative fluid balance\n -TNG off\n -Lopressor to continue\n -Maintain afterload reduction and rate control\n -Dr. in to evaluate patient and elicited a history of\n increased salt intake\n 2)Hypoxemic Respiratory Failure-\n -Continue with diuresis\n -Will continue with ongoing Rx for reactive airways disease which is\n pre-existing diagnosis and treated with inhalers\n -Influenza being ruled out but pre-test probability quite low\n -PA and Lateral CXR for any evolution of suspicion for active\n infection.\n 3)Atrial Fibrillation-\n -Patient now with resting bradycardia\n -Lopressor dose decreased to 50mg/d\n -Coumadin held with INR elevation to >3.0\n .H/O ACUTE CORONARY SYNDROME (ACS, UNSTABLE ANGINA, CORONARY\n ISCHEMIA)\n .H/O HEART FAILURE (CHF), SYSTOLIC AND DIASTOLIC, ACUTE ON CHRONIC\n HYPOKALEMIA (LOW POTASSIUM, HYPOPOTASSEMIA)\n HYPOMAGNESEMIA (LOW MAGNESEIUM)\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 18 Gauge - 01:10 PM\n Prophylaxis:\n DVT: Ambulation\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 40 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 351815,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 04:38 AM\n screening for MRSA\n Received 80mg IV Lasix X 2 last night, responding well with increased\n urine output. Nitro gtt weaned off at 5pm.\n This morning, pt is feeling better, denies SOB. Denies chest pain or\n other complaints.\n Allergies:\n Ambien (Oral) (Zolpidem Tartrate)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96\n HR: 75 (52 - 102) bpm\n BP: 131/71(85) {112/49(68) - 156/83(103)} mmHg\n RR: 22 (20 - 38) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 65.7 kg (admission): 65.1 kg\n Height: 59 Inch\n Total In:\n 844 mL\n 108 mL\n PO:\n 800 mL\n 80 mL\n TF:\n IVF:\n 44 mL\n 28 mL\n Blood products:\n Total out:\n 1,660 mL\n 1,120 mL\n Urine:\n 1,540 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -816 mL\n -1,012 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 1/2 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n 246 K/uL\n 12.2 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 103 mEq/L\n 143 mEq/L\n 36.1 %\n 11.4 K/uL\n [image002.jpg]\n 03:14 PM\n 10:19 PM\n 04:06 AM\n WBC\n 11.4\n Hct\n 36.1\n Plt\n 246\n Cr\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n Glucose\n 103\n 105\n Other labs: PT / PTT / INR:32.7/36.2/3.4, CK / CKMB /\n Troponin-T:71//<0.01, Ca++:8.7 mg/dL, Mg++:2.5 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea/CHF: Shortness of breath most likely from CHF exacerbation,\n possibly from dietary indiscretion vs. afib with RVR. Pt responding\n well to lasix with increased urine output and symptomatic relief. CXR\n improved. Also treating for COPD with inhalers (pt refusing) and\n ruling out flu. Possible LLL opacity on CXR concerning for PNA;\n however pt is afebrile, no cough, likely residual fluid. Cardiac\n enzymes negative but ECG with some ST depressions in V3-V5. These were\n present on ECG from admission, also on old ECG but somewhat more\n prominent today.\n -give Lasix 40 IV this morning\n - monitor Is/Os, wean O2 as tolerated\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP\n -monitor on tele\n - fluid restrict to 1L, low salt diet\n .\n # atrial fibrillation: Pt states that home metoprolol is 50mg PO BID.\n Received 50mg PO this morning, HR is in the 50s currently.\n -change Metoprolol to 50mg PO BID (home med regimen indicates pt should\n be on 100mg PO BID)\n -currently supratherapeutic on Coumadin. Will hold for now and restart\n as INR trends down.\n .\n # leukocytosis: Improved today, may have been stress response vs lab\n error.\n -nasal aspirate for respiratory viruses and influenza\n - continue to monitor\n .\n # HTN: home medications\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n - change aspirin to 81mg PO qday per patient request\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: low salt diet, replete lytes and check PM electrolytes\n .\n # PPx: Anticoagulated on Coumadin (supratherapeutic). Bowel regimen. No\n GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: Called out to floor today.\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 351829,
"text": "CHF exacerbation.\n Am woke up acutely SOB w/ mild inc in symptoms over 24 hrs. Woke up in\n AM \"couldn't catch my breath\", no fevers, N/V, sick contacts called\n EMS. In ambulance given 2 tab SL NTG, 80mg IV LAsix. On arrival to ED\n placed on NRB w/ ast 80%, diuresised total 680cc to Lasix, and placed\n on BIPAP, Nitro gtt. Able to wean to 6L NC w/ sat 90-95%- decreasing w/\n talking and activity prior to arrival. Arrival to MICU able to engage\n in conversation w/ mild SOB \"much better\" on Nitro gtt @ 5.7cc/hr.\n .H/O acute coronary syndrome (ACS, unstable angina, coronary ischemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O heart failure (CHF), Systolic and Diastolic, Acute on Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Hypokalemia (Low potassium, hypopotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 351795,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 04:38 AM\n screening for MRSA\n Received 80mg IV Lasix X 2\n Allergies:\n Ambien (Oral) (Zolpidem Tartrate)\n Confusion/Delir\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96\n HR: 75 (52 - 102) bpm\n BP: 131/71(85) {112/49(68) - 156/83(103)} mmHg\n RR: 22 (20 - 38) insp/min\n SpO2: 98%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 65.7 kg (admission): 65.1 kg\n Height: 59 Inch\n Total In:\n 844 mL\n 108 mL\n PO:\n 800 mL\n 80 mL\n TF:\n IVF:\n 44 mL\n 28 mL\n Blood products:\n Total out:\n 1,660 mL\n 1,120 mL\n Urine:\n 1,540 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -816 mL\n -1,012 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///31/\n Physical Examination\n GEN: Elderly female, resting comfortably in bed, tachypnic but not in\n acute distress.\n HEENT: NC/AT, EOMI, PERRL, O/P clear no oral lesions, MMM\n Neck: JVP ~10cm\n CV: Irregularly irregular, no murmurs appreciated\n PULM: Crackles 2/3 up from the base, no wheezing\n ABD: Soft, NT, ND +BS\n EXT: trace LE edema right greater than left. no clubbing or cyanosis\n PULSES: 2+ DP/PT pulses bilaterally\n NEURO: A&O x3, CN III-XII intact, sensation in tact to light touch\n throughout. Toes mute bilaterally. Bicep, brachioradialis reflexes\n normal. Could not elicit patellar reflexes. Did not assess gait\n currently.\n Labs / Radiology\n 246 K/uL\n 12.2 g/dL\n 105 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 103 mEq/L\n 143 mEq/L\n 36.1 %\n 11.4 K/uL\n [image002.jpg]\n 03:14 PM\n 10:19 PM\n 04:06 AM\n WBC\n 11.4\n Hct\n 36.1\n Plt\n 246\n Cr\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n Glucose\n 103\n 105\n Other labs: PT / PTT / INR:32.7/36.2/3.4, CK / CKMB /\n Troponin-T:71//<0.01, Ca++:8.7 mg/dL, Mg++:2.5 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 82 yo female with a PMH of diastolic CHF, a fib, CAD who presents with\n progressive SOB and found to have a CHF exacerbation likely secondary\n to afib with RVR.\n .\n # Dyspnea: History and presentation suggests that she likely had flash\n pulmonary edema causing her respiratory distress. Her chest xray and\n lung exam suggest she is still fluid overloaded but she is currently\n off of BIPAP and on NC. Other DDX includes pneumonia hidden under fluid\n on CXR but no fevers, cough or sputum production. She does have a\n leukocytosis and lymphocytosis. This is concerning for possible\n influenza. Also AMI (unlikely but will rule out) and PE (unlikely given\n she is therapeutic on coumadin), COPD (presumed diagnosis since last\n admission but currently no wheezing on exam).\n -given another 80mg IV furosemide x1\n -monitor I/O and likely will give more furosemide later today. Goal\n negative as possible.\n -nitro gtt to keep SBP between 100-130 and ween to off as quickly as\n possible\n -Ween oxygen prn and if worsens, will use BIPAP\n -sputum culture if able\n -influenza swab and other viral antigens, droplet precautions\n -control atrial fibrillation and BP (see below)\n -monitor on tele\n -EKG in AM\n -continue to cycle CE\n .\n # acute on chronic diastolic CHF exacerbation: hyperdynamic EF with\n grade II diastolic dysfunction.\n -diurese as above\n -fluid restrict to 1L per day\n -low salt diet\n .\n # leukocytosis: As above, could be stress reaction but lymphocytosis is\n concerning for possible viral infection.\n -nasal aspirate for respiratory viruses and influenza\n .\n # HTN: try to ween nitro gtt and continue home regimen.\n .\n # atrial fibrillation: currently tachycardic but has not received\n morning medications.\n -give metoprolol and verapamil per home regimen. If still tachycardic,\n will titrate up prn\n -continue coumadin. Currently therapeutic.\n .\n # CAD: h/o MI.\n -Continue metoprolol, statin, ACE inhibitor, and ASA.\n .\n # COPD: continue fluticasone, spiriva, and nebs prn\n .\n # anxiety: continue prn alprazolam\n .\n # FEN: clears for now while still tachypnic. Advance as tolerated.\n Monitor lytes.\n .\n # PPx: continue coumadin for DVT ppx. Currently therapeutic. Bowel\n regimen. No GI ppx needed at this time. Droplet precautions for now.\n .\n # Code: DNR/DNI per patient. There has been some confusion with the\n daughter wanting the patient to be full code, but currently patient is\n able to make own decisions and wants DNR/DNI.\n -SW consult\n .\n # Dispo: ICU for now\n .\n # Communication - pt's daughter : cell) h)\n W) \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1046764,
"text": " 8:38 AM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for pleural effusions or pulmonary edema.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with h/o COPD, CHF, AFib, who presented in flash pulmonary\n edema.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pleural effusions or pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD and CHF.\n\n FINDINGS: In comparison with the study of , there is again enlargement\n of the cardiac silhouette with mild pulmonary vascular congestion. No\n evidence of acute focal pneumonia or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046317,
"text": " 8:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess failure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with resp distress\n REASON FOR THIS EXAMINATION:\n assess failure\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: 82-year-old woman with respiratory distress. Evaluate for\n CHF.\n\n FINDINGS: AP upright portable chest radiograph is obtained. There is\n persistent cardiomegaly with interval increase development of pulmonary edema.\n There is asymmetric and more confluent opacity at the right mid to lower lung\n which is concerning for superimposed pneumonia. There is poor definition of\n the left hemidiaphragm which also raises concern for left lower lobe process,\n more likely atelectasis, though pneumonia cannot be excluded. Mediastinal\n contour is stable. Atherosclerotic calcification of the aortic knob is again\n noted. There is no pneumothorax. Osseous structures appear stable with\n scoliosis of the lower thoracic and lumbar spine again noted.\n\n IMPRESSION:\n\n Worsening CHF with increased asymmetric opacity at the right mid to lower lung\n raising concern for pneumonia. Possible atelectasis versus pneumonia at the\n left lung base.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1046523,
"text": " 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for fluid overload/infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with diastolic CHF, HTN, afib who presented with CHF\n exacerbation.\n REASON FOR THIS EXAMINATION:\n please eval for fluid overload/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CHF exacerbation, to evaluate for fluid overload.\n\n FINDINGS: In comparison with the study of , the degree of pulmonary\n vascular congestion has decreased. Enlargement of the cardiac silhouette\n persists. No evidence of acute focal pneumonia. The hemidiaphragms are now\n sharply seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2155-11-25 00:00:00.000",
"description": "Report",
"row_id": 253864,
"text": "Atrial fibrillation with controlled ventricular response. Left ventricular\nhypertrophy. Since the previous tracing the axis is less vertical.\nQRS voltage is more prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2155-11-24 00:00:00.000",
"description": "Report",
"row_id": 253865,
"text": "Atrial fibrillation with rapid ventricular response. Borderline\nintraventricular conduction delay. ST-T wave abnormalities. Since the\nprevious tracing of ventricular premature beat is no longer present.\nQRS voltage is less prominent. Axis is more vertical.\nTRACING #1\n\n"
}
] |
12,469 | 171,570 | He arrested in the trauma bay. Fast revealed no cardiac activity. He had left chest decopression with bilateral chest tubes placed. CPR resulted in some vital sigs. He waa taken to the operating room after opening his chest in the ED and hold his aorta. He was highly unstable in the Or and was brought to the TSICU where he expired. | medflighted to , pt into PEA arrest, bilat chest tubes placed w/ little response, vfib arrest persisted. pt stabilized enough to get to OR, ex lap revealed abd organs in chest, fractured spleen, huge lac to L kidney. nursing progress/admit notept 36 yo male s/p MVA, ejected from vehicle. upon arrival pt exsanguinating from open chest incision, abdominal wound, chest tube sites. abdomen packed, left open, transferred to TSICU as per OR team. total infusion including ED, OR, TSICU 38u prbc, 12u ffp, 12pack plts, 1u cryo. chest opened, defibrillated w/ internal paddles as per ED/surgical team. futile resuscitation determined, drip stopped at 2135, transfusion stopped at that time. epi drip titrated as high as 1.2mcg/kg/min w/ bp dropping despite dose. massive rescuscitation continued w/ no positive effect to bp. time of death determined by MD at 2138. pt's parents, cousin, aunt in to identify, spoke to Dr. and surgery teams. pt progressed from nsr w/ bp 60 systolic to PEA rhythm to asystolic rhythm. clergy called and in for blessing at 2230, family present until then. | 1 | [
{
"category": "Nursing/other",
"chartdate": "2153-01-30 00:00:00.000",
"description": "Report",
"row_id": 1425391,
"text": "nursing progress/admit note\n\npt 36 yo male s/p MVA, ejected from vehicle. found at scene unresponsive, intubated. medflighted to , pt into PEA arrest, bilat chest tubes placed w/ little response, vfib arrest persisted. chest opened, defibrillated w/ internal paddles as per ED/surgical team. pt stabilized enough to get to OR, ex lap revealed abd organs in chest, fractured spleen, huge lac to L kidney. abdomen packed, left open, transferred to TSICU as per OR team. upon arrival pt exsanguinating from open chest incision, abdominal wound, chest tube sites. massive rescuscitation continued w/ no positive effect to bp. epi drip titrated as high as 1.2mcg/kg/min w/ bp dropping despite dose. total infusion including ED, OR, TSICU 38u prbc, 12u ffp, 12pack plts, 1u cryo. futile resuscitation determined, drip stopped at 2135, transfusion stopped at that time. pt progressed from nsr w/ bp 60 systolic to PEA rhythm to asystolic rhythm. time of death determined by MD at 2138. pt's parents, cousin, aunt in to identify, spoke to Dr. and surgery teams. clergy called and in for blessing at 2230, family present until then.\n"
}
] |
74,626 | 126,832 | 70M with a h/o CAD s/p NSTEMI and PCI to the RCA, T2DM (A1c=6.8%), HTN, HLD, and COPD who presents with dyspnea and worsening edema. | Mild (1+) mitral regurgitation is seen. Mild mitral annularcalcification. There is mildregional left ventricular systolic dysfunction with inferior and basalinferolatearl hypokinesis. There is a trivial/physiologicpericardial effusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. There is mildsymmetric left ventricular hypertrophy with normal cavity size. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium and right atrium are normal in cavity size. Mild regional LVsystolic dysfunction. The mitral valve leaflets are mildlythickened. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Minor lateral ST-T wave abnormalities which are slightlymore pronounced compared with previous tracing of . No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mildmitral regurgitation.Compared with the prior study (images reviewed) of , the findings aresimilar. Thediameters of aorta at the sinus, ascending and arch levels are normal. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to the previous tracing of no significant changesare noted.TRACING #1 Right ventricular chamber size and free wall motion are normal. Left ventricular hypertrophy with secondary repolarizationchanges. S/P PCI to RCAHeight: (in) 67Weight (lb): 179BSA (m2): 1.93 m2BP (mm Hg): 139/51HR (bpm): 73Status: InpatientDate/Time: at 09:14Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. The remaining segments contract normally (LVEF =45%). No AS. Similar to tracing #1.TRACING #2 The pulmonary arterysystolic pressure could not be determined. No aortic regurgitation is seen. | 4 | [
{
"category": "Echo",
"chartdate": "2137-10-18 00:00:00.000",
"description": "Report",
"row_id": 94589,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. S/P PCI to RCA\nHeight: (in) 67\nWeight (lb): 179\nBSA (m2): 1.93 m2\nBP (mm Hg): 139/51\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 09:14\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size. There is mild\nregional left ventricular systolic dysfunction with inferior and basal\ninferolatearl hypokinesis. The remaining segments contract normally (LVEF =\n45%). Right ventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery\nsystolic pressure could not be determined. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild\nmitral regurgitation.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-18 00:00:00.000",
"description": "Report",
"row_id": 273366,
"text": "Sinus rhythm. Left ventricular hypertrophy with secondary repolarization\nchanges. Compared to the previous tracing of no significant changes\nare noted.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-17 00:00:00.000",
"description": "Report",
"row_id": 273367,
"text": "Sinus rhythm. Minor lateral ST-T wave abnormalities which are slightly\nmore pronounced compared with previous tracing of .\n\n"
},
{
"category": "ECG",
"chartdate": "2137-10-19 00:00:00.000",
"description": "Report",
"row_id": 273365,
"text": "Sinus rhythm. Similar to tracing #1.\nTRACING #2\n\n"
}
] |
22,963 | 135,747 | 49 yo M with history of HIV/AIDS (CD4 120), Hepatitis C, bleeding esophageal varices, and heroin and methadone abuse admitted for eval of melena. The patient was admitted to the ICU for monitoring and EGD. He underwent EGD and banding x 3 on . The Liver team was consulted and recommended 5 days of IV octreotide at 50 mcg/hr. He received a total of 4 units of pRBCs and 1 pack of platelets. After this, his Hct remained stable for the next 3 days. He received PO PPI and carafate. He received 2 days of levoflox for SBP but this was stopped since there was no evidence of ascites or infection. On the floor he was started on nadolol; this had to be stopped after one dose due to aymptomatic bradycardia to the 40s. On discharge the patient was tolerating POs well, with non-melenotic stools. . The patient's ICU course was complicated by continued heroin use. He admitted to ingesting heroin and was found to have heroin on his person, as well as methadone prescribed to another individual. Security and Administrator Supervisor were involved. A 1:1 sitter watched the patient after this event and he was allowed no visitors. was maintained on methadone 80 mg PO daily (although he is not prescribed this at home). The Substance abuse nurse met with the patient and discussed methadone programs with him. The patient was discharged with a 75 mcg fentanyl patch, to last him until Monday. On Monday he is to report to Habit Management to enroll in a methadone program. He was strongly warned about the fatal complications of taking heroin or methadone while on the fentanyl patch. The patient received a nicotine patch while in house. . The patient had been off HAART for his HIV/AIDS for several months. His CD4 was 128 on . ID was made aware of patient's admission (Dr. . We continued to hold his HAART per ID. He was continued on his dapsone and azithromycin prophyllaxis for PCP and MAC. . His Hepatitis C was stable, without indication of liver failure. An abdominal US on showed no ascites or HCC. HIs AFB from <1.01, LFTs stable. He received 2 days of SBP with Levoflox as above. . The patient has a cellulitis from skin popping and IVDU. He had been prescribed Keflex as an out-patient 1 week prior to admission, but patient has not taken. DVT of right LE was ruled out with ultrasound. He was started on a 14 days course on Ancef. . A right SC line was placed for access without complication. This was pulled on day of discharge. . He received pneumoboots for left leg and bowel regimen. | No hematemesis or melena noted.Int: Afebrile T max 97.8, has multilesions over his lower extremities secondary to his IV drug abuse, with warmth and erythema over right leg, minimal serisanguinous drainage, covered with wet dressing.Plan: Monitor Hct and if stable, transfer to regular floor. STARTED ON ATROVENT PUFFS.CV: NSR WITH NO ECTOPIES, HR 63-73, BP 83-109/33-67, WITH TWO PERIPHERAL IVS IN RT AND LT HAND, PERIPHERAL PULSES PRESENT, LOOKS PALE, STARTED ON OCTREOTIDE DRIP AT 50 MCG/HR, METHADONE IV, CEFAZOLIN AND LEVOFLOXACIN IV, AND NICOTINE PATCH, RECEIVED ONE UNIT OF PLATELETS AND TWO UNITS OF PACKED RBCS WITH NO REACTION. pt clearing on own otherwise cl lung sndscard: bp 90-125 sys hr 60,s nsr no ectopygi: banded 3 varices in endoscopy and gi feels potential to bleed again is high based on endoscopy. remains on Octreotide gtt.Pt passing good amounts of clear yellow urine to bottle.Social.No calls or contact made overnight, random security checks carried out overnight.Plan.Pt is called out to floor, transfer orders written.Will need 1:1 sitter to ensure pt not able to abuse drugs in hospital setting while has IV access. No signs of further drug usage this shift.Resp.SpO2 96-98% on RA, LS clear to all, non-productive cough.CVS.VSS, HR 50's SB with no ectopy felt. The cardiomediastinal silhouette and diaphragm and costophrenic sulci are within normal limits. crit at 1200 28.4 and recieving another unit prbcs, no vomiting and no stool. pt refused atrovent inhaler saying he doesn,t need itgi: no bleeding no bowel movement, tolerateing full liquids well, still continues on octreotide for poss bleed ing of varices.labs new line placed 1500 and proper placement confirmed by xray. CIWA SCALE IS 1, WITH MILD ANXIETY.RESP: BREATHING REGULARLY ON ROOM AIR, LS CLEAR TO WHEEZY, RR 9-21, SPO2 94-100 %. LE ulcers w/minimal drainage.OOB to ambulate around unit x2. VOIDING FREELY IN A URINAL ADEQUATE CLEAR YELLOWISH U/O.INT: BOTH LEGS HAS LIKE ABSCESSES FREOM RECENT DRUG USE, HE REPORTED THAT PREVIOUSLY THEY WERE DRAINING PUS, NOW SCRABBED OVER. crit at 1200 with new periph is not hemolyzed.plan: stay one more day in icu to monitor for acute bleeding. abd appears distended and ultsnd of abd done at bedside with no significant obvious findings. full code see med hx notesneuro: sleepy most of day post endoscopy but oriented and mae, standing at bedside to void. newe rt subclavian line placed, md use line only as peripheral due to tip placement and will not allow use as a central line.id: afeb, no change in medsactivity pt oob to chair and did all adl's independentlyillegal drug use history: pt had 3 visitors today. 49 yr old pt with esophogeal varices, s/p endoscopy with banding of 3 sites today. Nursing note (1900-0700) 04:30Neuro.A+Ox3, ambulating at will, no complaints of pain. o930: endoscopy for varices. CHEST: A single AP view of the chest is compared to previous examination of . BP stable.GI/GU.Tollerating soft diet well, +BS, no BM this shift. Grayscale, color, and pulse Doppler examination of the right common femoral, superficial femoral, and popliteal veins was performed. banded 3 sites pt recieved 12.5 mg phenergan, 4 mg versed and 100 mcg fent consious sedation. NPN 1900-0700:Neuro: pt is alert, oriented x3, comfortable, calm and cooperative, slept most of the night and didn't want to b disturbed, didnn't c/o any pain, CIWA scale 0, no valium needed.Resp: breathing regularly on room air, RR 12-20, SPO2 96-99 %, LS coarse to wheezes, clear after the inhalation puffs.CV: SB-SR HR , BP 87-120/61-79, with 2 peripheral IVs in both hands, received one unit of packed RBCs for Hct of 25.8 with no reaction, receiving antibiotics, peripheral pulses weak to palpate.GI/GU: On full fluids, asked for jello and water during the night, also requested his methodone to be given befrore its due time. minimal active bleeding seen during endoscopy. pt progress note:neuro: pt is A&O, mae oob to chair, no pain no weakness PERLcard bp 89-120 sys hr 49-68 nsr no ectopyresp: o2 sat 96-100 on room air. will need md to do art stick for bloodslabs: 0500 labs grossly hemolyzed and unable to repeat. CHEST X-RAY, PORTABLE AP: Comparison made to prior study of . RECEIVING NS 100 CC/HR.GI/GU: NPO, ABDOMEN IS SOFT AND TENDER, BS PRESENT, FOR ENDOSCOPY TOMORROW, PT IS ANXIOUS ABOUT PROCEDURE. pt recieved fentanyl 100 mcg and middzolam 4 mg iv from 0930-1000 for endoscopy. medicated with 5 mg po valium for c/o of being hot and sweaty at 1600 and pt c/o needing methodone.resp: 98% sat ra, some upper airway secretion post endoscopy. this nurse interupted the pt and visitor and pt withdrew a cup form under the blanket and when asked what he was doing he stated it is just water. A man called inquring information about the pt claimimg he's the cousin, informed that no information is to be passed over the phone, no visitors showed up during the night.Resp: Breathing regularly on room air, LS clear, coughing but not expectorating, RR 12-20, SPO2 97-100 %.CV: SB-SR HR 50-75, B.P 95-115/55-70, with rt s/c central line, patent, peripheral pulses are weak to palpate, Hct > 30, no blood transfusion or platelet transfused.GI/GU: on soft diet, tolerating jello, pudding and juice very well, good appetite, BS hypoactive, abdomen soft and distended, voiding freely in the urinal at the side of the bed adequate amber clear U/O.Int: Afebrile T max 97.8, both legs have celulitis like spots from drug abuse, for which he is receiving antibiotics. started sucrufate for gigu: voiding and pt is currently approximately 600 cc pos balance since midnightid: pt will need to start hiv meds but compliance is an issue with his dependencies. HE WAS TRANSFERRED TO FURTHER MANAGEMENT OF BLEEDING AND HYPOTENSION. AFEBRILE T MAX 98, PNEUMO-BOOTS APPLIED ON LT FOOT ONLY BECAUSE OF R/O DVT IN RT LEG, TO BE FOLLOWED UP TOMORROW BY ULTRASOUND.PLAN: CONTINUE ANTIBIOTICS AND OCTREOTIDE, ULTRASOUND AND ENDOSCOPY, PROBABLY TODAY, MONITOR CBC AND TRANSFUSE BLD FOR HCT < 30 AND PLT FOR PLT < 100, MONITOR CIWA SCALE FOR POSSIBLE WITHDRAWAL FROM BZ AND GIVE VALIUM PRN IF CIWA > 10. | 13 | [
{
"category": "Nursing/other",
"chartdate": "2182-12-21 00:00:00.000",
"description": "Report",
"row_id": 1562585,
"text": "ADMISSION AND NURSE'S NOTE: 09 PM -07 PM:\nTHIS IS A 49 YO MALE PT WITH A KNOWN HISTORY OF HIV/AIDS, HEPATITIS C, DRUG ABUSE (HEROIN, METHADONE, COCAINE, KLONIPIN). HE HAS A HISTORY OF ESOPHAGEAL VARICES. HE PRESENTED TO ED ON DUE TO NOTICING OF BLACK STOOL OF ONE DAY DURATION. ON RECTAL EXAM REVEALED HEME OCCULT POSITIVE BLACK STOOL. IN ED HIS SBP WAS NOTICED 90 AND HCT WAS 27.6 (BASELINE ~ 35). HE WAS STARTED ON OCTREOTIDE (50 MCG BOLUS) AND PROTONIX. HE WAS TRANSFERRED TO FURTHER MANAGEMENT OF BLEEDING AND HYPOTENSION. CURRENTLY:\n\nNEURO: PT IS ALERT, ORIENTED X3, CALM AND COOPERATIVE, PUPILS EQUAL IN SIZE (3) AND REACTIVE TO LIGHT, FOLLOWING VERBAL COMMANDS CONSISTENTLY. NOT COMPLAINING OF ANY PAIN, JUST MILD FATIGUE AND WEAKNESS. CIWA SCALE IS 1, WITH MILD ANXIETY.\n\nRESP: BREATHING REGULARLY ON ROOM AIR, LS CLEAR TO WHEEZY, RR 9-21, SPO2 94-100 %. STARTED ON ATROVENT PUFFS.\n\nCV: NSR WITH NO ECTOPIES, HR 63-73, BP 83-109/33-67, WITH TWO PERIPHERAL IVS IN RT AND LT HAND, PERIPHERAL PULSES PRESENT, LOOKS PALE, STARTED ON OCTREOTIDE DRIP AT 50 MCG/HR, METHADONE IV, CEFAZOLIN AND LEVOFLOXACIN IV, AND NICOTINE PATCH, RECEIVED ONE UNIT OF PLATELETS AND TWO UNITS OF PACKED RBCS WITH NO REACTION. RECEIVING NS 100 CC/HR.\n\nGI/GU: NPO, ABDOMEN IS SOFT AND TENDER, BS PRESENT, FOR ENDOSCOPY TOMORROW, PT IS ANXIOUS ABOUT PROCEDURE. VOIDING FREELY IN A URINAL ADEQUATE CLEAR YELLOWISH U/O.\n\nINT: BOTH LEGS HAS LIKE ABSCESSES FREOM RECENT DRUG USE, HE REPORTED THAT PREVIOUSLY THEY WERE DRAINING PUS, NOW SCRABBED OVER. HE ALSO HAS ONE ON HIS RT ARM THAT HE SAYS IS FROM SKIN POPPING. HE IS RECEIVING ANTIBIOTICS BECAUSE OF A CONCERN OF INFECTION IN THE LEGS. AFEBRILE T MAX 98, PNEUMO-BOOTS APPLIED ON LT FOOT ONLY BECAUSE OF R/O DVT IN RT LEG, TO BE FOLLOWED UP TOMORROW BY ULTRASOUND.\n\nPLAN: CONTINUE ANTIBIOTICS AND OCTREOTIDE, ULTRASOUND AND ENDOSCOPY, PROBABLY TODAY, MONITOR CBC AND TRANSFUSE BLD FOR HCT < 30 AND PLT FOR PLT < 100, MONITOR CIWA SCALE FOR POSSIBLE WITHDRAWAL FROM BZ AND GIVE VALIUM PRN IF CIWA > 10.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-21 00:00:00.000",
"description": "Report",
"row_id": 1562586,
"text": "o930: endoscopy for varices. banded 3 sites pt recieved 12.5 mg phenergan, 4 mg versed and 100 mcg fent consious sedation. o2 5-10 liters nc. tolerated procedure well\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-21 00:00:00.000",
"description": "Report",
"row_id": 1562587,
"text": "49 yr old pt with esophogeal varices, s/p endoscopy with banding of 3 sites today. allergies to pcn and bactrim. full code see med hx notes\n\nneuro: sleepy most of day post endoscopy but oriented and mae, standing at bedside to void. CIWA scale monitoring for withdrawl of heroin and cocaine with rating of 0-1 for slight agitation/anxiety pre endoscopy. no pain following commands. pt recieved fentanyl 100 mcg and middzolam 4 mg iv from 0930-1000 for endoscopy. medicated with 5 mg po valium for c/o of being hot and sweaty at 1600 and pt c/o needing methodone.\n\nresp: 98% sat ra, some upper airway secretion post endoscopy. pt clearing on own otherwise cl lung snds\n\ncard: bp 90-125 sys hr 60,s nsr no ectopy\n\ngi: banded 3 varices in endoscopy and gi feels potential to bleed again is high based on endoscopy. maintain on cl liquids and monitor for bleeding. crit at 1200 28.4 and recieving another unit prbcs, no vomiting and no stool. minimal active bleeding seen during endoscopy. bowel snds hypoactive. maintain octreotide gtt at 50 mcg/hr. abd appears distended and ultsnd of abd done at bedside with no significant obvious findings. started sucrufate for gi\n\ngu: voiding and pt is currently approximately 600 cc pos balance since midnight\n\nid: pt will need to start hiv meds but compliance is an issue with his dependencies. wbc 1.5 no changes in antibx coverage. cd4 cnt done in ew. no new meds started for hiv yet\n\nskin: multiple lesions on feet and legs with rt foot warm and red on medial aspect, no drainage of wounds rt foot. lt calf open area 3 cm/ 2cm draining sero-sang sm amt. washed with soap and water, wet to dry dsg applied and would change qd. cont compression sleeve to lt leg only. no compression to rt leg as ordered by md.\n\naccess: very difficult and unable to draw labs. a new 22 ga periph line in lt hand infusing octreotide and lt upper arm at kvo with blood and med line. will need md to do art stick for bloods\n\nlabs: 0500 labs grossly hemolyzed and unable to repeat. crit at 1200 with new periph is not hemolyzed.\n\nplan: stay one more day in icu to monitor for acute bleeding. transfusing blood. labs per mds. ciwa scale and medication administration\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-22 00:00:00.000",
"description": "Report",
"row_id": 1562588,
"text": "NPN 1900-0700:\nNeuro: pt is alert, oriented x3, comfortable, calm and cooperative, slept most of the night and didn't want to b disturbed, didnn't c/o any pain, CIWA scale 0, no valium needed.\n\nResp: breathing regularly on room air, RR 12-20, SPO2 96-99 %, LS coarse to wheezes, clear after the inhalation puffs.\n\nCV: SB-SR HR , BP 87-120/61-79, with 2 peripheral IVs in both hands, received one unit of packed RBCs for Hct of 25.8 with no reaction, receiving antibiotics, peripheral pulses weak to palpate.\n\nGI/GU: On full fluids, asked for jello and water during the night, also requested his methodone to be given befrore its due time. BS hypoactive, voiding freely in the urinal at the side of the bed adequate clear yellowish u/o. No hematemesis or melena noted.\n\nInt: Afebrile T max 97.8, has multilesions over his lower extremities secondary to his IV drug abuse, with warmth and erythema over right leg, minimal serisanguinous drainage, covered with wet dressing.\n\nPlan: Monitor Hct and if stable, transfer to regular floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-22 00:00:00.000",
"description": "Report",
"row_id": 1562589,
"text": "pt progress note:\nneuro: pt is A&O, mae oob to chair, no pain no weakness PERL\n\ncard bp 89-120 sys hr 49-68 nsr no ectopy\n\nresp: o2 sat 96-100 on room air. lung snds clear. pt refused atrovent inhaler saying he doesn,t need it\n\ngi: no bleeding no bowel movement, tolerateing full liquids well, still continues on octreotide for poss bleed ing of varices.\n\nlabs new line placed 1500 and proper placement confirmed by xray. labs ordered q6h and next due at 2300. 1700 crit 32 and plat 66,000\nmag replaced at 1600.\n\naccess all perpheral lines out due to clotting and infiltrating. newe rt subclavian line placed, md use line only as peripheral due to tip placement and will not allow use as a central line.\n\nid: afeb, no change in meds\n\nactivity pt oob to chair and did all adl's independently\n\nillegal drug use history: pt had 3 visitors today. all syringes and needles removed from pt room while visitors present. pt remained on monitors continously. this nurse witnessed pt and his girl friend doing some activity on right bedside out of my vision. this nurse interupted the pt and visitor and pt withdrew a cup form under the blanket and when asked what he was doing he stated it is just water. the visitor placed something in her purse and then proceeded to say goodby and left. this nurse explained to pt the need for his safety and that he should not be using illegal drugs in the hospital. the pt stated he had not used drugs at this time. pt then proceeded to ask for urinal and upon getting oob this nurse found a capped syringe in bed under the pt buttocks. nurse left room mom and another nurse walked in and found a lighter and tin canister on his bedside . when asked pt stated he had just swallowed drugs approx th gm heroin and that he has no other drugs in his possession. all pt belongings and opened food/drink containers removed from pt room. pt's bed searched for any other drugs, no body search done at this time. house staff and nursing supervisor notified and security called to come to floor.\npt told he must be visable to nurses at all times,curtain open. and that administration and security had been notified.\n\nplan: pt needs close monitoring for his onw safety.\ncont otreatide iv, monitor hct. monitor pt for any s/s of poss drug interactions and drug overdose since self administration of substance.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-23 00:00:00.000",
"description": "Report",
"row_id": 1562590,
"text": "NPN: 1900-0700:\nNeuro: pt is alert, oriented x3, observed closely during the night for any attempt of drug abuse, police security spot checked pt Q 30 min, conversing well, asking for juice, jello, and pudding, sitting at the side of the bed to void in the urinal, c/o no pain, no heamatemesis, anxiety, tremors, CIWA scale was zero, no valium needed. A man called inquring information about the pt claimimg he's the cousin, informed that no information is to be passed over the phone, no visitors showed up during the night.\n\nResp: Breathing regularly on room air, LS clear, coughing but not expectorating, RR 12-20, SPO2 97-100 %.\n\nCV: SB-SR HR 50-75, B.P 95-115/55-70, with rt s/c central line, patent, peripheral pulses are weak to palpate, Hct > 30, no blood transfusion or platelet transfused.\n\nGI/GU: on soft diet, tolerating jello, pudding and juice very well, good appetite, BS hypoactive, abdomen soft and distended, voiding freely in the urinal at the side of the bed adequate amber clear U/O.\n\nInt: Afebrile T max 97.8, both legs have celulitis like spots from drug abuse, for which he is receiving antibiotics. He is on universal precaution, full code.\n\nPlan: Monitor pt closely for any attempt of drug abuse, no visitors in, no information to be given over the phone about pt, no syringes or needles to be left inside room. Monitor Hct and transfuse if needed, transfer to floor when stable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-23 00:00:00.000",
"description": "Report",
"row_id": 1562591,
"text": "MICU EAST NPN 0700-1900\n\nA&O pleasant and cooperative. C/O being hungry. Diet advanced to reg. Tol well.\n\nNo stool or evidence of bleeding. Continues on Octreotide at 50mcgs/hr.\n\nAfebrile. Antibiotics changed to PO. LE ulcers w/minimal drainage.\n\nOOB to ambulate around unit x2. Tol well.\n\nPt spoke to sister over phone. No visitors. to transfer to floor in am. Pt will need sitters when he leaves d/t IV access.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-12-24 00:00:00.000",
"description": "Report",
"row_id": 1562592,
"text": "Nursing note (1900-0700) 04:30\n\nNeuro.\nA+Ox3, ambulating at will, no complaints of pain. No signs of further drug usage this shift.\n\nResp.\nSpO2 96-98% on RA, LS clear to all, non-productive cough.\n\nCVS.\nVSS, HR 50's SB with no ectopy felt. BP stable.\n\nGI/GU.\nTollerating soft diet well, +BS, no BM this shift. remains on Octreotide gtt.\nPt passing good amounts of clear yellow urine to bottle.\n\nSocial.\nNo calls or contact made overnight, random security checks carried out overnight.\n\nPlan.\nPt is called out to floor, transfer orders written.\nWill need 1:1 sitter to ensure pt not able to abuse drugs in hospital setting while has IV access.\n"
},
{
"category": "ECG",
"chartdate": "2182-12-26 00:00:00.000",
"description": "Report",
"row_id": 164659,
"text": "Sinus bradycardia. The tracing is marred by baseline artifact and wandering\nbaseline. No apparent abnormality. Compared to the previous tracing\nof no change, except the rate has slowed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-12-21 00:00:00.000",
"description": "RP UNILAT LOWER EXT VEINS RIGHT PORT",
"row_id": 889917,
"text": " 12:21 PM\n UNILAT LOWER EXT VEINS RIGHT PORT Clip # \n Reason: PLEASE EVAL FOR EVIDENCE OF CLOT, RLE EDEMA\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with hx of substance abuse, injection of IV drugs into lower\n extremities, now with increased RL ext edema\n REASON FOR THIS EXAMINATION:\n please eval for evidence of clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right lower extremity edema.\n\n Grayscale, color, and pulse Doppler examination of the right common femoral,\n superficial femoral, and popliteal veins was performed. There is normal flow,\n augmentation, compressibility, and waveforms. No intraluminal thrombus is\n identified.\n\n IMPRESSION: No evidence of right lower extremity DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-12-21 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 889918,
"text": " 12:22 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: eval for ascites, cirrhosis\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with HIV, HCV, esophageal vaarices\n REASON FOR THIS EXAMINATION:\n eval for ascites, cirrhosis\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: HCV, HIV, esophageal varices.\n\n Limited four-quadrant ultrasound examination was performed. No ascites is\n demonstrated. Spleen is enlarged.\n\n IMPRESSION: No intraabdominal ascites. Splenomegaly\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 889888,
"text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for evidence of infiltrate\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with hx of subtance abuse, HIV/AIDS, GI bleed - with wheezes on\n exam bilat\n REASON FOR THIS EXAMINATION:\n please eval for evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of substance abuse, HIV, with GI bleed, with wheezes on\n exam.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of .\n The cardiomediastinal silhouette is within normal limits. The right\n costophrenic angle is not included on this film. The lungs are clear.\n\n IMPRESSION:\n No acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-12-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 890027,
"text": " 3:13 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p R subclavian line placement\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with hx of subtance abuse, HIV/AIDS, GI bleed - with wheezes\n on exam bilat\n REASON FOR THIS EXAMINATION:\n s/p R subclavian line placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: GI bleed, status post right subclavian line placement.\n\n CHEST: A single AP view of the chest is compared to previous examination of\n . Since the previous exam a right subclavian line has been\n inserted with the tip at the confluence of brachiocephalic veins and lateral\n view can be obtained for better assessment of the position of the subclavian\n line. The lungs are clear. The cardiomediastinal silhouette and diaphragm\n and costophrenic sulci are within normal limits.\n\n\n DR. \n"
}
] |
21,426 | 113,863 | On admission, Mr. was brought to the operating room and underwent three vessel coronary artery bypass grafting by Dr. . The operation was uneventful. Following the procedure, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics as he weaned from inotropic support. His CSRU course was otherwise uncomplicated and he transferred to the SDU on postoperative day three. He continued to require diuresis. Over the next several days, medical therapy was optimized. Beta blockade was resumed with most of his other preoperative medications. He remained in a normal sinus rhythm. By discharge, he was near his preoperative weight with room air oxygen saturations of 97%. His discharge chest x-ray was notable for only a resolving left pleural effusion. At time of discharge his blood pressure was 127/69 with a heart rate of 85 in sinus. All surgical wounds were clean, dry and intact. He will need to remain on supplemental Iron as an outpatient for his anemia. | Swan-Ganz catheter has been removed and a right introducer sheath remains. Output QS.GI: Abdomen soft, NT, +BSX4Q. INDICATION: Status post CABG, rule out pneumothorax or effusion. Rule out pneumothorax. In the interval, a Swan-Ganz catheter introducer sheath was removed. B/P STABLE, NEO OFF. CT OUT @ ~, POST CXR 'OK' PER DR. . SEE CAREVUE.ENDO: SSRIPLAN: D/C TRAUMA IJ. PERCOCET FOR PAIN.CV: SR, NO ECTOPY. Requires neo at 0.7mcg/kg/min for BP support. LSCTAB w/dim bases. No N/V.ASSESS: Stable 1st day postop.PLAN: Wean neo as tolerated. A&OX3 after extubation, no neural deficit noted.CV: A-paced from OR, SR 70's intrinsically. Bleeding resolved, INR 1.6. TMAX 100.7. R lung clr, L lung dim throughout. ON COLACE.GU: FOLEY CATH, DIURESING WELL AFTER LASIX. sats 100 on 3 l nc.Neuro: intact no defecits noted. HR 70's sr no ectopy. Neo drip titrated from 0.2 - 1.5mcg/kg/min for BP support, currently at 0.2 mcg/kg/min with SBP 104. uses call light appropriately.GI: abd obese, hypo bs. D/c chest tubes in am. ETT has been removed. Interval decrease in mediastinal width. There is a resolving left pleural effusion. ..VIA RIGHT IJ LINERESP LUNGS DIMINISHED AT BASES ..ON 4L NP ..NON-PROD COUGH..USING ...GU DIURESING TO LASIX ...GI TOLERATING SIPS OF CLEAR LIQUIDSHEME HCT DOWN TO 25 ...A/P HEMODYN STABLE ..BUT REMIANS ON LOW DOSE PRESSOR OOb after deline in AM. BP maintained throughout episode, no LOC. The Swan-Ganz catheter introducer sheath remains. Transfer to floor when neo d/c'd. There has been interval decrease in the mediastinal width. mechanically ventilated A/C 800*10-100%-5p. K repleted X3. Neuro: alert and oriented x 3, mae, ambulating, percocets for pain.Cardiac: nsr with no ectopy, weaned off neo gtt today, sbps wnls, palpible pedial pulses, skin warm dry and intact, +3 edema in extremities.Resp: on ra at rest satting at 95% with exertion does desat to 92 and put on 2 liters nc and sats at 98%, lungs are dim in bases, ct system to sxn with no air leak draining scant awaiting md to pull ct's, is using i/s.Skin: chest and ct dsds are cdi, left leg dsd is cdi.Gi/Gu: tolerating po's, abd is soft round and nontender, good bowel sounds, on riss, making good u/o while on lasix.Plan: f2 when bed is ready, monitor blood sugars, continue percocets, monitor bp. CONTINUES ON ZANTAC. meds ct's draining pale serosang fluid. ENCOURAGE I/S & CDB. Sternal dressing changed per verbal order Dr. . No further ectopy noted. NONPRODUCTIVE COUGH.GI: TOLERATING FULL DIET. Evaluate after wire removal. Small left pleural effusion. Skin warm dry and intact, sternal incision covered with operative dsd, scant serosang drainage remains occlusive. LYTES REPLEATED AS DOCUMENTED.RESP: SPO2 ON 2LNC >94%. 2 a 2 v epi wires sense and pace apropriately, back up rate 66 a demand. HCT 27.5, WBC 17.3. Rare PVC's. DIM BILAT BASES. pa line, CO >8, CI > 3 by thermodilution.Resp: LS dim at bases, poor cough effort. PIP/Plt 32/26,BS diminished throughout lung field. Pulses strong palp, refusing ace wrap on graft harvest leg(right). IMPRESSION: 1. Sinus rhythmNormal ECGNo change from previous CSRU NSG:NEURO: A&OX3, no neural deficit noted.CV: SR with one episode of wide complex, rapid rhythm X 7 beats. CSRU NSG:NEURO: Sedated on propofol until extubated at 1600 hrs. Recommend clinical correlation and short term radiographic followup. Post-chest tube pull film. IMPRESSION: No pneumothorax. 1250cc LR given.PULM: Weaned and extubated easily after reversal. UOP slowed, will continue to monitor. Left lower lobe atelectasis is present. Nursing Progress Notecvs: s/p cabg, neo at 0.4 mcg/kg to keep map >60. Will continue to wean neo as tol. IMPRESSION: Small amount of pleural fluid in the left costophrenic sulcus. + BS, STARTING TO FEEL 'GAS PAINS'. 12:05 PM CHEST PORT. The mediastinal contours are somewhat less pronounced than that seen previously - clearly there is no progression of that prominence. SEE CAREVUE. Lopressor not prescribed as of yet. No s/s of transusion rxn at this time. Peripheral pulses palpable, extremities warm & dry. AP erect portable chest radiograph was compared to the prior chest x- ray of at 8:23. Patient required crycoid pressure during intubation in OR to view vocal cords.GU: Urine clr, dilute, ouput QS.GI: Abdomen obese, soft, no BS heard.INTEG: Skin intact.ENDO: Insulin drip started @ 1U/hr for glucose 183.COMFORT: Morphine 2mg IVP X2 for pain w/good effect.ASSESS: Requires neo for BP support. Neo increased as high as 2.0, currently at 1.0. NO BM. CSRU NPNNEURO: A/OX3, NO NEURAL DEFICITS NOTED. Urine clr, yellow, dilute. Tol clears no nausea.GU: foley cath with urine conc amber > 30 cc hour.Endo: insulin gtt per csru protocol.Pain: percocet po x 2 tabs at 2330 with relief of insional discomfort.IV's: r rad a line zeroed, waveform with notch. 2 GM magnesium given. Comparison to . Unable to tolerate neo weaning X numerous attempts.PULM: SpO2 99% on O2 3L via NC. COMPARISON: . Patient intubated # 7.5 ETT @ 23 cm lips. NPNCSRU7 PM - 7 AM3VD S/P CABGREQUESTING TO SIT IN CHAIR THROUGHOUT NIGHT ..PERCOCETS 2 TABS Q4 ..FOR INCISIONAL PAIN.INCISIONAL/CT DSGS INTACTPACER A DEMAND ..SET AT 60...WIRES ATTACHED TO PACER..HR 70'SR ...SBP BY ALINE 90-110'S/50'S..ABLE TO WEAN NEO TO .5 MCGS...CT TO SUCTION WITH MINIMAL SEROUS OUTPUT .. FINDINGS: Chest tubes remain in place and there is no PTX. Three left chest tubes are present. No new consolidations. No new consolidations. No new consolidations. Portable upright chest radiograph of at 10:35 is compared to the prior radiograph of . No SOB or dyspnea noted. No SOB or dyspnea noted. 2. Awaiting ABG to alter vent parameters as necessary. Continue to control BS, assess and treat pain, encourage pulmo toilet. HypotensionPatient hypotensive with change of neo to different line, blood transfusion began for crit 24.8 per dr . Patient extubated @ 16:00 and placed on 5 L NC RR 22,BS diminished,sat 100% plan to decrease 02 to 2 L then to R/A.Alert,coop,complaining of pain RN aware will continue to follow. | 14 | [
{
"category": "Nursing/other",
"chartdate": "2162-01-08 00:00:00.000",
"description": "Report",
"row_id": 1543612,
"text": "55 yr old male with PMHX:HTN,CAD,^cholesterol,3VD;S/P CABG. Patient intubated # 7.5 ETT @ 23 cm lips. mechanically ventilated A/C 800*10-100%-5p. PIP/Plt 32/26,BS diminished throughout lung field. Awaiting ABG to alter vent parameters as necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-08 00:00:00.000",
"description": "Report",
"row_id": 1543613,
"text": "Patient extubated @ 16:00 and placed on 5 L NC RR 22,BS diminished,sat 100% plan to decrease 02 to 2 L then to R/A.Alert,coop,complaining of pain RN aware will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-08 00:00:00.000",
"description": "Report",
"row_id": 1543614,
"text": "CSRU NSG:\n\nNEURO: Sedated on propofol until extubated at 1600 hrs. A&OX3 after extubation, no neural deficit noted.\n\nCV: A-paced from OR, SR 70's intrinsically. Rare PVC's. K repleted X3. HCT 27.5, WBC 17.3. Protamine 50mg IVP X1 for ACT 142 w/90cc chest tube output in 30 min. Bleeding resolved, INR 1.6. Neo drip titrated from 0.2 - 1.5mcg/kg/min for BP support, currently at 0.2 mcg/kg/min with SBP 104. Peripheral pulses palpable, extremities warm & dry. 1250cc LR given.\n\nPULM: Weaned and extubated easily after reversal. SpO2 100% on O2 @ 5L via NC. R lung clr, L lung dim throughout. No SOB or dyspnea noted. Patient required crycoid pressure during intubation in OR to view vocal cords.\n\nGU: Urine clr, dilute, ouput QS.\n\nGI: Abdomen obese, soft, no BS heard.\n\nINTEG: Skin intact.\n\nENDO: Insulin drip started @ 1U/hr for glucose 183.\n\nCOMFORT: Morphine 2mg IVP X2 for pain w/good effect.\n\nASSESS: Requires neo for BP support. Insulin drip for glucise control.\n\nPLAN: Wean neo as tolerated, titrate insulin drip per protocol and switch to RISS ASAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-09 00:00:00.000",
"description": "Report",
"row_id": 1543615,
"text": "Nursing Progress Note\ncvs: s/p cabg, neo at 0.4 mcg/kg to keep map >60. PAD 16, CVP 14. HR 70's sr no ectopy. Pulses strong palp, refusing ace wrap on graft harvest leg(right). Skin warm dry and intact, sternal incision covered with operative dsd, scant serosang drainage remains occlusive. meds ct's draining pale serosang fluid. 2 a 2 v epi wires sense and pace apropriately, back up rate 66 a demand. pa line, CO >8, CI > 3 by thermodilution.\n\nResp: LS dim at bases, poor cough effort. teaching with encouragement to deep breath and cough usuing splint pillow. sats 100 on 3 l nc.\n\nNeuro: intact no defecits noted. uses call light appropriately.\n\nGI: abd obese, hypo bs. Tol clears no nausea.\n\nGU: foley cath with urine conc amber > 30 cc hour.\n\nEndo: insulin gtt per csru protocol.\n\nPain: percocet po x 2 tabs at 2330 with relief of insional discomfort.\n\nIV's: r rad a line zeroed, waveform with notch. R cdi.\n\nSocial: no contact from family/friends.\n\nPlan: attempt neo wean, convert to sc insulin in AM. transfer to floor bed late AM. Continue to control BS, assess and treat pain, encourage pulmo toilet. OOb after deline in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-09 00:00:00.000",
"description": "Report",
"row_id": 1543616,
"text": "Hypotension\nPatient hypotensive with change of neo to different line, blood transfusion began for crit 24.8 per dr . Neo increased as high as 2.0, currently at 1.0. Will continue to wean neo as tol. UOP slowed, will continue to monitor. Pt remains alert and oriented throughout episode. No s/s of transusion rxn at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-09 00:00:00.000",
"description": "Report",
"row_id": 1543617,
"text": "CSRU NSG:\n\nNEURO: A&OX3, no neural deficit noted.\n\nCV: SR with one episode of wide complex, rapid rhythm X 7 beats. BP maintained throughout episode, no LOC. 2 GM magnesium given. No further ectopy noted. Sternal dressing changed per verbal order Dr. . Lopressor not prescribed as of yet. Requires neo at 0.7mcg/kg/min for BP support. Unable to tolerate neo weaning X numerous attempts.\n\nPULM: SpO2 99% on O2 3L via NC. No SOB or dyspnea noted. LSCTAB w/dim bases. Chest tube drainage approximately 10cc/hr at this time.\n\nGU: Lasix 20 IV BID started. Urine clr, yellow, dilute. Output QS.\n\nGI: Abdomen soft, NT, +BSX4Q. Eats 25-75% meals. No stool. No N/V.\n\nASSESS: Stable 1st day postop.\n\nPLAN: Wean neo as tolerated. D/c chest tubes in am. Transfer to floor when neo d/c'd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-10 00:00:00.000",
"description": "Report",
"row_id": 1543618,
"text": "NPN\nCSRU\n7 PM - 7 AM\n3VD S/P CABG\nREQUESTING TO SIT IN CHAIR THROUGHOUT NIGHT ..PERCOCETS 2 TABS Q4 ..FOR INCISIONAL PAIN.\nINCISIONAL/CT DSGS INTACT\nPACER A DEMAND ..SET AT 60...WIRES ATTACHED TO PACER..\nHR 70'SR ...SBP BY ALINE 90-110'S/50'S..ABLE TO WEAN NEO TO .5 MCGS...CT TO SUCTION WITH MINIMAL SEROUS OUTPUT .. ..VIA RIGHT IJ LINE\nRESP LUNGS DIMINISHED AT BASES ..ON 4L NP ..NON-PROD COUGH..USING ...\nGU DIURESING TO LASIX ...\nGI TOLERATING SIPS OF CLEAR LIQUIDS\nHEME HCT DOWN TO 25 ...\nA/P HEMODYN STABLE ..BUT REMIANS ON LOW DOSE PRESSOR\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-10 00:00:00.000",
"description": "Report",
"row_id": 1543619,
"text": "Neuro: alert and oriented x 3, mae, ambulating, percocets for pain.\n\nCardiac: nsr with no ectopy, weaned off neo gtt today, sbps wnls, palpible pedial pulses, skin warm dry and intact, +3 edema in extremities.\n\nResp: on ra at rest satting at 95% with exertion does desat to 92 and put on 2 liters nc and sats at 98%, lungs are dim in bases, ct system to sxn with no air leak draining scant awaiting md to pull ct's, is using i/s.\n\nSkin: chest and ct dsds are cdi, left leg dsd is cdi.\n\nGi/Gu: tolerating po's, abd is soft round and nontender, good bowel sounds, on riss, making good u/o while on lasix.\n\nPlan: f2 when bed is ready, monitor blood sugars, continue percocets, monitor bp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2162-01-11 00:00:00.000",
"description": "Report",
"row_id": 1543620,
"text": "CSRU NPN\nNEURO: A/OX3, NO NEURAL DEFICITS NOTED. OOB>CHAIR ALL NIGHT. TMAX 100.7. PERCOCET FOR PAIN.\n\nCV: SR, NO ECTOPY. B/P STABLE, NEO OFF. SEE CAREVUE. CT OUT @ ~, POST CXR 'OK' PER DR. . LYTES REPLEATED AS DOCUMENTED.\n\nRESP: SPO2 ON 2LNC >94%. DIM BILAT BASES. NEEDS ENCOURAGEMENT WITH I/S. NONPRODUCTIVE COUGH.\n\nGI: TOLERATING FULL DIET. CONTINUES ON ZANTAC. + BS, STARTING TO FEEL 'GAS PAINS'. NO BM. ON COLACE.\n\nGU: FOLEY CATH, DIURESING WELL AFTER LASIX. SEE CAREVUE.\n\nENDO: SSRI\n\nPLAN: D/C TRAUMA IJ. 2 TRANSFER. INCREASE ACTIVITY. ENCOURAGE I/S & CDB.\n"
},
{
"category": "ECG",
"chartdate": "2162-01-08 00:00:00.000",
"description": "Report",
"row_id": 109662,
"text": "Sinus rhythm\nNormal ECG\nNo change from previous\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 892041,
"text": " 10:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval after wire removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p CABG\n\n REASON FOR THIS EXAMINATION:\n please eval after wire removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man status post CABG. Evaluate after wire removal.\n\n Portable upright chest radiograph of at 10:35 is compared to the\n prior radiograph of .\n\n In the interval, a Swan-Ganz catheter introducer sheath was removed. There is\n no evidence of pneumothorax. There is a resolving left pleural effusion.\n There has been interval decrease in the mediastinal width.\n\n IMPRESSION:\n\n 1. Interval decrease in mediastinal width.\n\n 2. No evidence for pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891761,
"text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p CABG\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 08:23\n\n INDICATION: CABG - check effusion.\n\n COMPARISON: .\n\n FINDINGS:\n\n Chest tubes remain in place and there is no PTX. Swan-Ganz catheter has been\n removed and a right introducer sheath remains.\n\n ETT has been removed. The mediastinal contours are somewhat less pronounced\n than that seen previously - clearly there is no progression of that\n prominence. No new consolidations.\n\n IMPRESSION:\n\n Small amount of pleural fluid in the left costophrenic sulcus. No new\n consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891829,
"text": " 7:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: post chest tube cxr film, please eval for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p CABG\n\n REASON FOR THIS EXAMINATION:\n post chest tube cxr film, please eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man status post CABG. Post-chest tube pull film. Rule\n out pneumothorax.\n\n AP erect portable chest radiograph was compared to the prior chest x- ray of\n at 8:23.\n\n Left-sided chest tubes have been removed and there is no evidence of\n pneumothorax. The Swan-Ganz catheter introducer sheath remains. Small left\n pleural effusion. No new consolidations.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-01-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 891591,
"text": " 12:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest port line placement.\n\n Comparison to .\n\n INDICATION: Status post CABG, rule out pneumothorax or effusion.\n\n FINDINGS: The mediastinum is significantly widened. This may be due to\n accentuation of postoperative changes secondary to supine positioning,\n rotation and low lung volumes, though a mediastinal hematoma should also be\n considered. Recommend clinical correlation and short term radiographic\n followup. CT may be helpful if this persists or is progressive on a repeat\n radiograph.\n\n Tip of a Swan-Ganz catheter lies in the main pulmonary artery. Three left\n chest tubes are present. ET tube is located 7 cm above the carina at the\n level of the clavicles. Left lower lobe atelectasis is present.\n\n These findings were communicated with Dr. at the time of the study.\n\n\n"
}
] |
55,281 | 151,991 | This is a 57 yo M with a history of ITP and autoimmune hemolytic anemia who presented to OSH with epistaxis and plt of , transferred here for further management. . # Thrombocytopenia/epistaxis/mucosal bleeding/petechiae: Felt to be due to ITP +/-degree of splenic sequestration given h/o enlarged spleen on prior CT scan. Bone marrow biopsy a year ago c/w reactive process. Pts plt have not responded to plt given at OSH and unit of plt given last night. Plt also did not respond to solumedrol or IVIG given at OSH. Per heme/onc, other options may include decadron, rhogam. No evidence of DIC or TTP on review of peripheral smear by heme/onc. Direct Coomb's test and ab screen are negative. Pt may ultimately need splenectomy. Plt still less than 5. Pt had some recurrent epistaxis now resolved earlier this morning, and some dried blood on his oral mucosa. No GI bleeding. -heme/onc following, appreciate input; pending recs tomorrow will likely need repeat CT scan abdomen to eval degree of splenomegaly -give prednisone 120 mg today (1 mg/kg); per heme onc we may consider decadron -give dose of 120 mg IVIG ; Benadryl/Tylenol prior to and during IVIG infusions -recheck plt after IVIG; will discuss with heme whether to start decadron if plt count does not bump -Patient underwent a splenectomy on and remained in the ICU monitoring his platelet count. He was transferred to the floor for continued monitoring. He continued on dexamethasone. He will be discharged on dexamethasone 8mg until follow up with heme/onc. . # Anemia/history of hemolytic anemia: Plt at OSH 44, 36 here. No evidence of DIC. Hemolytic labs are negative, so no evidence of hemolysis currently. Per heme/onc, IVIG and rhogam could potentially worsen his hemolytic anemia and cause hemolysis. -maintain active T&S -trend hct/hemolysis labs . # Diabetes Mellitus Type II, uncontrolled, without complications: Hyperglycemic here, but pt was not on his home regimen (was on NPH 70 U at home, but at OSH was on less dosing). Also hyperglycemia likely steroids. -NPH 70 U (can titrate up as needed with on steroids)/SSI -metformin . # HTN/LE swelling: BP well controlled. LE swelling noted. -Continue lasix (for LE edema)but increased from 60 mg daily to 100 mg daily given numerous infusions patient is receiving (will need to trend renal function and adjust based on it). Pt had been increased to 60 mg twice daily at OSH, but pt does not like receiving lasix at night -continue valsartan . # FEN: regular diet . # PPx: ambulation, stool softeners to prevent straining with bowel movements | S/p splenectomy - upon arrival to TSICU hypotensive and hct 19 platelets 6- given 2 units PRBSs, 2 units Platelets and 2 liters LR. S/p splenectomy - upon arrival to TSICU hypotensive and hct 19 platelets 6- given 2 units PRBSs, 2 units Platelets and 2 liters LR. Thrombocytopenia, acute Assessment: Pt arrived to TSICU s/p splecectomy hact 19.6 and platelets 6. Thrombocytopenia, acute Assessment: Pt arrived to TSICU s/p splecectomy hact 19.6 and platelets 6. Neuro checks Q: 2h Pain: Dilaudid PCA Cardiovascular: pt became more tachy and BP trended down to 80's, responded to blood product resusc. Neuro checks Q: 2h Pain: Dilaudid PCA Cardiovascular: pt became more tachy and BP trended down to 80's, responded to blood product resusc. Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding) Assessment: HCT post transfusion 24.7. He received multiple units of colloids and 2L of crystalloid for hypotension which has since resolved. Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS Nutrition: NPO Renal: Foley, Adequate UO, ITP, Hct check q4, tranfuse aggressively for dropping Hct. Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS Nutrition: NPO Renal: Foley, Adequate UO, ITP, Hct check q4, tranfuse aggressively for dropping Hct. Pt has increased confusion, head CT negative and cleared after decreasing dilauded dose. Surgery consulted re: emergent splenectomy given refractory ITP. Serial HCTs Hypotension (not Shock) Assessment: Upon arrival SBP 70-80s given Action: Given 2 liters LR, 2 units PRBCs and 2 units of Platelets. ITP, persistent thrombocytopenia; s/p IVIG , transfuse prn (over last 24 received 3 U PRBC and 1 U FFP), f/u final BM biopsy results, cont steroids. Wheezes continue Plan: Monitor O2 sats and resp. Nutrition: Clear liquids, sips adat to clears Renal: Foley, Adequate UO Hematology: Serial Hct, slow drift down, but stabilized out at around 23 ITP, persistent thrombocytopenia; s/p IVIG , transfuse prn (over last 24 received 3 U PRBC and 1 U FFP), f/u final BM biopsy results, cont steroids. Thrombocytopenia, acute Assessment: Pt arrived to TSICU s/p splecectomy hct 19.6 and platelets 6. Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding) Assessment: Melena stools continue. BP stable but was lightheaded with tachycardia on transfer to the MICU. S/p splenectomy - upon arrival to TSICU hypotensive and hct 19 platelets 6- given 2 units PRBSs, 2 units Platelets and 2 liters LR. Response: Repeat Hct 22.3 Plan: Transfuse another unit of PRBCs, then re-check Hct. Thrombocytopenia, acute Assessment: Pt continues with low platelet count, even after multiple platelet transfusions. Admitted to OSH on d/t epistaxis and plt count of . Admitted to OSH on d/t epistaxis and plt count of . Admitted to OSH on d/t epistaxis and plt count of . Admitted to OSH on d/t epistaxis and plt count of . Admitted to OSH on d/t epistaxis and plt count of . Hct 22- Action: Given 1 unit PRBC this shift Response: HCt post transfusion 24 pt continues to have melena stools this shift. Hct 22- Action: Given 1 unit PRBC this shift Response: HCt post transfusion 24 pt continues to have melena stools this shift. Hct 22- Action: Given 1 unit PRBC this shift Response: HCt post transfusion 24 pt continues to have melena stools this shift. As needed .H/O idiopathic Thrombocytopenic Purpura (ITP) Assessment: Platelets 10 this am, HCT 21, Pt. continues with Melana, HCT post transfusion pending at this time. Anemia, hemolytic Assessment: Pt with hct 21.2 this am. Anemia, hemolytic Assessment: Pt with hct 21.2 this am. elective Splenectomy on and was transferred to the T/SICU post-op. Continue with Metformin TID. Continue with Metformin TID. Continue with Metformin TID. Continue with Metformin TID. Admitted to OSH on d/t epistaxis and plt count of . Admitted to OSH on d/t epistaxis and plt count of . Admitted to OSH on d/t epistaxis and plt count of . The 0.018 guidewire was exchanged for wire which was advanced into the (Over) 3:41 AM MESSENERTIC Clip # Reason: embolize Admitting Diagnosis: EPISTAXIS Contrast: VISAPAQUE Amt: 700 FINAL REPORT (Cont) abdominal aorta under fluoroscopic guidance. (Over) 3:41 AM MESSENERTIC Clip # Reason: embolize Admitting Diagnosis: EPISTAXIS Contrast: VISAPAQUE Amt: 700 FINAL REPORT (Cont) | 78 | [
{
"category": "Nursing",
"chartdate": "2156-12-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 544549,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets.\n Thrombocytopenia, acute\n Assessment:\n Patient\ns initial platelet prior to transfusion ws\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 544552,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets.\n Thrombocytopenia, acute\n Assessment:\n Patient\ns initial platelet prior to transfusion was less than 5 with\n h/h 8.9 and 24.2\n Action:\n Given 2 units of PRBCs and 1 unit of platelets.\n Response:\n He has had no active bleeding since admission to the MICU. Has\n generalized petechaie, concentrated to the upper extremities and\n diffusely to the trunk and lower extremities.\n Plan:\n Continue with blood product administration MD orders. Monitor for\n signs of bleeding.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545042,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low platelets\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid pca, Insulin gtt, Methylprednisolone\n 24 Hour Events:\n ARTERIAL LINE - START 09:00 PM\n NUCLEAR MEDICINE - At 11:30 PM\n ANGIOGRAPHY - At 04:45 AM\n Post operative day:\n POD#4 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 12 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:24 PM\n Other medications:\n Flowsheet Data as of 04:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 97 (82 - 106) bpm\n BP: 137/66(88) {129/59(81) - 150/78(97)} mmHg\n RR: 18 (0 - 27) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 165.6 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 4,456 mL\n 1,321 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,347 mL\n 254 mL\n Blood products:\n 3,110 mL\n 1,068 mL\n Total out:\n 9,740 mL\n 600 mL\n Urine:\n 9,190 mL\n 600 mL\n NG:\n 550 mL\n Stool:\n Drains:\n Balance:\n -5,284 mL\n 721 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.48///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 8 K/uL\n 7.1 g/dL\n 156 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 110 mEq/L\n 148 mEq/L\n 19.4 %\n 36.0 K/uL\n [image002.jpg]\n 03:00 PM\n 04:00 PM\n 05:00 PM\n 05:07 PM\n 06:00 PM\n 08:00 PM\n 09:53 PM\n 10:00 PM\n 12:00 AM\n 02:20 AM\n WBC\n 36.7\n 39.2\n 36.0\n Hct\n 23.7\n 21.5\n 19.4\n Plt\n 5\n 6\n 8\n Creatinine\n 1.0\n 0.9\n Glucose\n 138\n 129\n 139\n 138\n 158\n 156\n 160\n 193\n 156\n Other labs: PT / PTT / INR:15.0/25.7/1.3, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.2 mmol/L, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP s/p splenectomy with continued\n thrombocytopenia and episodes of bleeding within lower GI tract\n Neurologic: Pain controlled\n Cardiovascular: HD stable\n Pulmonary: Stable, wean FiO2 as tolerated, cont diuresis as BP\n tolerates\n Gastrointestinal / Abdomen: Cont NGT to suction, f/u hepatitis panel\n Nutrition: NPO\n Renal: Foley, Adequate UO, cont diuresis\n Hematology: Serial Hct, goal Hct > 21, normalize INR, transfuse plts\n sparingly given poor response\n Endocrine: Insulin drip\n Infectious Disease: f/u hepatitis panel, f/u HIV\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: D10W while on insulin gtt\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-15 00:00:00.000",
"description": "TRICU resident progress note",
"row_id": 544686,
"text": "TITLE:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-15 00:00:00.000",
"description": "TRICU resident progress note",
"row_id": 544687,
"text": "TITLE:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 09:53 ------\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 544977,
"text": "SICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n .\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, Dilaudid, Insulin, MethylPREDNISolone, blood products:\n PRBC/PLT/FFP, Amicar\n 24 Hour Events:\n ARTERIAL LINE - START 09:00 PM\n NUCLEAR MEDICINE - At 11:30 PM\n ANGIOGRAPHY - At 04:45 AM\n lasix increased to 20 tid. rapid taper on steroids written. trophic\n feeds started and vaccines given. Pt has increased confusion, head CT\n negative and cleared after decreasing dilauded dose. Hct to 20 with\n no obvius source of bleed and no change in physical exam, transfused 2U\n of PRBC. repeat Hct. Had large melena stool, likely HD and Hct changes\n to this. Pt became hypotensive and more tachy, transfused total of\n 5 U prbc, 2 U platelets, 1U FFP, Amicar. tagged RBC scan showed active\n bleeding site that seemed to be in small intestine. In angio\n Post operative day:\n POD#3 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 9 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:26 PM\n Furosemide (Lasix) - 02:58 AM\n Other medications:\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.7\nC (99.8\n HR: 96 (87 - 139) bpm\n BP: 114/53(72) {93/53(65) - 126/65(80)} mmHg\n RR: 26 (9 - 26) insp/min\n SPO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Wgt (current): 165.6 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,836 mL\n 2,035 mL\n PO:\n Tube feeding:\n 185 mL\n IV Fluid:\n 1,094 mL\n 767 mL\n Blood products:\n 2,526 mL\n 1,268 mL\n Total out:\n 4,015 mL\n 1,980 mL\n Urine:\n 3,165 mL\n 1,980 mL\n NG:\n 450 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n -179 mL\n 55 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.46/39/111/31/3\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: Anxious, ill appearing\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely > at bases), (Sternum: Stable )\n Abdominal: Soft, Tender: over wound, Obese\n Left Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: diffuse ecchymossis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, after transfion, improved MS\n / Radiology\n 8 K/uL\n 8.7 g/dL\n 97 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 112 mEq/L\n 150 mEq/L\n 24.1 %\n 34.8 K/uL\n [image002.jpg]\n 03:23 PM\n 09:12 PM\n 03:41 AM\n 05:44 PM\n 09:15 PM\n 09:26 PM\n 10:46 PM\n 12:50 AM\n 05:03 AM\n 07:12 AM\n WBC\n 30.4\n 32.7\n 32.7\n 31.5\n 20.9\n 31.6\n 32.9\n 34.8\n Hct\n 25.9\n 24.9\n 24.2\n 20.1\n 24.4\n 25.5\n 24.0\n 23.6\n 24.1\n Plt\n 8\n 8\n 6\n 6\n 7\n 38\n 8\n 19\n 8\n Creatinine\n 0.8\n 1.0\n 1.3\n 1.3\n 1.0\n TCO2\n 29\n Glucose\n 120\n 126\n 135\n 108\n 97\n Other : PT / PTT / INR:15.2/25.4/1.3, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:3.3 mmol/L, Ca:7.7 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN, HYPERGLYCEMIA,\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING), ANEMIA,\n HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management\n Neurologic: Neuro checks Q: 2 hr, pt became more confused throughout\n day, thought initially high doses of dilauded, though likely \n bleeding and dropping Hct. after transfusion improved.\n Neuro checks Q: 2h\n Pain: Dilaudid PCA\n Cardiovascular: pt became more tachy and BP trended down to 80's,\n responded to blood product resusc. w/ HR to 100s and BP improved to\n 120s.\n Pulmonary: Extubated, wean O2 as tolerated, pulmonary toilet. pt had\n crackles diffusely, likely general hypovolemia. watched closely\n without changes after transfusion, will give lasix prn.\n Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS\n Nutrition: NPO\n Renal: Foley, Adequate UO, ITP, Hct check q4, tranfuse aggressively for\n dropping Hct. goal stable > 21. Total overnight 5U prbc, 2U plt, 1U\n ffp, Amicor. Pt went for tagged rbc scan, then angio active\n bleeding source identified.\n Hematology: Serial Hct, q4\n Endocrine: Insulin drip\n Infectious Disease: Afebrile, WBC 32, no Abx\n Lines / Tubes / Drains: Foley, NGT, NGT, femoral central line, 2 18g\n b/l ivs, aline\n Wounds: Dry dressings\n Imaging: tagged rbc scan, agniography\n Fluids: d10@20\n Consults: General surgery, Trauma surgery\n Billing Diagnosis: (Hemorrhage, NOS), Other: GIB, ITP\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n 18 Gauge - 10:01 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 544985,
"text": "Subjective\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 163 kg\n 165.6 kg ( 08:00 AM)\n 56.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 242%\n Diagnosis: epitaxis\n PMH :\n Food allergies and intolerances: NKFA\n Pertinent medications: SS lytes, pepcid, solumedrol, bowel meds, lasix,\n insulin gtt, D10W @10mL/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 128\n 01:00 PM\n Glucose Finger Stick\n 136\n 10:00 AM\n BUN\n 38 mg/dL\n 10:49 AM\n Creatinine\n 1.0 mg/dL\n 10:49 AM\n Sodium\n 146 mEq/L\n 10:49 AM\n Potassium\n 3.7 mEq/L\n 10:49 AM\n Chloride\n 108 mEq/L\n 10:49 AM\n TCO2\n 32 mEq/L\n 10:49 AM\n PO2 (arterial)\n 111 mm Hg\n 09:26 PM\n PCO2 (arterial)\n 39 mm Hg\n 09:26 PM\n pH (arterial)\n 7.48 units\n 12:37 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 09:26 PM\n Calcium non-ionized\n 8.4 mg/dL\n 10:49 AM\n Phosphorus\n 3.8 mg/dL\n 10:49 AM\n Ionized Calcium\n 1.11 mmol/L\n 12:37 PM\n Magnesium\n 2.3 mg/dL\n 10:49 AM\n WBC\n 41.2 K/uL\n 10:49 AM\n Hgb\n 9.3 g/dL\n 10:49 AM\n Hematocrit\n 25.1 %\n 10:49 AM\n Current diet order / nutrition support: Replete c/ Fiber @20mL/hr (on\n hold)\n GI: Abd: obese/+bs\n Assessment of Nutritional Status\n Obese, but At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs based on adjusted wt\n Calories: 1600-1780 (18-20 cal/kg)\n Protein: 107-122 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate NPO\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via nutrition support\n Tube feeding / TPN recommendations:\n Would consider TPN if unable to resume TF's GIB\n BG and lyte management as you are\n"
},
{
"category": "Nutrition",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 544986,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 163 kg\n 165.6 kg ( 08:00 AM)\n 56.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 242%\n 89\n Diagnosis: epitaxis\n PMH : DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP,\n obesity\n Food allergies and intolerances: NKFA\n Pertinent medications: SS lytes, pepcid, solumedrol, bowel meds, lasix,\n insulin gtt, D10W @10mL/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 128\n 01:00 PM\n Glucose Finger Stick\n 136\n 10:00 AM\n BUN\n 38 mg/dL\n 10:49 AM\n Creatinine\n 1.0 mg/dL\n 10:49 AM\n Sodium\n 146 mEq/L\n 10:49 AM\n Potassium\n 3.7 mEq/L\n 10:49 AM\n Chloride\n 108 mEq/L\n 10:49 AM\n TCO2\n 32 mEq/L\n 10:49 AM\n PO2 (arterial)\n 111 mm Hg\n 09:26 PM\n PCO2 (arterial)\n 39 mm Hg\n 09:26 PM\n pH (arterial)\n 7.48 units\n 12:37 PM\n CO2 (Calc) arterial\n 29 mEq/L\n 09:26 PM\n Calcium non-ionized\n 8.4 mg/dL\n 10:49 AM\n Phosphorus\n 3.8 mg/dL\n 10:49 AM\n Ionized Calcium\n 1.11 mmol/L\n 12:37 PM\n Magnesium\n 2.3 mg/dL\n 10:49 AM\n WBC\n 41.2 K/uL\n 10:49 AM\n Hgb\n 9.3 g/dL\n 10:49 AM\n Hematocrit\n 25.1 %\n 10:49 AM\n Current diet order / nutrition support: Replete c/ Fiber @20mL/hr (on\n hold)\n GI: Abd: obese/+bs\n Assessment of Nutritional Status\n Obese, but At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs based on adjusted wt\n Calories: 1600-1780 (18-20 cal/kg)\n Protein: 107-122 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of previous intake: Excessive\n Estimation of current intake: Inadequate NPO\n Specifics:\n 57 y/o male c/ h/o ITP transferred form OSH c/ epistaxis, transferred\n to TSICU p/ failed medical management and elective splenectomy .\n Pt started on TF\ns yesterday, now on hold as pt c/ melena and large Hct\n drop. Pt receiving FFP, plts and RBC prn. Tagged RBC scan showed\n likely source small intestine, therefore went to angio. If unable to\n resume TF\ns will need to consider TPN in next 3-4 days.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via nutrition support\n Would consider TPN if unable to resume TF's GIB\n Will follow plan, ability to resume TF and need for TPN.\n BG and lyte management as you are\n Please page c/ ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544774,
"text": "57yr old male originally admitted to the for medical\n management of ITP. Decision was made to take him to the OR for\n splencetomy dropping platelet count and melanic stools. He received\n multiple units of colloids and 2L of crystalloid for hypotension which\n has since resolved. He was extubated this am and is currently on 50%\n face tent. Lungs have been clear bilaterally and he is using his IS\n with good effort. Coughing, deep breathing and splinting technique\n reinforced.\n Thrombocytopenia, acute\n Assessment:\n Persistent oozing of blood from central line site. Several small clots\n noted in urine with some bloody discharge noted around meatus. Old dark\n blood draining via NGT with total for shift 250cc. Petechiae across\n trunk and lower extremities.\n Action:\n Serial hcts and platelet values obtained\n Response:\n Hct stable at 25, platelet count up from 5 to 8. Pt hemodynamicaly\n stable\n Plan:\n Observe for frank bleeding and hemodynamic instability and increased\n petechiae. Follow hcts/platelets and replete as ordered and indicated.\n Acute Pain\n Assessment:\n Pt rating abdominal incision pain as an 8 at rest\n Action:\n Prn Dilaudid per \n Response:\n Pain score minimally improved to 7, and increases with any activity.\n Dilaudid PCA imitated with good effect\n Plan:\n Continue to monitor comfort level, encourage pca use before activities.\n Notify team of increased or unrelieved pain.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544771,
"text": "Thrombocytopenia, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 544843,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n dilaudid pca, famotidine, insulin gtt\n 24 Hour Events:\n EXTUBATION - At 10:30 AM\n +cuff leak, +cough/gag, refer to abg's. Pt extubated without\n diffuiculty. Respiratory effort unlabored, no stridor appreciated.\n ARTERIAL LINE - STOP 01:57 AM\n Post operative day:\n POD#2 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 6.5 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 05:07 PM\n Famotidine (Pepcid) - 07:38 AM\n Other medications:\n Flowsheet Data as of 09:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37\nC (98.6\n HR: 100 (82 - 100) bpm\n BP: 116/70(81) {108/58(73) - 127/70(82)} mmHg\n RR: 14 (11 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n Wgt (current): 165.6 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 5,208 mL\n 419 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,293 mL\n 419 mL\n Blood products:\n 2,915 mL\n Total out:\n 4,940 mL\n 1,290 mL\n Urine:\n 4,650 mL\n 1,240 mL\n NG:\n 290 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 268 mL\n -871 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n PS : 0 cmH2O\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 25\n PIP: 2 cmH2O\n SPO2: 100%\n ABG: 7.41/43/115/32/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 230\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Wheezes : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 6 K/uL\n 8.8 g/dL\n 126 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 109 mEq/L\n 146 mEq/L\n 24.2 %\n 32.7 K/uL\n [image002.jpg]\n 10:29 PM\n 01:58 AM\n 02:05 AM\n 05:54 AM\n 06:05 AM\n 09:59 AM\n 10:25 AM\n 03:23 PM\n 09:12 PM\n 03:41 AM\n WBC\n 16.8\n 14.1\n 30.4\n 32.7\n 32.7\n Hct\n 20.3\n 21.7\n 25.8\n 25.0\n 25.9\n 24.9\n 24.2\n Plt\n 10\n 17\n 9\n 6\n 8\n 8\n 6\n Creatinine\n 0.9\n 0.9\n 0.8\n 1.0\n TCO2\n 29\n 28\n 28\n Glucose\n 176\n 116\n 120\n 126\n Other labs: PT / PTT / INR:13.0/24.0/1.1, Lactic Acid:1.0 mmol/L,\n Ca:7.9 mg/dL, Mg:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ACUTE PAIN, HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS\n (HEMORRHAGE, BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM\n - ENTER DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M ITP s/p splenectomy with continued\n thrombocytopenia\n Neurologic: Pain controlled, cont dilaudid pca\n Cardiovascular: HD stable\n Pulmonary: will diuresis\n Gastrointestinal / Abdomen: clamp NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO, cont diuresis\n Hematology: Serial Hct, platelets low, hct Q12, plt Q12\n Endocrine: Insulin drip, cont solumedrol taper\n Infectious Disease: Stable\n Lines / Tubes / Drains: Foley, NGT, right femoral TLC line\n Wounds:\n Imaging:\n Fluids: D10W at 20cc/hr while on insulin gtt\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Post-op hypotension, Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 11:30 AM\n Multi Lumen - 06:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 544844,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n dilaudid pca, famotidine, insulin gtt\n 24 Hour Events:\n EXTUBATION - At 10:30 AM\n +cuff leak, +cough/gag, refer to abg's. Pt extubated without\n diffuiculty. Respiratory effort unlabored, no stridor appreciated.\n ARTERIAL LINE - STOP 01:57 AM\n Post operative day:\n POD#2 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 6.5 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 05:07 PM\n Famotidine (Pepcid) - 07:38 AM\n Other medications:\n Flowsheet Data as of 09:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37\nC (98.6\n HR: 100 (82 - 100) bpm\n BP: 116/70(81) {108/58(73) - 127/70(82)} mmHg\n RR: 14 (11 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SA (Sinus Arrhythmia)\n Wgt (current): 165.6 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 5,208 mL\n 419 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,293 mL\n 419 mL\n Blood products:\n 2,915 mL\n Total out:\n 4,940 mL\n 1,290 mL\n Urine:\n 4,650 mL\n 1,240 mL\n NG:\n 290 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n 268 mL\n -871 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n PS : 0 cmH2O\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 25\n PIP: 2 cmH2O\n SPO2: 100%\n ABG: 7.41/43/115/32/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 230\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: No(t) CTA\n bilateral : , Wheezes : , Rhonchorous : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 6 K/uL\n 8.8 g/dL\n 126 mg/dL\n 1.0 mg/dL\n 32 mEq/L\n 4.3 mEq/L\n 32 mg/dL\n 109 mEq/L\n 146 mEq/L\n 24.2 %\n 32.7 K/uL\n [image002.jpg]\n 10:29 PM\n 01:58 AM\n 02:05 AM\n 05:54 AM\n 06:05 AM\n 09:59 AM\n 10:25 AM\n 03:23 PM\n 09:12 PM\n 03:41 AM\n WBC\n 16.8\n 14.1\n 30.4\n 32.7\n 32.7\n Hct\n 20.3\n 21.7\n 25.8\n 25.0\n 25.9\n 24.9\n 24.2\n Plt\n 10\n 17\n 9\n 6\n 8\n 8\n 6\n Creatinine\n 0.9\n 0.9\n 0.8\n 1.0\n TCO2\n 29\n 28\n 28\n Glucose\n 176\n 116\n 120\n 126\n Other labs: PT / PTT / INR:13.0/24.0/1.1, Lactic Acid:1.0 mmol/L,\n Ca:7.9 mg/dL, Mg:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ACUTE PAIN, HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS\n (HEMORRHAGE, BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM\n - ENTER DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M ITP s/p splenectomy with continued\n thrombocytopenia\n Neurologic: Pain controlled, cont dilaudid pca\n Cardiovascular: HD stable\n Pulmonary: will diuresis\n Gastrointestinal / Abdomen: clamp NGT\n Nutrition: NPO\n Renal: Foley, Adequate UO, cont diuresis\n Hematology: Serial Hct, platelets low, hct Q12, plt Q12\n Endocrine: Insulin drip, cont solumedrol taper\n Infectious Disease: Stable\n Lines / Tubes / Drains: Foley, NGT, right femoral TLC line\n Wounds:\n Imaging:\n Fluids: D10W at 20cc/hr while on insulin gtt\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Post-op hypotension, Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 11:30 AM\n Multi Lumen - 06:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-14 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 544553,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets.\n Thrombocytopenia, acute\n Assessment:\n Patient\ns initial platelet prior to transfusion was less than 5 with\n h/h 8.9 and 24.2\n Action:\n Given 2 units of PRBCs and 1 unit of platelets.\n Response:\n He has had no active bleeding since admission to the MICU. Has\n generalized petechaie, concentrated to the upper extremities and\n diffusely to the trunk and lower extremities.\n Plan:\n Continue with blood product administration MD orders. Monitor for\n signs of bleeding.\n Hypotension (not Shock)\n Assessment:\n SBP in the 70\n 100\n Action:\n Given fluid bolus total of 2000mls since admission to the ICU. Has also\n received blood products as mentioned as above.\n Response:\n Patient\ns mental status has not been altered. He however admits to\n lightheadedness and mild headache for which he received Tylenol with\n effect.\n Plan:\n Continue to monitor hemodynamic status.\n Last had oral contrast for CT scan at 1200. Prior to that he had been\n NPO MD ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544952,
"text": "Events:\n Pt. to nuclear med for GI study then angio overnight d/t decreasing\n HCT and Platelets. Pt. with multiple large episodes of Melena\n overnight.\n Pt. receving 7units PRBC, 5 units Platelets and 2 units FFP, amicar\n gtt. started then d\ncd overnight.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Most recent HCT 24 after 7 units PRBC, multiple episodes of melena\n overnight, NGT draining brown fluid, urine more clear overnight.\n Action:\n 7 units PRBC\ns given overnight, pt. to nuclear med, then angio to stop\n bleeding\n Response:\n Most recent HCT 24\n Plan:\n Continue to monitor HCT, angio\n Thrombocytopenia, acute\n Assessment:\n Most recent platelets 19 after 5 units given,\n Action:\n Pt. continues to receive platelets for dropping count, pt. given bolus\n of amicar and placed on gtt.\n Response:\n Amicar gtt. d/cd this am, pt. shortly responding to platelets\n Plan:\n Monitor platelets, administer as necessary\n Problem - Description In Comments- fluid overload\n Assessment:\n LS crackles overnight with exp. Wheezes this am\n Action:\n Lasix 20mg IV given\n Response:\n Pt. responding well, dumping 1200ml urine\n Plan:\n ? Repeat Lasix dose this am if hemodynamically stable\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 544956,
"text": "SICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n .\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, Dilaudid, Insulin, MethylPREDNISolone, blood products:\n PRBC/PLT/FFP, Amicar\n 24 Hour Events:\n ARTERIAL LINE - START 09:00 PM\n NUCLEAR MEDICINE - At 11:30 PM\n ANGIOGRAPHY - At 04:45 AM\n lasix increased to 20 tid. rapid taper on steroids written. trophic\n feeds started and vaccines given. Pt has increased confusion, head CT\n negative and cleared after decreasing dilauded dose. Hct to 20 with\n no obvius source of bleed and no change in physical exam, transfused 2U\n of PRBC. repeat Hct. Had large melena stool, likely HD and Hct changes\n to this. Pt became hypotensive and more tachy, transfused total of\n 5 U prbc, 2 U platelets, 1U FFP, Amicar. tagged RBC scan showed active\n bleeding site that seemed to be in small intestine. In angio\n Post operative day:\n POD#3 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 9 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:26 PM\n Furosemide (Lasix) - 02:58 AM\n Other medications:\n Flowsheet Data as of 08:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.7\nC (99.8\n HR: 96 (87 - 139) bpm\n BP: 114/53(72) {93/53(65) - 126/65(80)} mmHg\n RR: 26 (9 - 26) insp/min\n SPO2: 94%\n Heart rhythm: SA (Sinus Arrhythmia)\n Wgt (current): 165.6 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,836 mL\n 2,035 mL\n PO:\n Tube feeding:\n 185 mL\n IV Fluid:\n 1,094 mL\n 767 mL\n Blood products:\n 2,526 mL\n 1,268 mL\n Total out:\n 4,015 mL\n 1,980 mL\n Urine:\n 3,165 mL\n 1,980 mL\n NG:\n 450 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n -179 mL\n 55 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SPO2: 94%\n ABG: 7.46/39/111/31/3\n PaO2 / FiO2: 222\n Physical Examination\n General Appearance: Anxious, ill appearing\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely > at bases), (Sternum: Stable )\n Abdominal: Soft, Tender: over wound, Obese\n Left Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Cool), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: diffuse ecchymossis\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, after transfion, improved MS\n / Radiology\n 8 K/uL\n 8.7 g/dL\n 97 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 3.9 mEq/L\n 40 mg/dL\n 112 mEq/L\n 150 mEq/L\n 24.1 %\n 34.8 K/uL\n [image002.jpg]\n 03:23 PM\n 09:12 PM\n 03:41 AM\n 05:44 PM\n 09:15 PM\n 09:26 PM\n 10:46 PM\n 12:50 AM\n 05:03 AM\n 07:12 AM\n WBC\n 30.4\n 32.7\n 32.7\n 31.5\n 20.9\n 31.6\n 32.9\n 34.8\n Hct\n 25.9\n 24.9\n 24.2\n 20.1\n 24.4\n 25.5\n 24.0\n 23.6\n 24.1\n Plt\n 8\n 8\n 6\n 6\n 7\n 38\n 8\n 19\n 8\n Creatinine\n 0.8\n 1.0\n 1.3\n 1.3\n 1.0\n TCO2\n 29\n Glucose\n 120\n 126\n 135\n 108\n 97\n Other : PT / PTT / INR:15.2/25.4/1.3, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:3.3 mmol/L, Ca:7.7 mg/dL, Mg:2.4 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN, HYPERGLYCEMIA,\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING), ANEMIA,\n HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management\n Neurologic: Neuro checks Q: 2 hr, pt became more confused throughout\n day, thought initially high doses of dilauded, though likely \n bleeding and dropping Hct. after transfusion improved.\n Neuro checks Q: 2h\n Pain: Dilaudid PCA\n Cardiovascular: pt became more tachy and BP trended down to 80's,\n responded to blood product resusc. w/ HR to 100s and BP improved to\n 120s.\n Pulmonary: Extubated, wean O2 as tolerated, pulmonary toilet. pt had\n crackles diffusely, likely general hypovolemia. watched closely\n without changes after transfusion, will give lasix prn.\n Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS\n Nutrition: NPO\n Renal: Foley, Adequate UO, ITP, Hct check q4, tranfuse aggressively for\n dropping Hct. goal stable > 21. Total overnight 5U prbc, 2U plt, 1U\n ffp, Amicor. Pt went for tagged rbc scan, then angio active\n bleeding source identified.\n Hematology: Serial Hct, q4\n Endocrine: Insulin drip\n Infectious Disease: Afebrile, WBC 32, no Abx\n Lines / Tubes / Drains: Foley, NGT, NGT, femoral central line, 2 18g\n b/l ivs, aline\n Wounds: Dry dressings\n Imaging: tagged rbc scan, agniography\n Fluids: d10@20\n Consults: General surgery, Trauma surgery\n Billing Diagnosis: (Hemorrhage, NOS), Other: GIB, ITP\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n 18 Gauge - 10:01 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545140,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid pca, Insulin gtt, MethylPREDNISolone,\n 24 Hour Events:\n Remained hemodynamically stable. Required 2 units of PRBCs for\n decreasing Hct.\n Post operative day:\n POD#5 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:12 PM\n Lorazepam (Ativan) - 09:30 PM\n Other medications:\n Flowsheet Data as of 04:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.1\nC (97\n HR: 107 (93 - 133) bpm\n BP: 157/65(92) {120/60(78) - 157/86(103)} mmHg\n RR: 25 (16 - 27) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,723 mL\n 95 mL\n PO:\n Tube feeding:\n IV Fluid:\n 995 mL\n 95 mL\n Blood products:\n 2,728 mL\n Total out:\n 6,415 mL\n 740 mL\n Urine:\n 5,140 mL\n 540 mL\n NG:\n 650 mL\n 200 mL\n Stool:\n 625 mL\n Drains:\n Balance:\n -2,692 mL\n -645 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.52///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 8 K/uL\n 8.3 g/dL\n 109 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 43 mg/dL\n 113 mEq/L\n 150 mEq/L\n 23.0 %\n 36.7 K/uL\n [image002.jpg]\n 10:45 AM\n 01:00 PM\n 01:34 PM\n 02:00 PM\n 05:42 PM\n 07:00 PM\n 08:00 PM\n 08:10 PM\n 10:00 PM\n 01:30 AM\n WBC\n 36.9\n 26.5\n 36.7\n Hct\n 22.3\n 24.7\n 23.0\n Plt\n 7\n 5\n 8\n Creatinine\n 1.0\n Glucose\n 151\n 161\n 128\n 102\n 134\n 132\n 127\n 109\n Other labs: PT / PTT / INR:15.4/24.8/1.4, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, Ca:8.0 mg/dL, Mg:2.5 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management, persistent\n thrombocytopenia ?related to cirrhosis\n Neurologic: Pain controlled, A+Ox3, follows commands\n Cardiovascular: HD stable off pressors, fluid/product resuscitate prn\n Pulmonary: Stable on nasal canula, diurese as BP tolerates\n Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS, f/u hepatitis\n panel\n Nutrition: NPO\n Renal: Foley, Adequate UO, Stable, maintain diruresis.\n Hematology: Serial Hct, ITP, persistent thrombocytopenia; s/p IVIG\n , transfuse prn, f/u final BM biopsy results, cont steroids 125 mg\n Solumedrol daily\n Endocrine: Insulin drip\n Infectious Disease: Check cultures, Afebrile, f/u hepatitis panel, f/u\n HIV results\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: D10@10\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: (Hemorrhage, NOS), Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544611,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets. S/p splenectomy\n - upon arrival to TSICU hypotensive and hct 19 platelets 6- given\n 2 units PRBSs, 2 units Platelets and 2 liters LR.\n Thrombocytopenia, acute\n Assessment:\n Pt arrived to TSICU s/p splecectomy hact 19.6 and platelets 6. Also\n bleeding moderately from nose and also some from gums. Petichiae noted\n all over body. Repeat HCt 20.3 repeat platelets 10\n Action:\n Given total 4 units PRBCs and 4 units Platelets and 1 unit FFP\n Response:\n Bleeding has slowed from nose.\n Plan:\n Continue to transfuse as needed and monitor for s/s of bleeding.\n Hypotension (not Shock)\n Assessment:\n Upon arrival SBP 70-80\ns given\n Action:\n Given 2 liters LR, 2 units PRBCs and 2 units of Platelets. Given\n another 2 units PRBCs and 2 units Platelets after repeawt labs. For\n total of 4 and 4 and 1 unit FFP.\n Response:\n SBP 100\ns-110\ns now. MAPs mid 60\n Plan:\n Continue to monitor hemodynamic status.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545083,
"text": "Hyperglycemia\n Assessment:\n Glucose levels 94\n 161 this shift.\n Action:\n Insulin drip titrated. Currently at 9 units/hr. D10W at 10cc/hr.\n Continues on prednisone.\n Response:\n Glucose levels usually in goal range.\n Plan:\n Continue D 10 W drip and insulin drip titration.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Clots in urine, melena stool, occ bloody nose. Occ bloody NG\n drainage. Hct 23.6 at 0530, Hct at 0930 down to 21.4\n Action:\n Transfused 1 unit PRBC\ns for Hct 21.4.\n Response:\n Repeat Hct 22.3\n Plan:\n Transfuse another unit of PRBC\ns, then re-check Hct. Monitor blood\n loss.\n See previous notes for history.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544607,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets. S/p splenectomy\n - upon arrival to TSICU hypotensive and hct 19 platelets 6- given\n 2 units PRBSs, 2 units Platelets and 2 liters LR.\n Thrombocytopenia, acute\n Assessment:\n Pt arrived to TSICU s/p splecectomy hact 19.6 and platelets 6. Also\n bleeding moderately from nose and also some from gums. Petichiae noted\n all over body.\n Action:\n Given 2 units of PRBCs and2 unit of platelets.\n Response:\n Bleeding has slowed from nose.\n Plan:\n Continue to transfuse as needed and monitor for s/s of bleeding.\n Hypotension (not Shock)\n Assessment:\n Upon arrival SBP 70-80\ns given\n Action:\n Given 2 liters LR, 2 units PRBCs and 2 units of Platelets.\n Response:\n SBP 100\ns now. MAPs mid 60\n Plan:\n Continue to monitor hemodynamic status.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545133,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n HCT post transfusion 24.7. Scant amts of melena, low ngt output and\n bloody urine.\n Action:\n Repeated HCT with am labs.\n Response:\n HCT 23.\n Plan:\n Cont to monitor for signs bleeding and frequent HCTs.\n Hyperglycemia\n Assessment:\n Insulin gtt at 9 units. Bg <150.\n Action:\n No change to gtt this shift.\n Response:\n Plan:\n Cont frequent glucose checks and adjust gtt as indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-14 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 544513,
"text": "Chief Complaint: Anemia, GI bleeding, thrombocytopenia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with hx of ITP and autoimmune hemolytic anemia for several\n years. ITP responded to steroids and IGG initially. Platelet count down\n acutely now. Started on solumedrol. Developed melena last night. BP\n stable but was lightheaded with tachycardia on transfer to the MICU.\n Given volume with NS and transfused 1 unit PRBC's and platelets.\n BP has been marginal in past hour with persistent tachycardia.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n solumedrol, senna, insulin, colace, protonix\n Past medical history:\n Family history:\n Social History:\n DM - type II\n Hypertension\n Hemolytic anemia - Coombs test negative in in past week\n sister with ITP\n Occupation: Works at \n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Ear, Nose, Throat: Epistaxis\n Neurologic: lightheaded\n Flowsheet Data as of 10:23 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 113 (105 - 113) bpm\n BP: 95/43(51) {95/43(51) - 102/46(51)} mmHg\n RR: 20 (19 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 24 mL\n PO:\n TF:\n IVF:\n 24 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 24 mL\n Respiratory\n SpO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, Overweight\n / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube, Dry mucus membranes\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: No(t) Normal, Distant,\n No(t) Loud, No(t) Widely split , No(t) Fixed), No(t) S3, No(t) S4,\n No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular Dorsalis pedis 3+ bilarterally Respiratory / Chest:\n (Expansion: Symmetric), (Breath Sounds: Clear : Anteriorally and\n laterally, No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : ,\n No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Tender: Mild RUQ, Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice Diffuse petechiae.\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, and time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n less than 5\n 27.6\n 258\n 1.1\n 71\n 27\n 98\n 3.2\n 137\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2, LDH:195\n Imaging: Head CT: negative.\n Assessment and Plan\n 1) GI BLEED\n 2) ANEMIA\n 3) THROMBOCYTOPENIA\n Patient with refractory thrombocytopenia and GI bleeding. Attempting to\n volume resuscitate and replace blood products. Patient on steroids for\n ITP. Continues on protonix. Surgery consulted re: emergent splenectomy\n given refractory ITP. No evidence of hemolytic anemia now. Patient\n having problems with venous access. Will try to get additional\n peripheral access or midline catheter, although still not ideal for\n rapid volume resuscitation. If necessary will place IJ under ultrasound\n guidance.\n Gas exchange good. Patient mentating well. Difficult to assess urine\n output without Foley and hesitatant to place now with low platelet\n count.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 06:50 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-14 00:00:00.000",
"description": "resident admission note",
"row_id": 544537,
"text": "TITLE:\n Resident Admission Note\n .\n Reason for MICU Admission: observation of acute blood loss anemia\n .\n Primary Care Physician: , \n .\n CC: bleed, low plt,\n HPI: Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. In he was treated with prednisone for similar\n episode and was able to be tapered off in the course of 2 months. He\n then presented in with thrombocytopenia after a viral\n syndrome. He was again treated with IVIG and prednisone with\n improvement in his counts.\n Currently, he feels well, except for the petechiae and nose and mouth\n bleeds. He denies any fevers, chills or night sweats. He endorses some\n LH, dizziness, no headaches. He denies any recent viral syndromes or\n colds. He denies any sore throat, rhinorrhea, minor nosebleeds, cough,\n chest pain or SOB. He denies any abdominal pain, nausea or vomiting. He\n denies any diarrhea or constipation. He denies any urinary symptoms. He\n deneis any new medications or recent travel. He was seen in his PCP's\n office approximately 3 weeks ago and had labs drawn which were\n reportedly normal.\n PMH:\n # DM type II\n # HTN\n # h/o autoimmune hemolytic anemia\n # h/o ITP\n .\n MEDICATIONS: (at home)\n valsartan 40mg PO daily\n lasix 100mg PO daily\n metformin 500mg PO TID\n protonix 40mg PO daily\n miconazole powder 2% appl TP TID prn\n .\n ALL: NKDA\n .\n FAM HX: Sister was diagnosed with ITP and treated with some type of\n \"chemotherapy\". She has done well since. There are no other family\n members with autoimmune disorders or blood disorders. There is no\n family history of bleeding or clotting, except for his father who died\n of a cerebral hemorrhage.\n .\n SOCIAL HX: Works for . Lives in , NH.\n EXAM:\n .\n VS T 98.6, BP 90/60, HR 110, RR 16, sats 98% on RA\n GEN: WDWN obese male in obviouse disstress\n HEENT: Sclera anicteric. PERRL. EOMI. OP with multiple blood blisters\n along buccal mucosa and along gums. No active bleeding. Crusted blood\n seen at tip of nares.\n NECK: No LAD.\n CV: RR, normal S1, S2. No murmurs.\n LUNGS: CTAB\n ABD: Soft, obese, NTND. No appreciable HSM, but difficult to assess due\n to pt's body habitus.\n EXT: No edema, but diffuse almost confluent petechiae across his\n bilateral LE, from his knees to his toes. Petechiae also seen on the\n dorsum of his hands and scattered over his forearms and arms, abdomen,\n and across back of his neck. Large ecchymoses and ? hematoma formation\n in R antecubital fossa due to IV attempts.\n .\n .\n A/P: 57yo male with DM, HTN and history of autoimmune hemolytic anemia\n and ITP who presents with epistaxis and recurrent ITP. He does not seem\n to be bumping appropriately to transfusions. He is currently loosing\n blood due to active bleed rather hemolysis based on labs.\n .\n ITP: not responding to meds, not responding to transfusion. called\n surgery for emergent splenectomy\n - attempt to transfuse to keep plts >10,000 but goal >20,000\n - check post-platelet count no more than 30 minutes post plts\n - cont solumedrole\n - could get repeat ivig, as currently no hemolysis\n .\n # Anemia/history of hemolytic anemia: Plt at OSH 44, 36 here. No\n evidence of DIC. Hemolytic labs are negative, so no evidence of\n hemolysis currently. Per heme/onc,.\n -maintain active T&S\n -trend hct/hemolysis labs\n - transfuse as long as actively bleeding\n .\n # Diabetes Mellitus Type II, uncontrolled, without complications:\n Hyperglycemic here, but pt was not on his home regimen (was on NPH 70 U\n at home, but at OSH was on less dosing). Also hyperglycemia likely\n steroids.\n -NPH 70 U (can titrate up as needed with on steroids)/SSI\n -cont. metformin\n .\n # HTN/LE swelling: BP well controlled. LE swelling noted.\n -Continue lasix (for LE edema)but increased from 60 mg daily to 100 mg\n daily given numerous infusions patient is receiving (will need to trend\n renal function and adjust based on it). Pt had been increased to 60 mg\n twice daily at OSH, but pt does not like receiving lasix at night\n -continue valsartan\n .\n # FEN: regular diet\n .\n # Access: PIVs consider midline\n .\n # PPx: ambulation, stool softeners to prevent straining with bowel\n movements, ppi\n .\n # FULL CODE\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544648,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets. S/p splenectomy\n - upon arrival to TSICU hypotensive and hct 19 platelets 6- given\n 2 units PRBSs, 2 units Platelets and 2 liters LR.\n Thrombocytopenia, acute\n Assessment:\n Pt arrived to TSICU s/p splecectomy hct 19.6 and platelets 6. Given 2\n units PRBC and 2 units Platelts Also bleeding moderately from nose and\n also some from gums. Petichiae noted all over body. Feet\n purple/cyanotic with + pulses. Repeat HCt 20.3 repeat platelets\n 10-given another 2 PRBC and 2Platelets 1 unit FFP-0200 labs HCT 21.7\n and platelets 17- txfd another 2 units PRBC and 2 Platelets\n Action:\n Given total 4 units PRBCs and 4 units Platelets and 1 unit FFP after\n 0200 labs given another 2 units PRBCs and 2 units Platelets. For a\n total of 6 units PRBC and 6 units Platelets.\n Response:\n Bleeding has slowed from nose.\n Plan:\n Continue to transfuse as needed and monitor for s/s of bleeding. Serial\n HCTs\n Hypotension (not Shock)\n Assessment:\n Upon arrival SBP 70-80\ns given\n Action:\n Given 2 liters LR, 2 units PRBCs and 2 units of Platelets. Given\n another 2 units PRBCs and 2 units Platelets after repeat labs. For\n total of 6 PRBC and 6 Platelets and 1 unit FFP.\n Response:\n SBP 100\ns-110\ns now. MAPs mid 60\n Plan:\n Continue to monitor hemodynamic status.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545061,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n IVIG infusing. HCT dropping. Plts remain between . VSS with HR\n 90-110s with freq PACs, SBP 130-160s. Bloody urine, dark red to brown\n NGT output, melena stool x3.\n Action:\n Transfused 2units PRBCs and 1u FFP.\n Response:\n HCT increased.\n Plan:\n Cont hct checks Q4. Monitor volume of melena and other signs of\n bleeding.\n Hyperglycemia\n Assessment:\n Insulin gtt infusion with D10 gtt. BGs climbing.\n Action:\n Insulin gtt increased scale.\n Response:\n BG remain > 150. Gtt increased more aggressively.\n Plan:\n Bg trending down.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545062,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n IVIG infusing. HCT dropping. Plts remain between . VSS with HR\n 90-110s with freq PACs, SBP 130-160s. Bloody urine, dark red to brown\n NGT output, melena stool x3.\n Action:\n Transfused 2units PRBCs and 1u FFP.\n Response:\n HCT increased.\n Plan:\n Cont hct checks Q4. Monitor volume of melena and other signs of\n bleeding.\n Hyperglycemia\n Assessment:\n Insulin gtt infusion with D10 gtt. BGs climbing.\n Action:\n Insulin gtt increased scale.\n Response:\n BG remain > 150. Gtt increased more aggressively.\n Plan:\n Bg trending down.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545188,
"text": "Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Melena stools continue. Clots in urine continue. Small amt bleeding\n via nose. Hct 21-24\n Action:\n Transfused 3 u PRBC\ns and 1 unit FFP today\n Response:\n . Last plt count up. WBC up to 31. Hct up to 24.,\n Plan:\n Repeat CBC., keep clot in Blood Bank current.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 544641,
"text": "Demographics\n Day of intubation: 2\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason: Elective; Comments: For surgical procedure\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 7 cmH2O\n Cuff volume: 26 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n :\n Secretions\n Sputum color / consistency: Blood Tinged /\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Decrease support as tolerated.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Hemodynimic instability, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544809,
"text": " Problem - Description In Comments- Fluid overload\n Assessment:\n LS with crackles and exp. Wheezes this am, pt. received Lasix 20mg IV\n yesterday\n Action:\n HO aware, HOB 45 degrees\n Response:\n Crackles and exp. Wheezes continue\n Plan:\n Monitor O2 sats and resp. status, ?possible Lasix, will discuss on\n rounds\n Thrombocytopenia, acute\n Assessment:\n Platelets 6 this am , HCT 24. Pt. continues with petechiae and bruising\n over extremities and trunk, NGT draining dark red blood, urine red this\n am with clots, a-line out last evening, Right fem. CVL oozing, large\n clot present, gums no longer bleeding\n Action:\n Pressure held on radial a-line site for 5 mins, Surgicell hemostat dsg\n applied over clot\n Response:\n CVL stopped oozing, urine remains red this am\n Plan:\n Monitor platelets and HCT, monitor urine, monitor for possible sources\n of bleeding\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545054,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low platelets\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid pca, Insulin gtt, Methylprednisolone\n 24 Hour Events:\n ARTERIAL LINE - START 09:00 PM\n NUCLEAR MEDICINE - At 11:30 PM\n ANGIOGRAPHY - At 04:45 AM\n Post operative day:\n POD#4 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 12 units/hour\n Other ICU medications:\n Furosemide (Lasix) - 03:24 PM\n Other medications:\n Flowsheet Data as of 04:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 97 (82 - 106) bpm\n BP: 137/66(88) {129/59(81) - 150/78(97)} mmHg\n RR: 18 (0 - 27) insp/min\n SPO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 165.6 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 4,456 mL\n 1,321 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,347 mL\n 254 mL\n Blood products:\n 3,110 mL\n 1,068 mL\n Total out:\n 9,740 mL\n 600 mL\n Urine:\n 9,190 mL\n 600 mL\n NG:\n 550 mL\n Stool:\n Drains:\n Balance:\n -5,284 mL\n 721 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: 7.48///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 8 K/uL\n 7.1 g/dL\n 156 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 110 mEq/L\n 148 mEq/L\n 19.4 %\n 36.0 K/uL\n [image002.jpg]\n 03:00 PM\n 04:00 PM\n 05:00 PM\n 05:07 PM\n 06:00 PM\n 08:00 PM\n 09:53 PM\n 10:00 PM\n 12:00 AM\n 02:20 AM\n WBC\n 36.7\n 39.2\n 36.0\n Hct\n 23.7\n 21.5\n 19.4\n Plt\n 5\n 6\n 8\n Creatinine\n 1.0\n 0.9\n Glucose\n 138\n 129\n 139\n 138\n 158\n 156\n 160\n 193\n 156\n Other labs: PT / PTT / INR:15.0/25.7/1.3, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.2 mmol/L, Ca:7.7 mg/dL, Mg:2.3 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP s/p splenectomy with continued\n thrombocytopenia and episodes of bleeding within lower GI tract.\n Neurologic: Pain controlled\n Cardiovascular: HD stable.\n Pulmonary: Stable, wean FiO2 as tolerated, cont diuresis as BP\n tolerates\n Gastrointestinal / Abdomen: Cont NGT to suction, f/u hepatitis panel\n Nutrition: NPO\n Renal: Foley, Adequate UO, cont diuresis\n Hematology: Serial Hct, goal Hct > 21, normalize INR, transfuse plts\n sparingly given poor response.\n Endocrine: Insulin drip. Pulse steroids and IGG for thrombocytopenia.\n Infectious Disease: f/u hepatitis panel, f/u HIV\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: D10W while on insulin gtt\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545104,
"text": "Hyperglycemia\n Assessment:\n Glucose levels 94\n 161 this shift.\n Action:\n Insulin drip titrated. Currently at 9 units/hr. D10W at 10cc/hr.\n Continues on prednisone.\n Response:\n Glucose levels usually in goal range.\n Plan:\n Continue D 10 W drip and insulin drip titration.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Clots in urine, melena stool, occ bloody nose. Occ bloody NG\n drainage. Hct 23.6 at 0530, Hct at 0930 down to 21.4\n Action:\n Transfused 1 unit PRBC\ns for Hct 21.4.\n Response:\n Repeat Hct 22.3\n Plan:\n Transfuse another unit of PRBC\ns, then re-check Hct. Monitor blood\n loss.\n See previous notes for history.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545115,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid pca, Insulin gtt, MethylPREDNISolone,\n 24 Hour Events:\n Remained hemodynamically stable. Required 2 units of PRBCs for\n decreasing Hct.\n Post operative day:\n POD#5 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:12 PM\n Lorazepam (Ativan) - 09:30 PM\n Other medications:\n Flowsheet Data as of 04:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 36.1\nC (97\n HR: 107 (93 - 133) bpm\n BP: 157/65(92) {120/60(78) - 157/86(103)} mmHg\n RR: 25 (16 - 27) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,723 mL\n 95 mL\n PO:\n Tube feeding:\n IV Fluid:\n 995 mL\n 95 mL\n Blood products:\n 2,728 mL\n Total out:\n 6,415 mL\n 740 mL\n Urine:\n 5,140 mL\n 540 mL\n NG:\n 650 mL\n 200 mL\n Stool:\n 625 mL\n Drains:\n Balance:\n -2,692 mL\n -645 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.52///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 8 K/uL\n 8.3 g/dL\n 109 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 43 mg/dL\n 113 mEq/L\n 150 mEq/L\n 23.0 %\n 36.7 K/uL\n [image002.jpg]\n 10:45 AM\n 01:00 PM\n 01:34 PM\n 02:00 PM\n 05:42 PM\n 07:00 PM\n 08:00 PM\n 08:10 PM\n 10:00 PM\n 01:30 AM\n WBC\n 36.9\n 26.5\n 36.7\n Hct\n 22.3\n 24.7\n 23.0\n Plt\n 7\n 5\n 8\n Creatinine\n 1.0\n Glucose\n 151\n 161\n 128\n 102\n 134\n 132\n 127\n 109\n Other labs: PT / PTT / INR:15.4/24.8/1.4, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, Ca:8.0 mg/dL, Mg:2.5 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management, persistent\n thrombocytopenia ?related to cirrhosis\n Neurologic: Pain controlled, A+Ox3, follows commands\n Cardiovascular: HD stable off pressors, fluid/product resuscitate prn\n Pulmonary: Stable on nasal canula, diurese as BP tolerates\n Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS, f/u hepatitis\n panel\n Nutrition: NPO\n Renal: Foley, Adequate UO, Stable, maintain diruresis to keep I=O\n Hematology: Serial Hct, ITP, persistent thrombocytopenia; s/p IVIG\n , transfuse prn, f/u final BM biopsy results, cont steroids\n Endocrine: Insulin drip\n Infectious Disease: Check cultures, Afebrile, f/u hepatitis panel, f/u\n HIV results\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: D10@10\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: (Hemorrhage, NOS), Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n 18 Gauge - 09:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545229,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid pca, Insulin gtt, MethylPREDNISolone,\n 24 Hour Events:\n After am PRBC had Hct 23 -> 21, and BP drifted down, so transfused\n 2 more after that and 1 U FFP. had adequate bump in Hct and HD\n stabilized. Still tachy w/ intermittant tach to >170s. Had 300cc\n melenotic stool again. Advanced diet to sips and then clears. Consider\n need to change CVL today.\n Post operative day:\n POD#6 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 11 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 103 (101 - 141) bpm\n BP: 119/50(69) {95/42(60) - 133/67(86)} mmHg\n RR: 23 (16 - 31) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,040 mL\n 2,536 mL\n PO:\n 1,250 mL\n 2,400 mL\n Tube feeding:\n IV Fluid:\n 510 mL\n 136 mL\n Blood products:\n 1,280 mL\n Total out:\n 3,695 mL\n 1,270 mL\n Urine:\n 2,545 mL\n 1,120 mL\n NG:\n 700 mL\n Stool:\n 450 mL\n 150 mL\n Drains:\n Balance:\n -655 mL\n 1,266 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 92%\n ABG: ///26/\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Tender: over surgical wound,\n appropriate\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Rash: diffuse eccymosis, arms and legs more, (Incision: Clean /\n Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 11 K/uL\n 8.4 g/dL\n 177\n 1.2 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 112 mEq/L\n 148 mEq/L\n 23.0 %\n 33.1 K/uL\n [image002.jpg]\n 04:00 PM\n 05:00 PM\n 05:28 PM\n 07:00 PM\n 09:00 PM\n 09:04 PM\n 11:00 PM\n 01:45 AM\n 02:00 AM\n 05:00 AM\n WBC\n 31.0\n 29.3\n 33.1\n Hct\n 24.9\n 23.9\n 23.0\n Plt\n 11\n 10\n 11\n Creatinine\n 1.2\n Glucose\n 200\n 179\n 126\n 85\n 150\n 182\n 180\n 177\n Other labs: PT / PTT / INR:17.4/27.0/1.6, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, Ca:7.6 mg/dL, Mg:2.6 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management, persistent\n thrombocytopenia ?related to cirrhosis\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, A+Ox3, follows\n commands\n Neuro checks Q: 2h\n Pain: Dilaudid PCA\n pt is complaining of confusion and visual hallucinations at times. is\n appropriate and has normal eye exam. possibly lack of sleep/icu\n psychosis.\n Cardiovascular: No pressors, BP drifted down w/ mild inc tachy, but\n normalized w/ blood, fluid/product resuscitate prn.\n Pulmonary: Stable on nasal canula, diurese as BP tolerates\n Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS, f/u hepatitis\n panel. has small melenotic stool, continue to monitor.\n Nutrition: Clear liquids, sips adat to clears\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, slow drift down, but stabilized out at around\n 23\n ITP, persistent thrombocytopenia; s/p IVIG , transfuse prn (over\n last 24 received 3 U PRBC and 1 U FFP), f/u final BM biopsy results,\n cont steroids. Discuss w/ heme regarding the trial Rx regimen to start\n today.\n Endocrine: Insulin drip, Stable, maintain diruresis to keep I=O\n Infectious Disease: Afebrile, f/u hepatitis panel, f/u HIV results\n Lines / Tubes / Drains: Foley, NGT, NGT, femoral central line (consider\n replacement to new site), aline\n Wounds: Dry dressings\n Imaging:\n Fluids: d10\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: (Hemorrhage, NOS), Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544901,
"text": "HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management. Extubated on\n .\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented x 3 this morning. Clear speech.\n Action:\n Given PCA button for pain, Lasix as ordered and patient requested, tube\n feedings restarted.\n Response:\n Patient became confused, with increased agitation at times, slurring\n his speech at times.\n Plan:\n CT of the brain, decreased PCA doses, hold evening Lasix doses,\n continue tube feeds as tolerated, monitor for any changes in mental\n status, recheck labs.\n Acute Pain\n Assessment:\n Complaints of pain everywhere, yells out when touched by staff\nouch\n complains of pain to abdomen and incision site, complaints of a\n headache at times.\n Action:\n Able to use PCA button independently, turned and repositioned\n frequently, dressing changed by MD team, Head CT.\n Response:\n Pain after use of PCA, tolerates turns in bed and can turn with\n assist of 1, dressing removed from abdomen and gauze placed on left\n side of incision for small amount of drainage.\n Plan:\n Continue PCA use, encourage pt to participate in care, monitor\n abdominal incision for signs of infection, continue to monitor for\n sedation.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545233,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid pca, Insulin gtt, MethylPREDNISolone,\n 24 Hour Events:\n After am PRBC had Hct 23 -> 21, and BP drifted down, so transfused\n 2 more after that and 1 U FFP. had adequate bump in Hct and HD\n stabilized. Still tachy w/ intermittant tach to >170s. Had 300cc\n melenotic stool again. Advanced diet to sips and then clears. Consider\n need to change CVL today.\n Post operative day:\n POD#6 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 11 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.9\nC (98.4\n HR: 103 (101 - 141) bpm\n BP: 119/50(69) {95/42(60) - 133/67(86)} mmHg\n RR: 23 (16 - 31) insp/min\n SPO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,040 mL\n 2,536 mL\n PO:\n 1,250 mL\n 2,400 mL\n Tube feeding:\n IV Fluid:\n 510 mL\n 136 mL\n Blood products:\n 1,280 mL\n Total out:\n 3,695 mL\n 1,270 mL\n Urine:\n 2,545 mL\n 1,120 mL\n NG:\n 700 mL\n Stool:\n 450 mL\n 150 mL\n Drains:\n Balance:\n -655 mL\n 1,266 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 92%\n ABG: ///26/\n Physical Examination\n General Appearance: Overweight / Obese\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Tender: over surgical wound,\n appropriate\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: Rash: diffuse eccymosis, arms and legs more, (Incision: Clean /\n Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 11 K/uL\n 8.4 g/dL\n 177\n 1.2 mg/dL\n 26 mEq/L\n 3.8 mEq/L\n 50 mg/dL\n 112 mEq/L\n 148 mEq/L\n 23.0 %\n 33.1 K/uL\n [image002.jpg]\n 04:00 PM\n 05:00 PM\n 05:28 PM\n 07:00 PM\n 09:00 PM\n 09:04 PM\n 11:00 PM\n 01:45 AM\n 02:00 AM\n 05:00 AM\n WBC\n 31.0\n 29.3\n 33.1\n Hct\n 24.9\n 23.9\n 23.0\n Plt\n 11\n 10\n 11\n Creatinine\n 1.2\n Glucose\n 200\n 179\n 126\n 85\n 150\n 182\n 180\n 177\n Other labs: PT / PTT / INR:17.4/27.0/1.6, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, Ca:7.6 mg/dL, Mg:2.6 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management, persistent\n thrombocytopenia ?related to cirrhosis\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, A+Ox3, follows\n commands\n Neuro checks Q: 4h pt is complaining of confusion and visual\n hallucinations at times. Is appropriate and has normal eye exam.\n possibly lack of sleep/icu psychosis.\n Cardiovascular: No pressors, BP drifted down w/ mild inc tachy, but\n normalized w/ blood, fluid/product resuscitate prn.\n Pulmonary: Stable on nasal canula, diurese as BP tolerates\n Gastrointestinal / Abdomen: s/p splenectomy, NGT to LCWS, f/u hepatitis\n panel. has small melenotic stool, continue to monitor.\n Nutrition: Clear liquids, sips adat to clears\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, slow drift down, but stabilized out at around\n 23. Will give one unit now.\n ITP, persistent thrombocytopenia; s/p IVIG , transfuse prn (over\n last 24 received 3 U PRBC and 1 U FFP), f/u final BM biopsy results,\n cont steroids. Discuss w/ heme regarding the trial Rx regimen to start\n today.\n Endocrine: Insulin drip, Stable, maintain diruresis to keep I=O\n Infectious Disease: Afebrile, f/u hepatitis panel, f/u HIV results\n Lines / Tubes / Drains: Foley, NGT, NGT, femoral central line (consider\n replacement to new site), aline\n Wounds: Dry dressings\n Imaging:\n Fluids: d10\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: (Hemorrhage, NOS), Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 06:42 PM\n Arterial Line - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2156-12-20 00:00:00.000",
"description": "Generic Note",
"row_id": 545238,
"text": "TITLE:\n Rehab Services Physical Therapy:\n Consult received. Events noted. Pt not ready to initiate physical\n therapy at this time. Will f/u as appropriate for consult.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545291,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid prn, Insulin gtt, Methylprednisolone,\n metformin\n 24 Hour Events:\n Post operative day:\n POD#7 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:23 PM\n Other medications:\n Flowsheet Data as of 02:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.3\nC (99.1\n HR: 96 (86 - 152) bpm\n BP: 111/49(66) {100/45(61) - 132/64(82)} mmHg\n RR: 17 (14 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 5,888 mL\n 39 mL\n PO:\n 4,550 mL\n Tube feeding:\n IV Fluid:\n 638 mL\n 39 mL\n Blood products:\n 700 mL\n Total out:\n 3,480 mL\n 220 mL\n Urine:\n 3,130 mL\n 220 mL\n NG:\n Stool:\n 350 mL\n Drains:\n Balance:\n 2,408 mL\n -181 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: 7.47/35/74/28/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 9 K/uL\n 7.6 g/dL\n 160\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 43 mg/dL\n 109 mEq/L\n 143 mEq/L\n 21.7 %\n 39.8 K/uL\n [image002.jpg]\n 02:00 PM\n 03:00 PM\n 03:20 PM\n 04:00 PM\n 05:00 PM\n 06:00 PM\n 07:00 PM\n 09:14 PM\n 09:55 PM\n 11:57 PM\n WBC\n 39.8\n Hct\n 21.3\n 21.7\n Plt\n 9\n Creatinine\n 1.0\n TCO2\n 26\n 26\n Glucose\n 130\n 126\n 114\n 124\n 122\n 114\n 160\n Other labs: PT / PTT / INR:17.7/27.9/1.6, Differential-Neuts:78.0 %,\n Band:0.0 %, Lymph:8.0 %, Mono:11.0 %, Eos:0.0 %, Fibrinogen:222 mg/dL,\n Lactic Acid:1.6 mmol/L, Albumin:2.8 g/dL, Ca:7.3 mg/dL, Mg:2.6 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M thrombocytopenia s/p splenectomy with\n continued episodes thrombocytopenia and melena\n Neurologic: Pain controlled, episodes hallucinations ?aura from\n migraines vs ICU psychosis, cont dilaudid prn\n Cardiovascular: HD stable\n Pulmonary: Stable\n Gastrointestinal / Abdomen: D/C NGT, f/u hep B viral load\n Nutrition: Full liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO, lasix prn\n Hematology: Serial Hct, Q12, transfuse for hct > 21, f/u bone marrow\n biopsy results, cont methylprednisolone\n Endocrine: Insulin drip, cont metformin, cont Methylprednisolone\n Infectious Disease: Stable\n Lines / Tubes / Drains: Foley, NGT\n Wounds: Dry dressings\n Imaging:\n Fluids: D10W while on insulin gtt\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 09:00 PM\n Multi Lumen - 11:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 544716,
"text": "SICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n fentanyl prn, famotidine, propofol gtt, insulin gtt\n 24 Hour Events:\n OR RECEIVED - At 06:30 PM\n ARTERIAL LINE - START 06:41 PM\n MULTI LUMEN - START 06:42 PM\n s/p splenectomy , EBL ~1L, 4 units plts, 2500cc crystalloid, 1\n PRBC's, 250cc cell , transferred to TICU for further management.\n transfused 6 units PRBC's, 1 unit FFP, 6 units plts for continued low\n hct's and low plts. No acute sources of EBL noted, UOP maintained\n throughout.\n Post operative day:\n POD#1 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Fentanyl - 02:25 AM\n Famotidine (Pepcid) - 08:36 AM\n Other medications:\n Flowsheet Data as of 12:27 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 37.2\nC (98.9\n HR: 85 (72 - 134) bpm\n BP: 146/70(93) {85/39(54) - 148/75(96)} mmHg\n RR: 20 (0 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 67 Inch\n Total In:\n 11,486 mL\n 4,754 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,654 mL\n 1,838 mL\n Blood products:\n 3,832 mL\n 2,915 mL\n Total out:\n 4,215 mL\n 2,690 mL\n Urine:\n 2,935 mL\n 2,490 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 7,271 mL\n 2,064 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 650) mL\n Vt (Spontaneous): 254 (254 - 493) mL\n PS : 0 cmH2O\n RR (Set): 0\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 25\n RSBI Deferred: Hemodynamic Instability\n PIP: 2 cmH2O\n Plateau: 20 cmH2O\n SPO2: 99%\n ABG: 7.41/43/115/27/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: obese, vented\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 6 K/uL\n 9.9 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 43 mg/dL\n 109 mEq/L\n 142 mEq/L\n 25.0 %\n 14.1 K/uL\n [image002.jpg]\n 06:51 PM\n 07:57 PM\n 09:09 PM\n 10:29 PM\n 01:58 AM\n 02:05 AM\n 05:54 AM\n 06:05 AM\n 09:59 AM\n 10:25 AM\n WBC\n 16.8\n 14.1\n Hct\n 20.3\n 21.7\n 25.8\n 25.0\n Plt\n 10\n 17\n 9\n 6\n Creatinine\n 0.9\n 0.9\n TCO2\n 26\n 24\n 28\n 29\n 28\n 28\n Glucose\n 176\n 116\n Other labs: PT / PTT / INR:13.7/26.4/1.2, Lactic Acid:1.0 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management\n Neurologic: Neuro checks Q: hr, Pain controlled, Clear C-spine,\n intubated and sedated on propofol - ween sedation\n Pain: fentanyl prn\n Cardiovascular: HD stable, IVF bolus as needed, transfuse for hct > 21\n Pulmonary: Extubate today,\n Gastrointestinal / Abdomen: s/p splenectomy, will need post splenectomy\n prophylaxis, clamp NGT\n Nutrition: NPO, Advance diet as tolerated , NPO pending extubation\n Renal: Stable\n Hematology: Serial Hct, ITP, transfuse for hct > 21, Plts > 50, hct\n Q4hrs\n will hold on plt transfusion given stable hct and no significant\n bleeding Plt count has not increased appropriately with transfusion\n Endocrine: Insulin drip\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, NGT, ETT, fem central line, art line\n Wounds:\n Imaging:\n Fluids: LR, 100, KVO now\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Other: GIB, anemia, thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 11:30 AM\n Arterial Line - 06:41 PM\n Multi Lumen - 06:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n will obtain ICU consent pending stay\n Code status: Full code\n Disposition: TSICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545017,
"text": "HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management. Extubated on\n .\n Events :\n Pt. with multiple large episodes of Melena overnight. Pt. to nuclear\n med for GI study and angio overnight d/t decreasing HCT and Platelets.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt with small melena stool this shift, NGT continues to drain brown\n drainage, hematuria noted throughout the shift.\n Action:\n Pt to angio early am, unable to find bleeding vessel, returned to \n at 0930. Angio site (right groin) intact, no bleeding, no hematoma,\n pedal pulses intact.\n Response:\n Most recent HCT 23.7\n Plan:\n Continue to monitor HCT Q6/hr, transfuse as needed.\n Thrombocytopenia, acute\n Assessment:\n Pt continues with low platelet count, even after multiple platelet\n transfusions.\n Action:\n Heme/onc team discussed pt\ns poor prognosis to pt and family since\n platelet transfusions are not working.\n IVIG infusing at this time, pt to receive total of 120gm\n Response:\n Most recent platelet count 5\n Plan:\n Monitor platelets, administer if pt starts to actively bleed. Possible\n administration of Factor 7 to be given if pt actively bleeds.\n Problem - Description In Comments- fluid overload\n Assessment:\n LS with crackles and wheezing\n Action:\n IV Lasix and albuteral nebs given\n Response:\n Pt responded well, +diuresis, less crackles noted. No respiratory\n distress noted.\n Plan:\n Continue to monitor respirtory status, continue with TID IV lasix.\n Ineffective Coping\n Assessment:\n Pt and family told of pt\ns poor prognosis (due to low platelet count\n that is not responding to treatment).\n Action:\n Social work and pastoral care consulted\n Response:\n Pastoral care spoke with family, priest into visit.\n Plan:\n Continue with emotional support.\n"
},
{
"category": "Social Work",
"chartdate": "2156-12-19 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 545164,
"text": "Family Information\n Next of : (sister)\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record, (sister)\n Family Spokesperson designated: sister \n Communication or visitation restriction: none\n Patient Information:\n Previous living situation: Pt lives alone in own home.\n Previous level of functioning: Independent\n Previous or other hospital admissions: none\n Past psychiatric history: none known\n Past addictions history: none known\n Employment status: Pt works for in scheduling dept.\n Legal involvement: none known\n Mandated Reporting Information: none\n Additional Information:\n Patient / Family Assessment: Pt is 57 yr-old gentleman adm\n w/epistaxis. Reviewed chart/OMR. Pt with h/o DMII, HTN, autoimmune\n hemolytic anemia, ITP, obesity. Pt w/difficult hosp course, not\n responding to treatment, poor prognosis. Met w/pt at bedside, his\n fianc\ne, , is with him. She reports that they have\n been together for 28 yrs, just recently officially engaged (in ).\n They met at where both continue to work. They do not live\n together.\n Pt is A&Ox2, engages easily although appears uncomfortable; he keeps\n his eyes closed for most of interview. He states he is\nvery\n frightened\n by hosp course so far and copes by praying. \n confirms that both of them are religious and faith as well as their\n love for each other is what keeps both of them going. She is very\n attentive and supportive, pt playfully telling her she talks too much.\n She reports that although she and his family get along very well and\n she is well informed, she has found it difficult that his sister is\n HCP. Pt states that not having enough information or incorrect\n information about treatment, test results, adds to his fears about how\n he is doing medically. He is appreciative of visits by Clergy.\n SW provided empathic listening, validated concerns about and reactions\n to situation, and provided emotional support to pt and . They\n appear to be coping as well as can be expected under these difficult\n circumstances. SW will continue to follow & assist as needed.\n Clergy Contact: Name: Priest\n Communication with Team:\n Primary Nurse: \n Officer: Dr \n / Follow up: SW will follow & continue to assess coping & provide\n support to pt/family as needed. Please page PRN.\n , LICSW\n #\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545007,
"text": "HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management. Extubated on\n .\n Events :\n Pt. with multiple large episodes of Melena overnight. Pt. to nuclear\n med for GI study and angio overnight d/t decreasing HCT and Platelets.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545213,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect. Underwent\n elective Splenectomy on and was transferred to the T/SICU\n post-op. Underwent GI study and angio on d/t decreasing Hct and\n plts. Continues to receive PRBCs, FFPs, and plts PRN.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct between 23-24.9. Plts. . VSS with HR 90s-120s with frequent\n PACs. One episode of melena overnight. Scant epistaxis and bloody\n urine.\n Action:\n Received 1 Unit of FFP. Repeat Hct drawn.\n Response:\n Hct remains between 23-23.9.\n Plan:\n Continue to check serial Hct. Monitor amt and frequency of melena\n stools and other signs of bleeding.\n Hyperglycemia\n Assessment:\n Glucose between 85-180. On insulin drip and D10 gtt.\n Action:\n Insulin drip titrated to 9 Units/hr from 11 Units/hr, then increased to\n 10 U/hr.\n Response:\n Glucose increased from 85 to 180, then to 177. Remains between 170-180\n on 10 U/hr.\n Plan:\n Continue to monitor glucose with q 2 hour glucose draws. Continue with\n D10 gtt and insulin gtt titration.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 544622,
"text": "Patient presented to OSH after developing epitasis on , where\n he was found to have a platelet count of . He was treated with IV\n IG 25gm x4 along with solumedrol. Found not to be responding to\n treatment favorably and thus transferred to for further\n management. On the morning of patient became hypotensive with\n active gum bleeding. Patient reports having dark stool as well, however\n this has been for several days. On admission to MICU he was treated\n with N/S 2000ml, 2 units of PRBCs and 1 unit Platelets. S/p splenectomy\n - upon arrival to TSICU hypotensive and hct 19 platelets 6- given\n 2 units PRBSs, 2 units Platelets and 2 liters LR.\n Thrombocytopenia, acute\n Assessment:\n Pt arrived to TSICU s/p splecectomy hact 19.6 and platelets 6. Also\n bleeding moderately from nose and also some from gums. Petichiae noted\n all over body. Repeat HCt 20.3 repeat platelets 10 0200 labs HCtT 21.7\n and platelets 17\n Action:\n Given total 4 units PRBCs and 4 units Platelets and 1 unit FFP after\n 0200 labs given another 2 units PRBCs and 2 units Platelets.\n Response:\n Bleeding has slowed from nose.\n Plan:\n Continue to transfuse as needed and monitor for s/s of bleeding. Serial\n HCTs\n Hypotension (not Shock)\n Assessment:\n Upon arrival SBP 70-80\ns given\n Action:\n Given 2 liters LR, 2 units PRBCs and 2 units of Platelets. Given\n another 2 units PRBCs and 2 units Platelets after repeat labs. For\n total of 6 PRBC and 6 Platelets and 1 unit FFP.\n Response:\n SBP 100\ns-110\ns now. MAPs mid 60\n Plan:\n Continue to monitor hemodynamic status.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 544709,
"text": "SICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n fentanyl prn, famotidine, propofol gtt, insulin gtt\n 24 Hour Events:\n OR RECEIVED - At 06:30 PM\n ARTERIAL LINE - START 06:41 PM\n MULTI LUMEN - START 06:42 PM\n s/p splenectomy , EBL ~1L, 4 units plts, 2500cc crystalloid, 1\n PRBC's, 250cc cell , transferred to TICU for further management.\n transfused 6 units PRBC's, 1 unit FFP, 6 units plts for continued low\n hct's and low plts. No acute sources of EBL noted, UOP maintained\n throughout.\n Post operative day:\n POD#1 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 10 units/hour\n Other ICU medications:\n Fentanyl - 02:25 AM\n Famotidine (Pepcid) - 08:36 AM\n Other medications:\n Flowsheet Data as of 12:27 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 37.2\nC (98.9\n HR: 85 (72 - 134) bpm\n BP: 146/70(93) {85/39(54) - 148/75(96)} mmHg\n RR: 20 (0 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SA (Sinus Arrhythmia)\n Height: 67 Inch\n Total In:\n 11,486 mL\n 4,754 mL\n PO:\n Tube feeding:\n IV Fluid:\n 7,654 mL\n 1,838 mL\n Blood products:\n 3,832 mL\n 2,915 mL\n Total out:\n 4,215 mL\n 2,690 mL\n Urine:\n 2,935 mL\n 2,490 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 7,271 mL\n 2,064 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 650) mL\n Vt (Spontaneous): 254 (254 - 493) mL\n PS : 0 cmH2O\n RR (Set): 0\n RR (Spontaneous): 18\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 25\n RSBI Deferred: Hemodynamic Instability\n PIP: 2 cmH2O\n Plateau: 20 cmH2O\n SPO2: 99%\n ABG: 7.41/43/115/27/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 164\n Physical Examination\n General Appearance: obese, vented\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Obese\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 6 K/uL\n 9.9 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 43 mg/dL\n 109 mEq/L\n 142 mEq/L\n 25.0 %\n 14.1 K/uL\n [image002.jpg]\n 06:51 PM\n 07:57 PM\n 09:09 PM\n 10:29 PM\n 01:58 AM\n 02:05 AM\n 05:54 AM\n 06:05 AM\n 09:59 AM\n 10:25 AM\n WBC\n 16.8\n 14.1\n Hct\n 20.3\n 21.7\n 25.8\n 25.0\n Plt\n 10\n 17\n 9\n 6\n Creatinine\n 0.9\n 0.9\n TCO2\n 26\n 24\n 28\n 29\n 28\n 28\n Glucose\n 176\n 116\n Other labs: PT / PTT / INR:13.7/26.4/1.2, Lactic Acid:1.0 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management\n Neurologic: Neuro checks Q: hr, Pain controlled, Clear C-spine,\n intubated and sedated on propofol - ween sedation\n Pain: fentanyl prn\n Cardiovascular: HD stable, IVF bolus as needed, transfuse for hct > 21\n Pulmonary: Extubate today,\n Gastrointestinal / Abdomen: s/p splenectomy, will need post splenectomy\n prophylaxis, clamp NGT\n Nutrition: NPO, Advance diet as tolerated , NPO pending extubation\n Renal: Stable\n Hematology: Serial Hct, ITP, transfuse for hct > 21, Plts > 50, hct\n Q4hrs\n will hold on plt transfusion given stable hct and no si bleeding, has\n not increased appropriately w/ plt transfusion\n Endocrine: Insulin drip\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, NGT, ETT, fem central line, art line\n Wounds:\n Imaging:\n Fluids: LR, 100, to 50\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: Other: GIB, anemia, thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 20 Gauge - 11:30 AM\n Arterial Line - 06:41 PM\n Multi Lumen - 06:42 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n will obtain icu consent pending stay\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545005,
"text": "HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management. Extubated on\n .\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545008,
"text": "HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management. Extubated on\n .\n Events :\n Pt. with multiple large episodes of Melena overnight. Pt. to nuclear\n med for GI study and angio overnight d/t decreasing HCT and Platelets.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Most recent HCT 24 after 7 units PRBC, multiple episodes of melena\n overnight, NGT draining brown fluid, urine more clear overnight.\n Action:\n 7 units PRBC\ns given overnight, pt. to nuclear med, then angio to stop\n bleeding\n Response:\n Most recent HCT 24\n Plan:\n Continue to monitor HCT, angio\n Thrombocytopenia, acute\n Assessment:\n Most recent platelets 19 after 5 units given,\n Action:\n Pt. continues to receive platelets for dropping count, pt. given bolus\n of amicar and placed on gtt.\n Response:\n Amicar gtt. d/cd this am, pt. shortly responding to platelets\n Plan:\n Monitor platelets, administer as necessary\n Problem - Description In Comments- fluid overload\n Assessment:\n LS crackles overnight with exp. Wheezes this am\n Action:\n Lasix 20mg IV given\n Response:\n Pt. responding well, dumping 1200ml urine\n Plan:\n ? Repeat Lasix dose this am if hemodynamically stable\n"
},
{
"category": "Nutrition",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 545359,
"text": "Subjective\n Tolerating clears c/ \"lots of gas\". Would like mint tea. Wary of\n taking milk based products.\n Objective\n Pertinent medications: SS lytes, pepcid, docusalt, solumedrol, insulin\n gtt, D10 gtt, others noted\n Labs:\n Value\n Date\n Glucose\n 87 mg/dL\n 02:26 AM\n Glucose Finger Stick\n 166\n 11:00 AM\n BUN\n 48 mg/dL\n 02:26 AM\n Creatinine\n 1.1 mg/dL\n 02:26 AM\n Sodium\n 141 mEq/L\n 02:26 AM\n Potassium\n 3.7 mEq/L\n 02:26 AM\n Chloride\n 108 mEq/L\n 02:26 AM\n TCO2\n 24 mEq/L\n 02:26 AM\n PO2 (arterial)\n 73. mm Hg\n 06:17 AM\n PCO2 (arterial)\n 40 mm Hg\n 06:17 AM\n pH (arterial)\n 7.43 units\n 06:17 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 06:17 AM\n Albumin\n 2.8 g/dL\n 02:20 AM\n Calcium non-ionized\n 7.2 mg/dL\n 02:26 AM\n Phosphorus\n 4.2 mg/dL\n 02:26 AM\n Ionized Calcium\n 1.06 mmol/L\n 11:57 PM\n Magnesium\n 2.6 mg/dL\n 02:26 AM\n Total Bilirubin\n 1.6 mg/dL\n 02:26 AM\n Current diet order / nutrition support: Full liquids\n GI: Abd: obese/+bs\n Assessment of Nutritional Status\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Oral supplements: CIB juice drink c/ meals\n Advance diet per team\n BG/Lyte management as you are\n Please page c/ ?'s #\n"
},
{
"category": "Nutrition",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 545360,
"text": "Subjective\n Tolerating clears c/ \"lots of gas\". Would like mint tea. Wary of\n taking milk based products.\n Objective\n Pertinent medications: SS lytes, pepcid, docusalt, solumedrol,\n metformin, insulin gtt, D10 gtt, others noted\n Labs:\n Value\n Date\n Glucose\n 87 mg/dL\n 02:26 AM\n Glucose Finger Stick\n 166\n 11:00 AM\n BUN\n 48 mg/dL\n 02:26 AM\n Creatinine\n 1.1 mg/dL\n 02:26 AM\n Sodium\n 141 mEq/L\n 02:26 AM\n Potassium\n 3.7 mEq/L\n 02:26 AM\n Chloride\n 108 mEq/L\n 02:26 AM\n TCO2\n 24 mEq/L\n 02:26 AM\n PO2 (arterial)\n 73. mm Hg\n 06:17 AM\n PCO2 (arterial)\n 40 mm Hg\n 06:17 AM\n pH (arterial)\n 7.43 units\n 06:17 AM\n CO2 (Calc) arterial\n 27 mEq/L\n 06:17 AM\n Albumin\n 2.8 g/dL\n 02:20 AM\n Calcium non-ionized\n 7.2 mg/dL\n 02:26 AM\n Phosphorus\n 4.2 mg/dL\n 02:26 AM\n Ionized Calcium\n 1.06 mmol/L\n 11:57 PM\n Magnesium\n 2.6 mg/dL\n 02:26 AM\n Total Bilirubin\n 1.6 mg/dL\n 02:26 AM\n Current diet order / nutrition support: Full liquids\n GI: Abd: obese/+bs\n Assessment of Nutritional Status\n Specifics:\n 57 y/o male c/ refractory ITP continues to receive blood products prn.\n Pt was extubated over weekend and diet advanced. Pt currently\n tolerating clear liquids only. Pt is taking large amounts, but liquids\n he is taking do not have any protein. Will send clear liquid\n supplement c/ protein to trial. Pt continues on D10 and insulin gtt\n noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Oral supplements: CIB juice drink c/ meals\n Advance diet per team\n BG/Lyte management as you are\n Please page c/ ?'s #\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545345,
"text": "HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n Post operative day:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Respiratory support\n Physical Examination\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Creatinine\n Troponin T\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n Assessment and Plan:\n Neurologic:\n Cardiovascular:\n Pulmonary:\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal:\n Hematology:\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545431,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM remains on insulin gtt with BS from 80\ns- 190\ns this shift.\n Action:\n Insulin gtt and D10@20cc/hr. Metformin TID\n Response:\n Gtt titrated scale on computer.\n Plan:\n ? Start NPH, ? stop insulin gtt\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 14 this shift. Hct 22-\n Action:\n Given 1 unit PRBC this shift\n Response:\n HCt post transfusion 24 pt continues to have melena stools this shift.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 545520,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM. Pt on insulin drip at 9units/hr. BS checks Q1hr.\n Action:\n Pt taken off insulin drip. Continue with Metformin TID. Started on NPH\n 44 Units AC/HS. Also started on insulin SS. Pt started on Heart\n Healthy Diet. Tolerating PO intake well.\n Response:\n Pt BS less than 160 at this time.\n Plan:\n Continue to monitor pt BS per SS.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 17 this shift. Hct 24.\n Action:\n Lab rechecked at noon. Hct 23.2. MD aware of Hct level.\n Response:\n Pt continues to have melena stools this shift. No orders for PRBC\ns at\n this time. SBP 120-130. HR SR to ST with 80-120. Lots of PVC\n PAC\n MD aware.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed. See lab\n orders for next time HCT due.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 545522,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM. Pt on insulin drip at 9units/hr. BS checks Q1hr.\n Action:\n Pt taken off insulin drip. Continue with Metformin TID. Started on NPH\n 44 Units AC/HS. Also started on insulin SS. Pt started on Heart\n Healthy Diet. Tolerating PO intake well.\n Response:\n Pt BS less than 160 at this time.\n Plan:\n Continue to monitor pt BS per SS.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 17 this shift. Hct 24. Orthostatic issues last night and\n yesterday. Pt SBP would drop when the HOB was lowered.\n Action:\n Lab rechecked at noon. Hct 23.2. MD aware of Hct level.\n Response:\n Pt continues to have melena stools this shift. No orders for PRBC\ns at\n this time. SBP 120-130. No orthostatic issues this afternoon. HR SR\n to ST with 80-120. Lots of PVC\ns PAC\ns. MD aware.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed. See lab\n orders for next time HCT due. Pt still on bedrest at this time. Monitor\n for S/S of orthostatic issues.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n EPISTAXIS\n Code status:\n Full code\n Height:\n 67 Inch\n Admission weight:\n 163 kg\n Daily weight:\n 158.4 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin, Diabetes - Oral \n CV-PMH:\n Additional history: Thoracic surgery for lung infection, appendectomy.\n Surgery / Procedure and date: - splenectomy. Upon arrival to TSICU\n hypotensive requiring 2 units platelets, 2 units PRBCs, 2 liters LR.\n Moderate amount of bleeding noted from nose and some from gums.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:87\n D:58\n Temperature:\n 99.8\n Arterial BP:\n S:137\n D:60\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,098 mL\n 24h total out:\n 2,170 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 01:57 AM\n Potassium:\n 3.6 mEq/L\n 01:57 AM\n Chloride:\n 106 mEq/L\n 01:57 AM\n CO2:\n 22 mEq/L\n 01:57 AM\n BUN:\n 49 mg/dL\n 01:57 AM\n Creatinine:\n 1.1 mg/dL\n 01:57 AM\n Glucose:\n 97 mg/dL\n 01:57 AM\n Hematocrit:\n 23.2 %\n 11:02 AM\n Finger Stick Glucose:\n 153\n 01:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: T/\n Transferred to: CC628\n Date & time of Transfer: 1500\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545325,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect. Underwent\n elective Splenectomy on and was transferred to the T/SICU\n post-op. Underwent GI study and angio on d/t decreasing Hct and\n plts. Continues to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt. remains on insulin gtt. Taking water and diet soda PO\n Action:\n ,pt. remains on D10@ 20ml/hr, metformin started yesterday\n Response:\n Gtt. Titrated protocol\n Plan:\n Continue to titrated gtt. As needed \n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 10 this am, HCT 21, Pt. had vagal episode last evening while\n getting OOB-commode\n Action:\n Pt. recovered without intervention, No products given overnight\n Response:\n Pt. continue with Melana, bedpan used overnight\n Plan:\n Monitor HCT and platelets, give products as needed, maintain pt. safety\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545429,
"text": "elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with h/o DM, elevated BS this hospital stay\n Action:\n Pt remains on insulin gtt and D10@20cc/hr, Glucophage TID.\n Response:\n Gtt titrated protocol. Insulin gtt ranging 4-12 units/hr\n this shift.\n Plan:\n Continue to titrate gtt per Protocol. ? need to start NPH.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 10 this am, HCT 21.4 this am. Pt orthostatic this am when\n dangled on side of bed, SBP down to 70\n Action:\n 2 units PRBC\ns given this shift.\n Response:\n Pt. continues with Melana, HCT post transfusion pending at this time.\n Platelets 13 this afternoon. SBP improving, less orthostatic this\n afternoon.\n Plan:\n Continue to monitor HCT/Platelets/bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 545518,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM. Pt on insulin drip at 9units/hr. BS checks Q1hr.\n Action:\n Pt taken off insulin drip. Continue with Metformin TID. Started on NPH\n 44 Units AC/HS. Also started on insulin SS. Pt started on Heart\n Healthy Diet. Tolerating PO intake well.\n Response:\n Pt BS less than 160 at this time.\n Plan:\n Continue to monitor pt BS per SS.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 14 this shift. Hct 23\n Action:\n Response:\n Pt continues to have melena stools this shift.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545267,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect. Underwent\n elective Splenectomy on and was transferred to the T/SICU\n post-op. Underwent GI study and angio on d/t decreasing Hct and\n plts. Continues to receive PRBCs, FFPs, and plts PRN.\n Anemia, hemolytic\n Assessment:\n Pt with hct 21.2 this am. VSS. HR 80-100\ns, SR with frequent PVC\ns and\n PAC\n Action:\n Received 1 unit prbc, repeat hct 21.3, given second unit prbc this\n afternoon. Electrolytes repleted, EKG obtained.\n Response:\n Awaiting post-transfusion hct. SR with frequent PVC/PAC\n Plan:\n Continue to monitor hematocrit q 6 hours, administer blood products as\n ordered. Monitor hemodynamics.\n Hyperglycemia\n Assessment:\n Pt with history of DM II.\n Action:\n Pt continues on insulin gtt, metformin 500mg TID started(pt\ns home\n dose).\n Response:\n BS ranging 88-136.\n Plan:\n Continue to titrate insulin gtt protocol.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 545516,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM remains on insulin gtt with BS from 80\ns- 190\ns this shift.\n Action:\n Insulin gtt and D10@20cc/hr. Metformin TID\n Response:\n Gtt titrated scale on computer.\n Plan:\n ? Start NPH, ? stop insulin gtt\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 14 this shift. Hct 22-\n Action:\n Given 1 unit PRBC this shift\n Response:\n HCt post transfusion 24 pt continues to have melena stools this shift.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 545517,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM. Pt on insulin drip at 9units/hr. BS checks Q1hr.\n Action:\n Pt taken off insulin drip. Continue with Metformin TID. Started on NPH\n 44 Units AC/HS. Also started on insulin SS.\n Response:\n Pt BS less than 160 at this time.\n Plan:\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 14 this shift. Hct 22-\n Action:\n Given 1 unit PRBC this shift\n Response:\n HCt post transfusion 24 pt continues to have melena stools this shift.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545266,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect. Underwent\n elective Splenectomy on and was transferred to the T/SICU\n post-op. Underwent GI study and angio on d/t decreasing Hct and\n plts. Continues to receive PRBCs, FFPs, and plts PRN.\n Anemia, hemolytic\n Assessment:\n Pt with hct 21.2 this am. VSS. HR 80-100\ns, SR with frequent PVC\ns and\n PAC\n Action:\n Received 1 unit prbc, repeat hct 21.3, given second unit prbc this\n afternoon. Electrolytes repleted, EKG obtained.\n Response:\n Awaiting post-transfusion hct. SR with frequent PVC/PAC\n Plan:\n Continue to monitor hematocrit q 6 hours, administer blood products as\n ordered. Monitor hemodynamics.\n Hyperglycemia\n Assessment:\n Pt continues on insulin gtt.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545511,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid prn, Insulin gtt, Methylprednisolone,\n Metformin, Ambien\n 24 Hour Events:\n Transfused 3 units PRBC's\n Post operative day:\n POD#8 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 9 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 PM\n Furosemide (Lasix) - 11:12 PM\n Other medications:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.4\nC (99.4\n HR: 111 (91 - 133) bpm\n BP: 134/57(75) {83/38(51) - 134/66(84)} mmHg\n RR: 20 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,718 mL\n 597 mL\n PO:\n 1,500 mL\n 250 mL\n Tube feeding:\n IV Fluid:\n 1,093 mL\n 347 mL\n Blood products:\n 1,125 mL\n Total out:\n 2,880 mL\n 1,190 mL\n Urine:\n 2,880 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 838 mL\n -593 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.43/40/73./22/1\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 17 K/uL\n 8.5 g/dL\n 97 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 49 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.0 %\n 50.4 K/uL\n [image002.jpg]\n 06:00 PM\n 07:00 PM\n 09:14 PM\n 09:55 PM\n 11:57 PM\n 02:26 AM\n 06:17 AM\n 01:48 PM\n 07:00 PM\n 01:57 AM\n WBC\n 52.6\n 42.7\n 45.6\n 50.4\n Hct\n 21.7\n 21.4\n 22.3\n 22.0\n 24.0\n Plt\n 10\n 13\n 14\n 17\n Creatinine\n 1.1\n 1.1\n TCO2\n 26\n 26\n 27\n Glucose\n 114\n 160\n 87\n 97\n Other labs: PT / PTT / INR:18.0/29.3/1.6, Alk-Phos / T bili:/1.6,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:8.0 %, Mono:11.0 %,\n Eos:0.0 %, Fibrinogen:222 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.8\n g/dL, LDH:472 IU/L, Ca:7.0 mg/dL, Mg:2.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management, persistent\n thrombocytopenia ?related to cirrhosis\n Neurologic: Pain controlled, A+Ox3, follows commands, pt is complaining\n of confusion and visual hallucinations at times. is appropriate and has\n normal eye exam. possibly lack of sleep/icu psychosis/migraines\n Cardiovascular: HD stable off pressors, fluid/product resuscitate prn.\n Pulmonary: IS, Stable, diurese as BP tolerates\n Gastrointestinal / Abdomen: s/p splenectomy, f/u hepatitis B viral\n load. continues to have melenotic stool, continue to monitor hct Q12\n Nutrition: Full liquids, Advance diet as tolerated , fulls, ADAT\n Renal: Foley, Adequate UO, Stable, maintain diuresis to keep I=O\n Hematology: Serial Hct, ITP, persistent thrombocytopenia; s/p IVIG\n , transfuse prn, f/u final BM biopsy results, cont steroids. F/u\n hepatitis B viral load, Hematology considering starting Rituximab based\n on Hep B viral load\n Endocrine: Insulin drip, insulin gtt, metformin\n Infectious Disease: Check cultures, Afebrile, persistently elevated\n WBC, no signs of active infection, f/u hepatitis B viral load, hep c\n neg, hiv neg\n Lines / Tubes / Drains: Foley, PIV, right IJ, aline\n Wounds: Dry dressings, Abdomen\n Imaging:\n Fluids: Other, D10@20\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: (Hemorrhage, NOS), Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 09:00 PM\n Multi Lumen - 11:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545405,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect.\n -elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with h/o DM, elevated BS this hospital stay\n Action:\n Pt remains on insulin gtt and D10@20cc/hr, Glucophage TID.\n Response:\n Gtt titrated protocol. Insulin gtt ranging 4-12 units/hr\n this shift.\n Plan:\n Continue to titrate gtt per Protocol. ? need to start NPH.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 10 this am, HCT 21.4 this am. Pt orthostatic this am when\n dangled on side of bed, SBP down to 70\n Action:\n 2 units PRBC\ns given this shift.\n Response:\n Pt. continues with Melana, HCT post transfusion of 2 units PRBC\n _____.Platelets 13 this afternoon. SBP improving, less orthostatic this\n afternoon.\n Plan:\n Continue to monitor HCT/Platelets/bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545406,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect.\n -elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with h/o DM, elevated BS this hospital stay\n Action:\n Pt remains on insulin gtt and D10@20cc/hr, Glucophage TID.\n Response:\n Gtt titrated protocol. Insulin gtt ranging 4-12 units/hr\n this shift.\n Plan:\n Continue to titrate gtt per Protocol. ? need to start NPH.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 10 this am, HCT 21.4 this am. Pt orthostatic this am when\n dangled on side of bed, SBP down to 70\n Action:\n 2 units PRBC\ns given this shift.\n Response:\n Pt. continues with Melana, HCT post transfusion pending at this time.\n Platelets 13 this afternoon. SBP improving, less orthostatic this\n afternoon.\n Plan:\n Continue to monitor HCT/Platelets/bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545396,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect.\n -elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with h/o DM, elevated BS this hospital stay\n Action:\n Pt remains on insulin gtt and D10@20cc/hr, Glucophage TID.\n Response:\n Gtt titrated protocol. Insulin gtt ranging 4-12 units/hr\n this shift.\n Plan:\n Continue to titrate gtt per Protocol. ? need to start NPH.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets ___ this am, HCT 21____ this am. Pt orthostatic this am when\n dangled on side of bed, SBP down to 70\n Action:\n 2 units PRBC\ns given this shift.\n Response:\n Pt. continues with Melana, HCT post transfusion of 2 units PRBC\ns ____.\n Platelets 13 this afternoon.\n Plan:\n Continue to monitor HCT/Platelets/bleeding.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545397,
"text": "57 yo M with h/o ITP, autoimmune hemolytic anemia, and DM. Admitted to\n OSH on d/t epistaxis and plt count of . He was given IV\n solumedrol and IVIG at OSH and then transferred here to be followed by\n Dr. . Developed melena on with a Hct of 27.6. He received\n 2 Units of PRBCs and 1 Unit of platelets with little effect.\n -elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt with h/o DM, elevated BS this hospital stay\n Action:\n Pt remains on insulin gtt and D10@20cc/hr, Glucophage TID.\n Response:\n Gtt titrated protocol. Insulin gtt ranging 4-12 units/hr\n this shift.\n Plan:\n Continue to titrate gtt per Protocol. ? need to start NPH.\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 10 this am, HCT 21.4 this am. Pt orthostatic this am when\n dangled on side of bed, SBP down to 70\n Action:\n 2 units PRBC\ns given this shift.\n Response:\n Pt. continues with Melana, HCT post transfusion of 2 units PRBC\ns ____.\n Platelets 13 this afternoon. SBP improving, less orthostatic this\n afternoon.\n Plan:\n Continue to monitor HCT/Platelets/bleeding.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 545452,
"text": "TSICU\n HPI:\n Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n Current medications:\n Furosemide, famotidine, Dilaudid prn, Insulin gtt, Methylprednisolone,\n Metformin, Ambien\n 24 Hour Events:\n Transfused 3 units PRBC's\n Post operative day:\n POD#8 - s/p splenectomy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 9 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 PM\n Furosemide (Lasix) - 11:12 PM\n Other medications:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 37.4\nC (99.4\n HR: 111 (91 - 133) bpm\n BP: 134/57(75) {83/38(51) - 134/66(84)} mmHg\n RR: 20 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 158.4 kg (admission): 163 kg\n Height: 67 Inch\n Total In:\n 3,718 mL\n 597 mL\n PO:\n 1,500 mL\n 250 mL\n Tube feeding:\n IV Fluid:\n 1,093 mL\n 347 mL\n Blood products:\n 1,125 mL\n Total out:\n 2,880 mL\n 1,190 mL\n Urine:\n 2,880 mL\n 1,190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 838 mL\n -593 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: 7.43/40/73./22/1\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 17 K/uL\n 8.5 g/dL\n 97 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 49 mg/dL\n 106 mEq/L\n 138 mEq/L\n 24.0 %\n 50.4 K/uL\n [image002.jpg]\n 06:00 PM\n 07:00 PM\n 09:14 PM\n 09:55 PM\n 11:57 PM\n 02:26 AM\n 06:17 AM\n 01:48 PM\n 07:00 PM\n 01:57 AM\n WBC\n 52.6\n 42.7\n 45.6\n 50.4\n Hct\n 21.7\n 21.4\n 22.3\n 22.0\n 24.0\n Plt\n 10\n 13\n 14\n 17\n Creatinine\n 1.1\n 1.1\n TCO2\n 26\n 26\n 27\n Glucose\n 114\n 160\n 87\n 97\n Other labs: PT / PTT / INR:18.0/29.3/1.6, Alk-Phos / T bili:/1.6,\n Differential-Neuts:78.0 %, Band:0.0 %, Lymph:8.0 %, Mono:11.0 %,\n Eos:0.0 %, Fibrinogen:222 mg/dL, Lactic Acid:1.6 mmol/L, Albumin:2.8\n g/dL, LDH:472 IU/L, Ca:7.0 mg/dL, Mg:2.4 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ALTERED MENTAL STATUS (NOT DELIRIUM), ACUTE PAIN,\n HYPERGLYCEMIA, ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE,\n BLEEDING), ANEMIA, HEMOLYTIC, COAGULOPATHY, PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n Fluid overload, THROMBOCYTOPENIA, ACUTE\n Assessment and Plan: 57M h/o ITP presenting with profuse melena s/p\n splenectomy to TICU for further management, persistent\n thrombocytopenia ?related to cirrhosis\n Neurologic: Pain controlled, A+Ox3, follows commands, pt is complaining\n of confusion and visual hallucinations at times. is appropriate and has\n normal eye exam. possibly lack of sleep/icu psychosis/migraines\n Cardiovascular: HD stable off pressors, fluid/product resuscitate prn.\n Pulmonary: IS, Stable, diurese as BP tolerates\n Gastrointestinal / Abdomen: s/p splenectomy, f/u hepatitis B viral\n load. continues to have melenotic stool, continue to monitor hct Q12\n Nutrition: Full liquids, Advance diet as tolerated , fulls, ADAT\n Renal: Foley, Adequate UO, Stable, maintain diuresis to keep I=O\n Hematology: Serial Hct, ITP, persistent thrombocytopenia; s/p IVIG\n , transfuse prn, f/u final BM biopsy results, cont steroids. F/u\n hepatitis B viral load, Hematology considering starting Rituximab based\n on Hep B viral load\n Endocrine: Insulin drip, insulin gtt, metformin\n Infectious Disease: Check cultures, Afebrile, persistently elevated\n WBC, no signs of active infection, f/u hepatitis B viral load, hep c\n neg, hiv neg\n Lines / Tubes / Drains: Foley, PIV, right IJ, aline\n Wounds: Dry dressings, Abdomen\n Imaging:\n Fluids: Other, D10@20\n Consults: General surgery, Hem / Onc\n Billing Diagnosis: (Hemorrhage, NOS), Thrombocytopenia\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 09:00 PM\n Multi Lumen - 11:05 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 545453,
"text": "Mr. is a 57yo male with a PMH of HTN, DM type II, and\n autoimmune hemolytic anemia and ITP who presented to an OSH after\n developing epistaxis on Friday, found to have a platelet count of\n 2,000, was given prednisone, a bag of platelets, and was started on\n IVIG 25gm x4, along with solumedrol 100mg IV Q8. His repeat platelet\n count was 3,000. Pt was transferred to for failed medical\n management of ITP and underwent elective splenectomy . Pt\n transferred to TICU intubated for further management.\n Chief complaint:\n bleed (melena), low plt\n PMHx:\n DM type II, HTN, h/o autoimmune hemolytic anemia, h/o ITP, obesity\n elective Splenectomy on and was transferred to the T/SICU\n post-op.\n - GI study and angio on d/t decreasing Hct and plts. Continues\n to receive PRBCs, FFPs, and plts PRN.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Pt HX of DM remains on insulin gtt with BS from 80\ns- 190\ns this shift.\n Action:\n Insulin gtt and D10@20cc/hr. Metformin TID\n Response:\n Gtt titrated scale on computer.\n Plan:\n ? Start NPH, ? stop insulin gtt\n .H/O idiopathic Thrombocytopenic Purpura (ITP)\n Assessment:\n Platelets 14 this shift. Hct 22-\n Action:\n Given 1 unit PRBC this shift\n Response:\n HCt post transfusion 24 pt continues to have melena stools this shift.\n Plan:\n Continue to monitor hct, platelets and transfuse as needed\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-16 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 1047138,
"text": "GI BLEEDING STUDY Clip # \n Reason: 57YR OLD W/MELENA AND HYPOTENSION EVAL SOURCE OF BLEEDING\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 16.0 mCi Tc-m RBC ();\n HISTORY: 57 year old male with melena and hypotension.\n\n DECISION: Increased activity within small bowel, likely representing\n gastrointestinal bleed.\n\n INTERPRETATION: Following intravenous injection of autologous red blood cells\n labeled with Tc-m, dynamic images of the abdomen for minutes were obtained for\n 100 minutes. A left lateral view of the pelvis was also obtained.\n\n Dynamic blood pool images show increased activity within the left lower\n quadrant, first noted at 6 minutes that persisted throughout the study (100\n minutes). The activity overlies the area of the left iliac vessels. There was\n only a small amount of activity, an the exact location within the bowel could\n not be determined.\n\n IMPRESSION: Increased activity within bowel within the left lower quadrant,\n overlying the iliac vessels.\n\n Findings were discussed with Dr. on at 2:00am by Dr.\n .\n\n\n , M.D.\n , M.D. Approved: MON 3:06 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1047109,
"text": " 4:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? acute bleed\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with coagulopathy and confusion\n REASON FOR THIS EXAMINATION:\n ? acute bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:29 PM\n No evidence of hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old man with coagulopathy and confusion, evaluate for acute\n bleed.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head with and without IV contrast.\n\n FINDINGS: There is no hemorrhage, edema, mass effect, shift of normally\n midline structures, or infarct. Ventricles and sulci are prominent,\n compatible with atrophy. Visualized paranasal sinuses and mastoid air cells\n demonstrate mild mucosal thickening of bilateral maxillary sinuses. Osseous\n structures are unremarkable.\n\n IMPRESSION: No hemorrhage identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1047110,
"text": ", M. TSICU 4:42 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? acute bleed\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with coagulopathy and confusion\n REASON FOR THIS EXAMINATION:\n ? acute bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-17 00:00:00.000",
"description": "MOD SEDATION, EACH ADDL 15 MIN.",
"row_id": 1047155,
"text": " 3:41 AM\n MESSENERTIC Clip # \n Reason: embolize\n Admitting Diagnosis: EPISTAXIS\n Contrast: VISAPAQUE Amt: 700\n ********************************* CPT Codes ********************************\n * EA 1ST ORDER ABD/PEL/LOWER EXT EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with gi bleed\n REASON FOR THIS EXAMINATION:\n embolize\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): ARHb FRI 11:27 AM\n No evidence of arterial extravasation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with ITP and low platelet count with melena and\n hemodynamic instability. Left lower quadrant gastrointestinal bleeding noted\n on tagged red blood cell study.\n\n COMPARISON: GI bleeding study, .\n\n RADIOLOGISTS: Drs. , , and performed the\n procedure. Dr. , attending radiologist, performed and was present\n throughout the procedure.\n\n PROCEDURE/FINDINGS: After the risks and benefits of the procedure were\n explained to the patient, written informed consent was obtained. The patient\n was placed supine on the angiographic table and the right groin was prepped\n and draped in standard sterile fashion. A timeout and huddle were performed\n to confirm patient identity and the procedure to be performed.\n\n The right common femoral artery was accessed using a micropuncture needle\n under ultrasound guidance, and a 0.018 guidewire was fed through the needle\n into the common iliac artery under fluoroscopic guidance. A small skin\n incision was made and the needle was exchanged for a micropuncture sheath. The\n 0.018 guidewire was exchanged for wire which was advanced into the\n (Over)\n\n 3:41 AM\n MESSENERTIC Clip # \n Reason: embolize\n Admitting Diagnosis: EPISTAXIS\n Contrast: VISAPAQUE Amt: 700\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n abdominal aorta under fluoroscopic guidance. The micropuncture sheath was\n exchanged for a 5 French Avanti sheath. The wire was exchanged for a\n 0.035 Amplatz stiff wire. Attempts at cannulating the mesenteric arteries\n using a 5 French SOS Omni catheter were limited as manipulation of the\n catheter was limited by sharp-angled course of the right common iliac artery.\n The 5 French Avanti sheath was exchanged for a 5 French check-flow\n sheath which enabled engagement of the celiac artery origin. The celiac\n artery angiogram with the SOS catheter positioned in the orifice of the celiac\n artery demonstrated no extravasation, though evaluation was limited due to\n patient respiration and the patients large body habitus.\n\n Attention was then directed to the superior mesenteric artery. Once the\n orifice of the superior mesenteric artery was engaged, several arteriogram\n runs were performed which demonstrated a replaced right hepatic artery. No\n extravasation was seen, though several runs were limited by patient\n respiration.\n\n It was quite difficult to engage the orifice of the inferior mesenteric\n artery. The 5 French check-flow sheath with exchanged for a 5 French\n sheath and multiple attempts and catheters were pursued including a C2\n Cobra, SOS Omni, and a 5 French catheter. Eventually, the inferior\n mesenteric artery origin was engaged using a 5 French sheath in\n conjunction with the SOS catheter. An arteriogram at this level demonstrated\n no active extravasation.\n\n As no active extravasation was identified, no intervention was necessary. \n units of platelets were administered during the procedure and platelet count\n approximately one hour before closure was 28,000 per microliter. The decision\n was made to close with a 6 French StarClose vascular closure system after\n administration of an additional bag of platelets. The patient tolerated the\n procedure well and there were no immediate complications.\n\n Moderate sedation was provided by administering divided doses of 400 mcg of\n fentanyl and 1 mg of Versed throughout the total intraservice time of 5 hours\n and 20 minutes, during which the patient's hemodynamic parameters were\n continuously monitored.\n\n IMPRESSION:\n No evidence of arterial extravasation in celiac, superior mesenteric and\n inferior mesenteric arteries.\n\n Technically difficult exam due to tortous right iliac artery and the patients\n large body habitus.\n\n\n (Over)\n\n 3:41 AM\n MESSENERTIC Clip # \n Reason: embolize\n Admitting Diagnosis: EPISTAXIS\n Contrast: VISAPAQUE Amt: 700\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1047572,
"text": " 11:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: blood?\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with thrombocytopenia, HA, visual changes, ? bleed\n REASON FOR THIS EXAMINATION:\n blood?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MRGe SUN 3:05 PM\n No acute intracranial pathology.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thrombocytopenia, headache, visual changes.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial mass lesion,\n hydrocephalus, shift of normally midline structures, major vascular\n territorial infarct, or intracranial hemorrhage. The white matter\n differentiation is preserved. Prominence of the sulci and ventricles are seen\n consistent with atrophy. The visualized paranasal sinuses are clear. The\n osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: No acute intracranial pathology.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1047573,
"text": ", M. TSICU 11:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: blood?\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with thrombocytopenia, HA, visual changes, ? bleed\n REASON FOR THIS EXAMINATION:\n blood?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial pathology.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1046395,
"text": " 12:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o cerebral bleed\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with plts of 5 and heachache, r.o bleed\n REASON FOR THIS EXAMINATION:\n r/o cerebral bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb MON 1:46 PM\n No evidence for acute hemorrhage or acute ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED HEAD CT\n\n HISTORY: Low platelets and headaches, rule out bleed.\n\n There are no comparison studies.\n\n FINDINGS:\n\n There is volume loss for age with prominence of ventricles and sulci. There\n is no evidence for acute hemorrhage or acute transcortical infarction. There\n are small lacunes in bilateral basal ganglia.\n The visualized paranasal sinuses are clear.\n\n IMPRESSION:\n\n No evidence for acute hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1046396,
"text": ", V. MED 11R 12:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o cerebral bleed\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with plts of 5 and heachache, r.o bleed\n REASON FOR THIS EXAMINATION:\n r/o cerebral bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence for acute hemorrhage or acute ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1047697,
"text": " 11:03 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line placement\n Admitting Diagnosis: EPISTAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p CVL placement\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:11 A.M., \n\n HISTORY: Central venous line placement, please evaluate.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n A right jugular line can be traced as far as the low SVC. No pneumothorax,\n mediastinal widening. Elevation of the right lung base, of uncertain\n chronicity. A small volume of pleural fluid could be present. Mild\n cardiomegaly. Left lung clear. Nasogastric tube passes into the stomach, but\n the tip is not seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-17 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1047156,
"text": ", M. TSICU 3:41 AM\n MESSENERTIC Clip # \n Reason: embolize\n Admitting Diagnosis: EPISTAXIS\n Contrast: VISAPAQUE Amt: 700\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with gi bleed\n REASON FOR THIS EXAMINATION:\n embolize\n ______________________________________________________________________________\n PFI REPORT\n No evidence of arterial extravasation.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-12-17 00:00:00.000",
"description": "Report",
"row_id": 209303,
"text": "Sinus rhythm with atrial premature beats. Low precordial voltage. Since the\nprevious tracing of the atrial premature beats are new. The overall\nrate is diminished.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-12-16 00:00:00.000",
"description": "Report",
"row_id": 209304,
"text": "Sinus tachycardia with atrial premature beats. Low precordial voltage. Since\nthe previous tracing of the rate has increased.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-12-13 00:00:00.000",
"description": "Report",
"row_id": 209305,
"text": "Sinus rhythm with frequent atrial premature beats which are multifocal.\nLow precordial voltage. No previous tracing available for comparison.\n\n"
}
] |
10,389 | 145,767 | The patient was observed in the CCU. Her blood pressure remained stable with no further bleeding. She received three units of packed red blood cells and her hematocrit stabilized at around 30.0. She was continued on Aspirin and Plavix . Her Integrelin was stopped after the first episode of bleeding. The vascular surgery service followed her closely during this complication in case surgical intervention became necessary. Her groin bruit resolved by morning. Her creatinine remained stable after catheterization and was 1.0 on discharge. She was discharged home to follow-up with her primary cardiologist, Dr. and her primary care physician, . , with regards to her anemia that she had on presentation of unknown etiology. | The aorta is calcified. SHE WAS GIVEN ATROPINE, 1 L NS AND A UNIT PRBC. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. CCU ADMIT NOTEPT. + BOWEL SOUNDS.GU: FOLEY PATENT. SHE WAS TRANFERRED TO THE FLOOR WITH SHEATH IN PLACE AND IN STABLE CONDITION.WHILE ON 2 SHE SUDDENLY BECAME HYPOTENSIVE AND BRADYCARDIC. GIVEN 2MG MSO4 WITH FAIR EFFECT. DENIES SOB.GI: NPO OVERNIGHT. There are mild degenerative changes of the thoracic spine. GIVEN ADDITIONAL 1L NS. The mediastinal structures are within normal limits. DENIES C/O CP. PT. U/O MINIMAL. ST segment depression in leads V2-V4.Cannot exclude ischemia. Compared to the previous tracing of the rate has slowed.Otherwise, no change.TRACING #2 SEE FLOWSHEET FOR OBJECTIVE DATA.RESP: LUNGS CLEAR. Compared to the previous tracing of the rate is slower andthe ST segment depressions in the precordial leads have resolved.TRACING #3 HEMATOMA HAS INCREASED AND A NEW R FEM BRUIT. Motion artifact. # 20 X2 LEFT ANTECUB AND LLA. Sinus tachycardia. RECEIVED 1.5 MG IV TOTAL. Early R wave transition in the precordial leads. CHEST, TWO VIEWS: The heart is normal in size. + PEDAL PULSES BY DOPPLER. Compared to the previous tracing of the rate is increased.Otherwise, no change.TRACING #1 HO AWARE. Cough and chills. ABD. # 16 RIGHT WRIST. EXAM REVEALED A RIGHT GROIN HEMATOMA ( PRIOR TO SHEATH PULL). WITH FAIR RESPONSE. SHE STABILIZED AND SHEATH WAS PULLED WITHOUT DIFFICULTY. ADMITTED TO CCU LETHARGIC BUT AROUSABLE, UNCOMFORTABLE. SHE RECEIVED ATROPINE, INTEGRILIN WAS D/C'D AND MANUAL PRESSURE WAS APPLIED FOR 30 MIN. O2 SATS ON 2L NC 100%. LARGE, SOFT. The lungs are clear. O2 NOW OFF WITH O2 SATS 95%-97%. Compared to theprevious tracing of the rate is faster and there are ST segmentdepressions in the precordial leads.TRACING #2 A NUCLEAR STRESS PRIOR TO CATH SHOWED EF 70% AND REVERSABLE ANTERIOR DEFECT. A STENT WAS PLACED IN THE LAD HERE AT WITHOUT INCIDENT. Clinical correlation is suggested. 4:55 PM CHEST (PA & LAT) Clip # Reason: Pt c/o cough, chill. NO BLEEDING NOTED. APPROXIMATELY AN HOUR AFTER SHEATH PULLED SHE BECAME HYPOTENSIVE AND BRADYCARDIC. BECOMING MORE AGITATED LATER IN EVE REQUIRING ATIVAN IV. Please eval for infiltrate FINAL REPORT HISTORY: Right groin hematoma status post cardiac catheterization. IMPRESSION: No acute cardiopulmonary process. SHE STABILIZED AND TRASNFERRED TO CCU FOR FURTHER MANAGEMENT.PMH:HYPERTENSIONSEVERE ARTHRITISPSORIASISHYPOTHYROIDISMELEVATED LIPIDS YR. HX OF SSCP DURING STRESSPSH:S/P CHOLES/P SKIN CA RESECTIONS/P LUMBAR SURGERYALLERGIES:PERCODAN-HIVES, MS -RASHPHENOBARBITAL-RASHCLAMS- ANAPHYLAXISSOCIAL:MARRIED, LIVES WITH HUSBAND, 7 CHILDRENREMOTE TOBACCO HX, OCC ETOHPT. HAS NOT EXPANDED. GIVEN MSO4 2 MG FOR GROIN AND HIP PAIN WITH GOOD EFFECT.PIV'S X3. Motion artifact.No previous tracing available for comparison.TRACING #1 URINE CLEAR YELLOW.SKIN: RIGHT GROIN ECCHYMOTIC WITH LARGE HEMATOMA. NO N/V. DIFFICULT TO OBTAIN ACCESS. AN ELECTIVE CARDIAC CATH REVEALED A 90% LESION IN THE LAD ON . ( HCT 35-25) MANUAL PRESSURE WAS APPLIED FOR 40 MIN. SLEPT IN LONG NAPS, AWOKE THIS AM ALERT AND ORIENTED.CV: BP AND HR STABLE OVERNIGHT. SHE WAS ALSO ON DOPA FOR BRIEF TIME. There is no obvious hilar or mediastinal adenopathy. IS A 66 Y/O FEMALE ADMITTED TO FOR FURTHER INTERVENTION FOLLOWING A CARDIAC CATH AT . Please eval for infiltrate MEDICAL CONDITION: 66 year old woman with R groin hematoma s/p cath REASON FOR THIS EXAMINATION: Pt c/o cough, chill. | 7 | [
{
"category": "ECG",
"chartdate": "2152-01-09 00:00:00.000",
"description": "Report",
"row_id": 150667,
"text": "Sinus rhythm. Compared to the previous tracing of the rate is increased.\nOtherwise, no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2152-01-08 00:00:00.000",
"description": "Report",
"row_id": 150668,
"text": "Sinus rhythm. Compared to the previous tracing of the rate is slower and\nthe ST segment depressions in the precordial leads have resolved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2152-01-07 00:00:00.000",
"description": "Report",
"row_id": 150669,
"text": "Sinus tachycardia. Motion artifact. ST segment depression in leads V2-V4.\nCannot exclude ischemia. Clinical correlation is suggested. Compared to the\nprevious tracing of the rate is faster and there are ST segment\ndepressions in the precordial leads.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2152-01-07 00:00:00.000",
"description": "Report",
"row_id": 150670,
"text": "Sinus rhythm. Early R wave transition in the precordial leads. Motion artifact.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2152-01-10 00:00:00.000",
"description": "Report",
"row_id": 154163,
"text": "Sinus rhythm. Compared to the previous tracing of the rate has slowed.\nOtherwise, no change.\nTRACING #2\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-01-08 00:00:00.000",
"description": "Report",
"row_id": 1399507,
"text": "CCU ADMIT NOTE\nPT. IS A 66 Y/O FEMALE ADMITTED TO FOR FURTHER INTERVENTION FOLLOWING A CARDIAC CATH AT . SHE WAS IN THE PROCESS OF A CARDIAC EVAL PRIOR TO HIP REPLACEMENT SURGERY. A NUCLEAR STRESS PRIOR TO CATH SHOWED EF 70% AND REVERSABLE ANTERIOR DEFECT. AN ELECTIVE CARDIAC CATH REVEALED A 90% LESION IN THE LAD ON . A STENT WAS PLACED IN THE LAD HERE AT WITHOUT INCIDENT. SHE WAS TRANFERRED TO THE FLOOR WITH SHEATH IN PLACE AND IN STABLE CONDITION.\nWHILE ON 2 SHE SUDDENLY BECAME HYPOTENSIVE AND BRADYCARDIC. EXAM REVEALED A RIGHT GROIN HEMATOMA ( PRIOR TO SHEATH PULL). SHE RECEIVED ATROPINE, INTEGRILIN WAS D/C'D AND MANUAL PRESSURE WAS APPLIED FOR 30 MIN. SHE WAS ALSO ON DOPA FOR BRIEF TIME. SHE STABILIZED AND SHEATH WAS PULLED WITHOUT DIFFICULTY. APPROXIMATELY AN HOUR AFTER SHEATH PULLED SHE BECAME HYPOTENSIVE AND BRADYCARDIC. HEMATOMA HAS INCREASED AND A NEW R FEM BRUIT. SHE WAS GIVEN ATROPINE, 1 L NS AND A UNIT PRBC. ( HCT 35-25) MANUAL PRESSURE WAS APPLIED FOR 40 MIN. SHE STABILIZED AND TRASNFERRED TO CCU FOR FURTHER MANAGEMENT.\n\nPMH:\nHYPERTENSION\nSEVERE ARTHRITIS\nPSORIASIS\nHYPOTHYROIDISM\nELEVATED LIPIDS\n YR. HX OF SSCP DURING STRESS\n\nPSH:\nS/P CHOLE\nS/P SKIN CA RESECTION\nS/P LUMBAR SURGERY\n\nALLERGIES:\nPERCODAN-HIVES, MS \n-RASH\nPHENOBARBITAL-RASH\nCLAMS- ANAPHYLAXIS\n\nSOCIAL:\nMARRIED, LIVES WITH HUSBAND, 7 CHILDREN\nREMOTE TOBACCO HX, OCC ETOH\n\n\nPT. ADMITTED TO CCU LETHARGIC BUT AROUSABLE, UNCOMFORTABLE. GIVEN 2MG MSO4 WITH FAIR EFFECT. PT. BECOMING MORE AGITATED LATER IN EVE REQUIRING ATIVAN IV. RECEIVED 1.5 MG IV TOTAL. SLEPT IN LONG NAPS, AWOKE THIS AM ALERT AND ORIENTED.\n\nCV: BP AND HR STABLE OVERNIGHT. DENIES C/O CP. SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nRESP: LUNGS CLEAR. O2 SATS ON 2L NC 100%. O2 NOW OFF WITH O2 SATS 95%-97%. DENIES SOB.\n\nGI: NPO OVERNIGHT. NO N/V. ABD. LARGE, SOFT. + BOWEL SOUNDS.\n\nGU: FOLEY PATENT. U/O MINIMAL. HO AWARE. GIVEN ADDITIONAL 1L NS. WITH FAIR RESPONSE. URINE CLEAR YELLOW.\n\nSKIN: RIGHT GROIN ECCHYMOTIC WITH LARGE HEMATOMA. HAS NOT EXPANDED. NO BLEEDING NOTED. + PEDAL PULSES BY DOPPLER. GIVEN MSO4 2 MG FOR GROIN AND HIP PAIN WITH GOOD EFFECT.\n\nPIV'S X3. # 16 RIGHT WRIST. # 20 X2 LEFT ANTECUB AND LLA. DIFFICULT TO OBTAIN ACCESS.\n"
},
{
"category": "Radiology",
"chartdate": "2152-01-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 749906,
"text": " 4:55 PM\n CHEST (PA & LAT) Clip # \n Reason: Pt c/o cough, chill. Please eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with R groin hematoma s/p cath\n REASON FOR THIS EXAMINATION:\n Pt c/o cough, chill. Please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right groin hematoma status post cardiac catheterization. Cough and\n chills.\n\n CHEST, TWO VIEWS: The heart is normal in size. The lungs are clear.\n The mediastinal structures are within normal limits. There is no obvious\n hilar or mediastinal adenopathy. The aorta is calcified. There are mild\n degenerative changes of the thoracic spine.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
}
] |
17,997 | 186,252 | The patient's beta blocker, Lopressor, was held. Her blood pressure remained stable throughout the remainder of her hospitalization. On the first morning of her hospitalization, , she developed a leukocytosis with a left shift, eight bands. Blood cultures, urine cultures and sputum cultures were obtained and antibiotics were not initially started. The patient was not febrile and had no symptoms of infection. On the patient's urine culture showed 10,000 to 100,000 Gram-negative rods. It grew out Klebsiella, which was pansensitive. She was started on levofloxacin. The patient was also followed by rheumatology throughout her hospitalization. Her ESR, CRP were also repeated. CRP had decreased from previous admission. ESR had increased from 65 to 122. She also had a repeat echocardiogram which showed decreasing small effusion. Rheumatology suggested prednisone taper to decrease by 5 mg every day. The patient was also seen by cardiology. She was ruled out for an myocardial infarction and they suggested holding her Lopressor for the hypotension. The nephrology service suggested that her Lopressor not be restarted until she was back to her baseline dry weight from dialysis. The patient was also closely followed by and suggested that she continue her sliding scale as the prednisone was increasing her insulin requirements. The patient's blood pressure remained stable through . She was discharged to home in stable condition. | Mild tricuspid [1+]regurgitation is seen. FINDINGS: The cardiac and mediastinal silhouettes are within normal limits. WBCs lower today.CV: Pt remains hemodynamically stable. Otherwise NBP 120s-130s.GI/GU: Abd soft slightly distended. Cont and Renagel.ID: Pt remains afebrile. Continues on Prednisone taper. The mitralvalve appears structurally normal with trivial mitral regurgitation. Continue prednisone taper. CYCLIC PD DONE DURING NOC. BS+.GU: MOSTLY ANURIC D/T CRF. Hypoactive BS. Hypoactive BS. Given Dulcolax w/ marginal effect. There is a very small pericardialeffusion (seen posteriorly).Compared with the findings of the prior study (tape reviewed) of , apericardial effusion is now noted. Pt c/o constipation. Pt remains very 3rd spaced with periferal edema. PATIENT/TEST INFORMATION:Indication: F/U Pericardial effusion.BP (mm Hg): 141/62Status: InpatientDate/Time: at 11:39Test: Portable TTE(Focused views)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: The left ventricular cavity size is normal. Given instruction for Prednisone taper. Lopressor cont to be held in setting of hypotension/ marginal SBP. Pt up to commode w/ no effect. CCU NSG NOTE: ALT IN CV/RENALO: For complete VS see CCU flow sheet.ID: Pt afebrile. The ascending aorta is normal indiameter. Pt remains -869cc LOS. Normal sinus rhythm. Pt denies any pain.CV: Hemodynamically stable. Pt stated improved breathing. Compared tothe previous tracing of no diagnostic interim change.TRACING #1 Labs drawn at there suggestion.ENDO: Sugars continue labile. "O: For complete VS see CCU flow sheet.ID: PT afebrile. Ambulated to commode w/ supervision. BS CLEAR. During coarse of peritoneal dialysis SBP reached 127. CK today was 170/6.RENAL: Pt has not voided today. Lactate on venous gas was 2.2.CV: PT has been hemodynamically stable with HR in 77-80s NSR and BP trending up from 110 to 130-140s/60s. Pt took lactalose times 2. The leftventricular cavity size is normal. She is 1659 neg for the day.GI: No bm. CCU NSG NOTE: ALT IN CVS: "I'm feeling very good today. Episodes of decreased hearing resolved. Pt spirits improved. NBP 107-145/47-63. SBP remained <92 until 2200 when bump in SBP d/t was achieved. Notified HO. RR 12-19.CARDIAC: HEMODYNAMICALLY STABLE WITH HR 70-86 SR, NO ECTOPY. Right ventricularsystolic function is normal.PERICARDIUM: There is a small pericardial effusion.Conclusions:The left ventricular cavity size is normal. Unclear etiology.CV: Tele-> NSR. The left ventricular cavity size is normal. Tolerated well. PATIENT/TEST INFORMATION:Indication: Pericardial effusion.Height: (in) 63Weight (lb): 154BSA (m2): 1.73 m2BP (mm Hg): 140/80Status: InpatientDate/Time: at 10:26Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Right ventricular chamber size is normal. HR 80-90s NSR with no ectopy. H/H and electrolytes stable. Right ventricular chamber size andfree wall motion are normal. BOTH PT. Sinus rhythm. Sinus rhythm. Sinus rhythm. AS NEEDED. Pt denies any cp/discomfort. NBP normalized and SBP reached 127. Pt disappointed w/ readmission. No definite failure. The aortic arch is normal in diameter. BUN/CR continue to improve.Endo: BS 121-151 prior to lactulose/ juice administration. Rightventricular systolic function is normal. Left ventricular wall thicknesses arenormal. Compared tothe previous tracing of no diagnostic interim change.TRACING #2 Compared tothe previous tracing of no major change. BC PENDING.ENDO: BS 221->159. Rechecked BS at 224 and given 4u of Humalog per pt's request.Peritoneal dialysis cycle completed overnoc.ID: Remains afebrile overnoc. Since the previous tracing of no significant change. No further bolues needed. The aortic valve leaflets (3) appear structurallynormal with good leaflet excursion and no aortic regurgitation. There is mild pulmonary artery systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is a small pericardial effusion.Conclusions:The left atrium is mildly dilated. There is a very small pericardialeffusion (seen posteriorly).Compared with the findings of the prior study (tape reviewed) of , thepericardial effusion appears similar to slightly smaller. There is no aortic valvestenosis.MITRAL VALVE: The mitral valve appears structurally normal with trivial mitralregurgitation.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Tele-> NSR. Around 0330 pt c/o need to stool. Denies any pain. CONT. Pt removed NC not long afterwards and O2 sat remained 96% or greater.Endo: IDDM. Lopressor cont to be on hold at this time. Asymptomatic, mentating well. BP 124- 155/56-75.GI: APPETITE GOOD. Shortly after pt walking corridor w/ assistance of RN. THe edema in her legs has decreased.GI: Pt continues to co of constipation. At around 0300 ^ uncomfortable and given Dulcolax suppository. SL.DISTENDED. Pt to commode w/ some relief and able to sleep from that point on.Pt anuric. NBP 82-127/39-51. IMPRESSION: Improving left lower lobe atelectasis; no evidence of failure or consolidation. Tmax 97.9. Osseous structures remain unchanged. Pt requesting pneumoboots rather than SC heparin for DVT prophylaxis. Overall left ventricular systolic functionis normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Abd remains soft distended. BY HUSBAND.ID: AFEBRILE. Pt cont on free water restriction and intake remains marginal. Continue to cover w/ Humalog per sliding scale and establish NPH dosing as diet improves. (auscultated faint rales last pm prior to dialysis). Shortness of breath and edema. Na today is 128 and she is being free H2O restricted. BS remain labile following Prednisone doses and evening snack. Modest inferior T wave changes are non-specific and may be withinnormal limits. She transfered easily to the chair and has been resting comfortably without need for analgesia.A: Hemodynamically stableP: Monitor FS frequently. Frequent finger stick and variable levels of humalog given at pts determination.RESP: Lungs clear with 02 sat 98% on RA.MS: Pt A & O X 3. Otherwise anuric and continues on peritoneal dialysis performed by husband. Ambulated successfully and walked a great deal w/o difficulty and denied SOB. ABD. Cont to follow cks/troponin d/t hx of CAD/stenosis.Resp: LS CTA. Overall left ventricular systolicfunction is normal (LVEF>55%). There ismild pulmonary artery systolic hypertension. CHF or infiltrate. She was started on levofloxacin po for UTI. | 13 | [
{
"category": "Nursing/other",
"chartdate": "2125-08-21 00:00:00.000",
"description": "Report",
"row_id": 1499268,
"text": "Discharge Note\n\nPt seen by medical team early this am with plan for discharge home. VSS. Both pt and husband given discharge instructions with new mediations. Given instruction for Prednisone taper. Both pt and husband are clear on medication schedule. Follow up appt to be made by pt. Father in to pick up pt and husband.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-19 00:00:00.000",
"description": "Report",
"row_id": 1499264,
"text": "CCU NSG NOTE: ALT IN CV\nS: \"I'm feeling very good today.\"\nO: For complete VS see CCU flow sheet.\nID: PT afebrile. WBC up to 15 with 6 bands. Pt recultured and now has 3 sets of blood cultures pending. She conts on erythomycin, but no new ABX added at present. Lactate on venous gas was 2.2.\nCV: PT has been hemodynamically stable with HR in 77-80s NSR and BP trending up from 110 to 130-140s/60s. No further bolues needed. Post signs done with sitting 84 140/67, Lying 86 140/67, and standing 86 134/66. CK today was 170/6.\nRENAL: Pt has not voided today. Overnight she had ~2.5 liters taken off with PD. Pt remains very 3rd spaced with periferal edema. Na today is 128 and she is being free H2O restricted. She drank a lot of buillon today. She is 1659 neg for the day.\nGI: No bm. Pt took lactalose times 2. Has fair apetite.\nENDO: Finger sticks have varied with a high of 358 at 8am down to 121 at 6pm. She received humalog 7u at 8a, humalog 3u at 10, 3u at 1500 and 4u at 1600.\nRESP: Lungs clear with 02 sat 94-98% on RA.\nMS: Pt in good spirits. Huband, family and dogs in to visit. She transfered easily to the chair and has been resting comfortably without need for analgesia.\nA: Hemodynamically stable\nP: Monitor FS frequently. Check results of cultures. Monitor for fever. Support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 1499265,
"text": "CCU Nursing Progress Note 7p-7a\nS: \" I just don't know why I am having these problems\"\n\nO: Please see careview for complete VS/ additional objective data\n\nNeuro: AAOx3. Very pleasant and cooperative of care. MAE. OOB at beginning of shift, dozing in chair. After left w/ seeing eye dogs pt had a brief episode of being weepy but supported by husband. Shortly after pt walking corridor w/ assistance of RN. Pt spirits improved. Pt denies any pain.\n\nCV: Hemodynamically stable. Tele-> NSR. No ectopy noted. NBP 107-145/47-63. (^ NBP following walk and attempt to defecate). Otherwise NBP 120s-130s.\n\nGI/GU: Abd soft slightly distended. Hypoactive BS. No BM. Cont on bowel regimen including Lactulose. Pt still unable to stool despite ambulation. Around 0330 pt c/o need to stool. Pt up to commode w/ no effect. Notified HO of discomfort and request for assistance. Given Dulcolax w/ marginal effect. Pt voided approx 30cc of urine while up to commode. Unable to measure. Otherwise anuric and continues on peritoneal dialysis performed by husband. Pt remains -869cc LOS. BUN/CR continue to improve.\n\nEndo: BS 121-151 prior to lactulose/ juice administration. As of that time no Humalog given. At 2300 given Lactulose/OJ and 6u Humalog in preparation of ^ BS. At 0330 BS 325 requiring additional 7u of Humalog. Rechecked BS at 224 and given 4u of Humalog per pt's request.\nPeritoneal dialysis cycle completed overnoc.\n\nID: Remains afebrile overnoc. BC still pending.\n\nSocial: Husband remains at bedside overnoc. Very supportive of pt and greatly involved in care. and seeing eye dogs into visit prior to the start of peritoneal dialysis.\n\nA/P: Remains hemodynamically stable overnoc. Ambulated successfully and walked a great deal w/o difficulty and denied SOB. Cont to have difficulty defecating despite cont colace, lactulose and Dulcolax. Consult renal for appropriate alternatives. Pt cont on free water restriction and intake remains marginal. Cont emotional support of pt and husband. Probable call out to floor when bed becomes available.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 1499266,
"text": "CCU NSG NOTE: ALT IN CV/RENAL\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile. She was started on levofloxacin po for UTI. WBCs lower today.\nCV: Pt remains hemodynamically stable. HR 80-90s NSR with no ectopy. BP climbing from 130-140 to 150s/60s. She was to be started on 12.5 lopressor, but renal attending felt it would be better to wait until she loses extra fluid she has retained prior to starting this med.\nRENAL: Pt has not voided today. She is 840 neg for the day from the PD run overnight. THe edema in her legs has decreased.\nGI: Pt continues to co of constipation. SHe received a SSE with good results. She is eating well and trying to increase her protein.\nRHEUMATOLOGY: Rheumatology came in and discussed plans for prednisone taper. Labs drawn at there suggestion.\nENDO: Sugars continue labile. Frequent finger stick and variable levels of humalog given at pts determination.\nRESP: Lungs clear with 02 sat 98% on RA.\nMS: Pt A & O X 3. She and husband frustrated that they cannot return home today, but will stay until am. Husband will start PD run early. Pt walking in halls a number of times today.\nA: Stable\nP: Monitor for change in VS. Check labs in am. Continue prednisone taper. Check for results of blood cultures.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-21 00:00:00.000",
"description": "Report",
"row_id": 1499267,
"text": "NEURO: A&O X3. PLEASANT & COOPERATIVE WITH CARE. HUSBAND STAYS WITH\n PT. TO ASSIST HER WITH PD & INSULIN AS SHE IS BLIND. BOTH PT.\n & HER HUSBAND USE SEEING EYE DOGS.\nRESP: O2 SAT 98-99% ON RM. AIR. BS CLEAR. RR 12-19.\nCARDIAC: HEMODYNAMICALLY STABLE WITH HR 70-86 SR, NO ECTOPY. BP 124-\n 155/56-75.\nGI: APPETITE GOOD. ABD. SL.DISTENDED. BS+.\nGU: MOSTLY ANURIC D/T CRF. CYCLIC PD DONE DURING NOC. BY HUSBAND.\nID: AFEBRILE. CONT. ON PO LEVOFLOX FOR UTI & PO ERYTHROMYCIN FOR\n RHEUMATIC FEVER. WBC TRENDING DOWN. BC PENDING.\nENDO: BS 221->159. INSULIN ADDED TO DIALYSATE BY HUSBAND, & TAKING SC\n REG. AS NEEDED. SOME DIFFICULTY MANAGING BS D/T STEROID TAPER.\nPLAN: TO BE DISCHARGED HOME AFTER ROUNDS THIS AM.\nAM LABS PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-19 00:00:00.000",
"description": "Report",
"row_id": 1499263,
"text": "CCU Nursing Progress Note 7p-7a\nS: \"I just have to go so bad\"\n\nO: Please refer to careview for complete vs/ additional objective data\n\nNeuro: AAOx3. Fatigued. Very pleasant and cooperative w/ care. Denies any pain. States she is a bit achy associated w/ rhematic fever. MAE without difficulty. Ambulated to commode w/ supervision. Tolerated well. Declined use of sleeping aids. Legally blind assisted by seeing eye dog. Episodes of decreased hearing resolved. Unclear etiology.\n\nCV: Tele-> NSR. No ectopy noted. HR 75-90. NBP 82-127/39-51. Around 2100 pt experienced SBP 82. Asymptomatic, mentating well. Notified HO. Ordered for 250cc IVF bolus. SBP remained <92 until 2200 when bump in SBP d/t was achieved. During coarse of peritoneal dialysis SBP reached 127. By am while in deep sleep SBP trending 97-101. Lopressor cont to be held in setting of hypotension/ marginal SBP. Pt denies any cp/discomfort. H/H and electrolytes stable. Cont to follow cks/troponin d/t hx of CAD/stenosis.\n\nResp: LS CTA. (auscultated faint rales last pm prior to dialysis). Improved by 0400. Pt did express feeling of harder breathing. O2 sat was 97% at that time but applied 2L of supplemental O2 via NC. Pt stated improved breathing. Pt removed NC not long afterwards and O2 sat remained 96% or greater.\n\nEndo: IDDM. Receiving regular insulin via diasylate provided by husband. BS 89(following juice in EW) given peanut butter crackers and tuna . BS 104 but 85 only one hour later. Husband supplied pt w/ Nephro shake and BS was 246. Given 3u Humalog per sliding scale established by husband/HO. Continues on Prednisone taper. Serum acetone is being checked for DKA.\n\nGI/GU: Tolerating diet without difficulty. No N/V. Abd remains soft distended. Hypoactive BS. Pt c/o constipation. Given lactulose earlier in day but declined use last pm. At around 0300 ^ uncomfortable and given Dulcolax suppository. Pt to commode w/ some relief and able to sleep from that point on.\nPt anuric. Cycle of peritoneal dialysis performed by husband. Cont and Renagel.\n\nID: Pt remains afebrile. Tmax 97.9. WBC WNL.\n\nSocial: Husband very supportive and remains at bedside overnoc.\n\nS/P: Very pleasant 44 yo highly functional blind female. S/P stents x 3 to RCA 1 mos ago and discharged most recently w/ diagnosis of rhematic fever. Slightly hypotensive overnoc requiring 250cc bolus x1. NBP normalized and SBP reached 127. Lopressor cont to be on hold at this time. Pt requesting pneumoboots rather than SC heparin for DVT prophylaxis. BS remain labile following Prednisone doses and evening snack. Continue to cover w/ Humalog per sliding scale and establish NPH dosing as diet improves. Husband cont to provide peritoneal dialysis w/ added regular insulin to diasylate. Continue to monitor.\nHusband and family very supportive. Pt disappointed w/ readmission. Continue to provide emotional support as indicated to pt and husband. Require the assistance of seeing eye dogs which will be brought in later today.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 795383,
"text": " 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf vs infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with ESRD and CAD with recent diagnosis of rhematic fever,\n now with recurrent fever, SOB, lower extremity edema.\n REASON FOR THIS EXAMINATION:\n r/o chf vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End stage renal disease and coronary artery disease with rheumatic\n fever. Shortness of breath and edema. ? CHF or infiltrate.\n\n COMPARISON: Six days ago.\n\n FINDINGS: The cardiac and mediastinal silhouettes are within normal limits.\n There is some linear atelectasis at the left lung base which is improved since\n the prior study. No other focal pulmonary opacities, pleural effusion, or\n pneumothorax. No definite failure. Osseous structures remain unchanged.\n\n IMPRESSION: Improving left lower lobe atelectasis; no evidence of failure or\n consolidation.\n\n"
},
{
"category": "Echo",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 60583,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 63\nWeight (lb): 154\nBSA (m2): 1.73 m2\nBP (mm Hg): 140/80\nStatus: Inpatient\nDate/Time: at 10:26\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter. The aortic arch is normal in diameter. No 2D echo or Doppler\nevidence of coarctation of the distal aortic arch.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. There is no aortic valve\nstenosis.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is a small pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve appears structurally normal with trivial mitral regurgitation. There is\nmild pulmonary artery systolic hypertension. There is a very small pericardial\neffusion (seen posteriorly).\n\nCompared with the findings of the prior study (tape reviewed) of , a\npericardial effusion is now noted. .\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 60689,
"text": "PATIENT/TEST INFORMATION:\nIndication: F/U Pericardial effusion.\nBP (mm Hg): 141/62\nStatus: Inpatient\nDate/Time: at 11:39\nTest: Portable TTE(Focused views)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function is normal.\n\nPERICARDIUM: There is a small pericardial effusion.\n\nConclusions:\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size is normal. Right\nventricular systolic function is normal. There is a very small pericardial\neffusion (seen posteriorly).\n\nCompared with the findings of the prior study (tape reviewed) of , the\npericardial effusion appears similar to slightly smaller.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 109646,
"text": "Normal sinus rhythm. Non-diagnostic repolarization abnormalities. Compared to\nthe previous tracing of no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-19 00:00:00.000",
"description": "Report",
"row_id": 109647,
"text": "Sinus rhythm. Non-specific inferolateral ST-T wave abnormalities. Compared to\nthe previous tracing of no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-18 00:00:00.000",
"description": "Report",
"row_id": 109648,
"text": "Sinus rhythm. Non-specific inferolateral ST-T wave abnormalities. Compared to\nthe previous tracing of no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 109649,
"text": "Sinus rhythm. Modest inferior T wave changes are non-specific and may be within\nnormal limits. Since the previous tracing of no significant change.\n\n"
}
] |
73,971 | 182,744 | The patient was brought to the Operating Room on where he underwent Coronary Artery Bypass x 4 with Dr. . Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He developed rapid atrial fibrillation and was bolused with Amiodarone. He did require epicardial pacing and NeoSynephrine for blood pressure support. He converted to Sinus Rhythm. The patient was neurologically intact. Hemodynamics improved and he was weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Lisinopril was started for further blood pressure control in the setting of systolic heart failure with an EF 10-15%. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. As he had no benefits for rehabilitation admission he was kept in house for further recovery prior to returning home with his wife. By the time of discharge on POD 13 the patient was ambulating with his walker, the wound was healing and pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions. PT WILL TAPER HIS AMIO, NO COUMADIN | Mild right ventricular dilation and free wallhypokinesis. WJMLEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. [Intrinsic RV systolic function likely more depressed given theseverity of TR].AORTA: Normal aortic diameter at the sinus level. Mild to moderate(+) MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild PA systolic hypertension. There is mild symmetric left ventricularhypertrophy. Status post median sternotomy for CABG with overall stable cardiomediastinal postoperative contours. Left-to-right shunt acrossthe interatrial septum at rest.LEFT VENTRICLE: Severely depressed LVEF.RIGHT VENTRICLE: Mild global RV free wall hypokinesis.AORTA: Normal ascending aorta diameter. The right ventricular cavity ismildly dilated with mild global free wall hypokinesis. There is a trivial/physiologic pericardial effusion. Stable mild interstitial edema. Noaortic regurgitation is seen. Noaortic regurgitation is seen. There are noechocardiographic signs of tamponade.Compared with the prior study (TEE - report reviewed) of and withTTE done , overall systolic function is similar. FINDINGS: Mild heterogeneous plaque is seen along the proximal right internal carotid artery. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Likely small left effusion and retrocardiac atx. There is mild perihilar haziness with vascular indistinctness and Kerley B lines compatible with mild interstitial pulmonary edema. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The rightventricular cavity is moderately dilated with moderate global free wallhypokinesis. There is nopericardial effusion.IMPRESSION: Moderately dilated left ventricle with severe regional and globalsystolic dysfunction. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. No TEE related complications.Conclusions:Pre-CPB:Mild spontaneous echo contrast is present in the left atrial appendage.A patent foramen ovale is present. Two mediastinal drains and a left-sided chest tube are unchanged. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No resting LVOT gradient.RIGHT VENTRICLE: Moderately dilated RV cavity. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild to moderate (+)mitral regurgitation is seen.There is no pericardial effusion.There is a small left pleural effusion.The tip of the SGC is at the PA bifurcation.Post-CPB:The patient is AV-Paced, on infusions of epinephrine and nitroglycerine.RV systolic fxn is unchanged.The LV is slightly improved, with all walls moving slightly better thanpre-bypass. FINDINGS: There is some mild wedging of the L2 vertebral body. Suboptimalimage quality - bandages, defibrillator pads or electrodes.Conclusions:The left atrium is mildly dilated. The right atrium is moderately dilated.Left ventricular wall thicknesses are normal. Mild global RV free wallhypokinesis.AORTA: Normal aortic diameter at the sinus level. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen.The mitral valve leaflets are moderately thickened. PATIENT/TEST INFORMATION:Indication: CABGStatus: InpatientDate/Time: at 16:36Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild spontaneous echo contrast in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Only mild postoperative mediastinal widening is evident. Moderate cardiomegaly is comparable to the preoperative appearance. The mitral valve leaflets are mildly thickened.Moderate (2+) mitral regurgitation is seen. PATIENT/TEST INFORMATION:Indication: R/O TamponadeHeight: (in) 62Weight (lb): 130BSA (m2): 1.59 m2BP (mm Hg): 105/60HR (bpm): 85Status: InpatientDate/Time: at 12:58Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Normal LV wall thickness. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. A left-to-right shunt across theinteratrial septum is seen at rest.Overall left ventricular systolic function is severely depressed (LVEF= 10 -15 %), with septal, lateral and anterior hypokinesis, and inferior akinesis.There is mild echo contrast in all .There is mild global free wall hypokinesis.There are simple atheroma in the descending thoracic aorta.The aortic valve leaflets (3) are mildly thickened. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate (2+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate cardiomegaly and mediastinal widening is unchanged. No AR.MITRAL VALVE: Normal mitral valve leaflets. Trivial mitral regurgitation isseen. There are some mild degenerative changes of both hips with spurring of superolateral acetabula. Moderately dilated LV cavity. The left ventricular cavity is moderately dilated. Mild interstitial edema is stable. The right-sided catheter has been removed. Right jugular line ends just above the clavicle in the right neck, as before. IMPRESSION: Degenerative changes without acute fracture. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; midinferolateral - akinetic; mid anterolateral - hypo; inferior apex - akinetic;apex - akinetic;RIGHT VENTRICLE: Mildly dilated RV cavity. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: Mild congestive heart failure with retrocardiac atelectasis and probable trace left pleural effusion. Right internal jugular introducer remains in place with interval removal of the Swan-Ganz catheter, left basilar chest tube, the mediastinal drains. Moderate to severe [3+] tricuspid regurgitation is seen.There is mild pulmonary artery systolic hypertension. Evaluate for pleural effusions. Right lung is grossly clear. Pre-Op CABGHeight: (in) 70Weight (lb): 150BSA (m2): 1.85 m2BP (mm Hg): 134/50HR (bpm): 57Status: InpatientDate/Time: at 11:34Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings: Location corrected. There issevere regional left ventricular systolic dysfunction with focal akinesis ofthe inferior and inferolateral walls. Bony structures are intact aside for some median sternotomy wires. Sacroiliac joints are grossly normal. There are some mild degenerative changes of both hip joints with some minimal spurring of the superolateral acetabula and some mild joint space narrowing on the right side. IMPRESSION: AP chest compared to preoperative chest radiograph on : Mild pulmonary edema has improved. IMPRESSION: No acute fracture. Stable enlarged cardiac contour and stable postoperative appearance to mediastinum in this patient status post median sternotomy for CABG. Possible left atrial abnormality. The left ventricular cavity ismoderately dilated. FINDINGS: The patient has been extubated. [Intrinsic right ventricular systolic function is likely moredepressed given the severity of tricuspid regurgitation.] | 14 | [
{
"category": "Radiology",
"chartdate": "2133-12-13 00:00:00.000",
"description": "LUMBO-SACRAL SPINE (AP & LAT)",
"row_id": 1215526,
"text": " 7:34 AM\n LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: please r/o frx in the sacrum/ low L-spine, please also evalu\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M s/p CABG x 4(LIMA->LAD,SVG->Diag,Ramus, PLV) s/p on\n sacrum w/hip and sacrum pain\n REASON FOR THIS EXAMINATION:\n please r/o frx in the sacrum/ low L-spine, please also evaluate the hips as\n well, please do before 7 am on \n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Lumbosacral spine, .\n\n CLINICAL HISTORY: 70-year-old man with CABG, status post fall.\n\n FINDINGS:\n\n There is some mild wedging of the L2 vertebral body. No abnormal antero- or\n retro-listhesis is identified. Sacroiliac joints are grossly normal. There\n are some mild degenerative changes of both hips with spurring of superolateral\n acetabula. Vascular calcifications are also seen. There is some irregularity\n of the sacrum and coccyx. No acute fracture is seen.\n\n IMPRESSION:\n\n Degenerative changes without acute fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-13 00:00:00.000",
"description": "BILAT HIPS (AP,LAT & AP PELVIS)",
"row_id": 1215527,
"text": " 7:36 AM\n BILAT HIPS (AP,LAT & AP PELVIS) Clip # \n Reason: r/o frx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M s/p CABG x 4(LIMA->LAD,SVG->Diag,Ramus, PLV) s/p fall\n REASON FOR THIS EXAMINATION:\n r/o frx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP pelvis and bilateral hips, .\n\n CLINICAL HISTORY: Status post fall. Evaluate for fracture.\n\n FINDINGS: No displaced fractures or dislocations are seen of either proximal\n femurs. There are some mild degenerative changes of both hip joints with some\n minimal spurring of the superolateral acetabula and some mild joint space\n narrowing on the right side. Vascular calcifications are present. There are\n some mild degenerative changes of lower lumbar spine and of the sacroiliac\n joints.\n\n IMPRESSION:\n\n No acute fracture. Degenerative changes as described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1215456,
"text": " 10:03 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest .\n\n CLINICAL HISTORY: 70-year-old man status post CABG. Evaluate for pleural\n effusions.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is stable cardiomegaly. The right-sided catheter has been removed.\n There is some atelectasis or focal consolidation within the left base. There\n is a persistent left-sided pleural effusion; however, this is decreased since\n the previous study. Bony structures are intact aside for some median\n sternotomy wires.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2133-12-05 00:00:00.000",
"description": "Report",
"row_id": 93711,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/O Tamponade\nHeight: (in) 62\nWeight (lb): 130\nBSA (m2): 1.59 m2\nBP (mm Hg): 105/60\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 12:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nSeverely depressed LVEF. [Intrinsic LV systolic function likely depressed\ngiven the severity of valvular regurgitation.] No resting LVOT gradient.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis. [Intrinsic RV systolic function likely more depressed given the\nseverity of TR].\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe\n[3+] TR. Mild PA systolic hypertension. Given severity of TR, PASP may be\nunderestimated due to elevated RA pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. Overall left ventricular systolic function is severely\ndepressed (LVEF= 15-20%). [Intrinsic left ventricular systolic function is\nlikely more depressed given the severity of valvular regurgitation.] The right\nventricular cavity is moderately dilated with moderate global free wall\nhypokinesis. [Intrinsic right ventricular systolic function is likely more\ndepressed given the severity of tricuspid regurgitation.] The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nModerate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. [In the setting of at\nleast moderate to severe tricuspid regurgitation, the estimated pulmonary\nartery systolic pressure may be underestimated due to a very high right atrial\npressure.] There is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (TEE - report reviewed) of and with\nTTE done , overall systolic function is similar. The function of the\ninferior wall is near-akinetic on all studies. The current degree of mitral\nregurgitation has increased in comparison to prior. There is a trivial\neffusion seen without evidence of tamponade.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2133-12-03 00:00:00.000",
"description": "Report",
"row_id": 93712,
"text": "PATIENT/TEST INFORMATION:\nIndication: CABG\nStatus: Inpatient\nDate/Time: at 16:36\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild spontaneous echo contrast in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right shunt across\nthe interatrial septum at rest.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nPre-CPB:\nMild spontaneous echo contrast is present in the left atrial appendage.\nA patent foramen ovale is present. A left-to-right shunt across the\ninteratrial septum is seen at rest.\nOverall left ventricular systolic function is severely depressed (LVEF= 10 -\n15 %), with septal, lateral and anterior hypokinesis, and inferior akinesis.\nThere is mild echo contrast in all .\nThere is mild global free wall hypokinesis.\nThere are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened. There is no aortic valve\nstenosis. No aortic regurgitation is seen.\nThe mitral valve leaflets are moderately thickened. Mild to moderate (+)\nmitral regurgitation is seen.\nThere is no pericardial effusion.\nThere is a small left pleural effusion.\nThe tip of the SGC is at the PA bifurcation.\n\nPost-CPB:\nThe patient is AV-Paced, on infusions of epinephrine and nitroglycerine.\nRV systolic fxn is unchanged.\nThe LV is slightly improved, with all walls moving slightly better than\npre-bypass. EF is now 15 - 20%.\nThe PFO is unchanged.\nMR is trace - 1+. No AI. Aorta intact.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2133-12-02 00:00:00.000",
"description": "Report",
"row_id": 93713,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Pre-Op CABG\nHeight: (in) 70\nWeight (lb): 150\nBSA (m2): 1.85 m2\nBP (mm Hg): 134/50\nHR (bpm): 57\nStatus: Inpatient\nDate/Time: at 11:34\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Location corrected. No changes made in findings. WJM\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severe\nregional LV systolic dysfunction. No LV mass/thrombus. TDI E/e' >15,\nsuggesting PCWP>18mmHg. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic; mid anterolateral - hypo; inferior apex - akinetic;\napex - akinetic;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Calcified tips of\npapillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is moderately dilated. There is\nsevere regional left ventricular systolic dysfunction with focal akinesis of\nthe inferior and inferolateral walls. There is hypokinesis of the remaining\nsegments (LVEF = <20 %). Tissue Doppler imaging suggests an increased left\nventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is\nmildly dilated with mild global free wall hypokinesis. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. There is no mitral valve prolapse. Trivial mitral regurgitation is\nseen. The estimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nIMPRESSION: Moderately dilated left ventricle with severe regional and global\nsystolic dysfunction. Mild right ventricular dilation and free wall\nhypokinesis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-02 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1214081,
"text": " 9:14 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: PREOP CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man preop CABG\n REASON FOR THIS EXAMINATION:\n eval for stenosis\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID DOPPLER ULTRASOUND\n\n INDICATION: Preoperative evaluation prior to CABG.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral carotid\n arteries were obtained.\n\n FINDINGS: Mild heterogeneous plaque is seen along the proximal right internal\n carotid artery. Significant heterogeneous plaque is seen along the left\n carotid bulb and the proximal internal carotid artery. The peak systolic\n velocity in the right internal carotid artery ranges from 93 to 124 cm/sec,\n and along the left internal carotid artery ranges from 52 to 253 cm/sec. The\n peak systolic velocity in the right common carotid artery is 70 cm/sec and in\n the left common carotid artery 71 cm/sec. Bilateral external carotid arteries\n are patent. There is antegrade flow in the bilateral vertebral arteries. The\n ICA/CCA ration on the right is 1.7 and on the left 3.6.\n\n IMPRESSION: 70-79% stenosis in the left internal carotid artery and 40-59%\n stenosis in the right internal carotid artery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1214324,
"text": " 6:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CARDIAC SURGERY FAST TRACK EXTUBATION. eval for ptx, effusio\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n CARDIAC SURGERY FAST TRACK EXTUBATION. eval for ptx, effusions. cvicu provider\n is , please page her if there is concern with findings\n ______________________________________________________________________________\n WET READ: 11:38 PM\n Lines and tubes appropriate. Note enteric tube w side port above GEJ. Likely\n small left effusion and retrocardiac atx. Trace interstitial edema.\n Postoperative mediastinal prominence. - \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:44 P.M., \n\n HISTORY: Cardiac surgery. Evaluate for complications.\n\n IMPRESSION: AP chest compared to preoperative chest radiograph on :\n\n Mild pulmonary edema has improved. Moderate cardiomegaly is comparable to the\n preoperative appearance. Only mild postoperative mediastinal widening is\n evident. ET tube, nasogastric tube, Swan-Ganz catheter, midline and pleural\n drains are in standard placements. Moderate left lower lobe atelectasis is\n unchanged since the preoperative study. There is no apparent pneumothorax or\n appreciable pleural effusion though some pleural effusion is presumed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1214373,
"text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p cabg with tiny right ptx on cxr\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG with tiny right pneumothorax.\n\n PORTABLE AP CHEST RADIOGRAPH.\n\n COMPARISON: Chest radiographs from and .\n\n FINDINGS: The patient has been extubated. The tip of a Swan-Ganz catheter is\n in the right main pulmonary artery. Two mediastinal drains and a left-sided\n chest tube are unchanged. No pneumothorax is present. Left basilar\n consolidation and effusion have increased. Mild interstitial edema is stable.\n Moderate cardiomegaly and mediastinal widening is unchanged.\n\n IMPRESSION:\n\n 1. No pneumothorax.\n\n 2. Extubation accounts for increased basilar atelectasis and effusions.\n Stable mild interstitial edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-01 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1214010,
"text": " 6:15 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man preop CABG\n REASON FOR THIS EXAMINATION:\n eval preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation for CABG.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: The heart size is mildly enlarged. The\n aorta is slightly unfolded. There is mild perihilar haziness with vascular\n indistinctness and Kerley B lines compatible with mild interstitial pulmonary\n edema. Patchy opacity in the retrocardiac region may reflect atelectasis. A\n trace left pleural effusion is likely present. No pneumothorax is identified.\n There are no acute osseous abnormalities.\n\n IMPRESSION: Mild congestive heart failure with retrocardiac atelectasis and\n probable trace left pleural effusion.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1214627,
"text": " 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 12:06\n\n CLINICAL INDICATION: 70-year-old with CABG, evaluate for pleural effusions.\n\n Comparison to at 16:05.\n\n Portable chest film at 12:06 is submitted.\n\n IMPRESSION:\n\n 1. Stable enlarged cardiac contour and stable postoperative appearance to\n mediastinum in this patient status post median sternotomy for CABG. There are\n bilateral layering pleural effusions, left greater than right and patchy\n bibasilar airspace disease more pronounced in the retrocardiac vicinity which\n most likely represents compressive atelectasis although pneumonia cannot be\n excluded. The pulmonary vascularity appears somewhat more ill-defined on the\n current study which also raises concern for superimposed interstitial edema.\n Clinical correlation is advised.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1214474,
"text": " 5:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST FILM, AT 1605 HOURS\n\n CLINICAL INDICATION: A 70-year-old status post chest tube removal, rule out\n pneumothorax.\n\n Comparison is made to the patient's previous study of at 0738\n hours.\n\n Single portable AP upright chest film, at 1605 hours is submitted.\n\n IMPRESSION:\n\n 1. Status post median sternotomy for CABG with overall stable\n cardiomediastinal postoperative contours. Right internal jugular introducer\n remains in place with interval removal of the Swan-Ganz catheter, left basilar\n chest tube, the mediastinal drains. Right lung is grossly clear. Left lung\n demonstrates probable pleural effusion and airspace opacity which may\n represent atelectasis and/or pneumonia. Clinical correlation is advised. No\n pneumothorax. No evidence of pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1214723,
"text": " 11:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for wheezing\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for wheezing\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:14 A.M. \n\n HISTORY: CABG. Evaluate for wheezing.\n\n IMPRESSION: AP chest compared to through 6:\n\n Previous mild pulmonary edema and small right pleural effusion have decreased\n since . Moderate cardiomegaly is stable. Small left pleural\n effusion and mild left lower lobe atelectasis have also improved. Right\n jugular line ends just above the clavicle in the right neck, as before. No\n pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-12-04 00:00:00.000",
"description": "Report",
"row_id": 251029,
"text": "Sinus rhythm. Possible left atrial abnormality. Left bundle-branch block with\nST-T wave change. No previous tracing available for comparison.\n\n"
}
] |
11,190 | 100,121 | Respiratory: He remained stable in room air throughout hospitalization. He had no episodes of apnea or desaturations. | Tolvolume well. C/S for nrfht under GA. Min asp. Tol procedure well. Mom was given general anestheia. If unable tomake min - or dropping dstick consider NGT.#2 - G&D: Temps stable in open crib. ABD EXAM BENIGN. Infant had circ this am. Active bowel sounds.Will cont to monitor D/S ac and po feed as tol.Infant stable in OAC. AC D/S 59 and 74 while stillon D12W. Tolerating feedswell. Will cont to check ac D/S asordered. Requiring gavage this am for not making mins..A bdomen benign.SL jaundiced. waking q 3h. Bili to be checked.Continue as at presentwhile awaiting maturation of resp control and feeds. CONTINUEDEVELOPEMNTAL CARES. Largestool heme neg. Checked with NNP. IV started. Occassionally wakingearly. Guaic neg. NPNAddendum to earlier note. NeonatologyDoing well. VOIDING AND STOOLING WELL. Activeand alert w/cares. Attending aware. STOOL GUAIC NEG.D/S TODAY 77. Adequate dstickP. Will continue to offer po feeds Q4.G/D: Open crib, swaddled, temps are stable. Abdominal exam benign. Tolerating feeds at ad lib. Circumcised. Coordinated suck/swallow pattern. ABdomen soft, normal active bowel sounds. asked appr. LS clear. Remains in RA. today), bottling at each feeding. Instructed on temp taking and diaper changing. Awake at 2330 and took43cc. Abdomen soft, nondistended, normal active bowel sounds. Active bs. Abd soft active bowel sounds. A: bottling welltonight, needing some gavage. Vaseline gauzeapplied. were also shown circ care. Min of 73ccQ4hours is needed to meet min Infant has been takingbetween 60-75cc via bottle , remainder gavaged via NGT.Abdomen is soft, pink, active bowel sounds, no loops,voiding and stooling guiac neg stools. Ampi and gent d/c'd. A: DS stable P: Cont to mtr as advancement offeeds progress. Comfortable apeparing.Wt 2925 down 10. Benignabd exam. dischargeteaching done with . Tonewithin normal limits. Will repeat.Passed hearing.Potential for dc home in am if continues to take po well.COntineu as at present. Bottled well w/good coordination x 1 for 73cc. Dsticks stable. BBS =/clear. BBS =/clear. Wellcoordinated. P: Contdev supportive care.#1 FENs/o: DS 84, 57, 69 ac this shift. I have placed EIP & VNA options in record. continue toencourage po feedings.2: g/dtemps stable in an oac. Abd benign. Abd benign. Good intake through day. 24 cal. Maintaining temp. NeonatologyDoing well. NeonatologyDoing well. Comfortable apeparingContinues with drifts in saturations during bottling.Wt 2900 down 10 . TOnegood. D- Sticks today 76,90,68 . BS to be followed.Bili 10.2 this am. Abdominalexam benign; soft, +BS. Bottles well. Continue d/cteaching/ planning. Procedureal time out observed. Occasional mild desats (80s) w/bottle feeds - quick recovery. Remains in RA. REmains in RA. WIll follow.Off abx after 48 h r/o. Abdomen benign. Abdomen benign. No intervention required.Wt 2910 down 15. Perfusion good.FEN: Wt=2900g (- 10g). BS in 80s this am. NeonatologyREmains in RA. Each asking appropriatequestions. aga. Perfusion good.FEN: Wt=2910g (- 15g). fed infant. asking appropriate questions.updated by this rn. NP NOTEProcedure Note:UVC removal: centralaccess no longer needed. TF=min 140cc/kg/d (= 73cc q 4 h). ABdomen soft, nondistended, normal active bowel sounds. Plan toincrease Po/Pg feeds by 15cc/k/ and decrease IVF andmonitor Dsticks closely - keep above 60. will continue withcurrent plan and monitor closely.G/D: Infant is currently on open radiant warmer nested,temps are stable, infant is alert and active with cares,beginning to wake/demand feeds. P: Cont to wean UVC as ordered.#2 O: Remains nested on warmer. Neonatology Attending NoteDOL #9, CGA 35 wks.CVR: Remains in RA. Temp stable. Voiding but not stooled.Monitor ds.G/DInfant on open warmer. P:Support.#4 O: Blood cultures neg to date. sepsis: Continues on amp and gent for 48hour rule outsepsis. HCT and plts in careview, WNL. NPN 7a7pFENInfant remains NPO. Alert withcares. will continue tosupport and update family.Pot. wakng for cares.A/P: Cont to support dev.#3 :O: no contact this shift. NeonatologyDoing well. Plan to obtain 24hour lytes and DS with nextcares. Back under open warmer since UVC placed. DS NOC borderline, see careview. Willcont to support dev needs. Umbiline began and infant presently on 80 cc/k/d of D15. NNP Physical ExamPE: pink, jaundiced, AFOF, sutures override, breath sounds clear/equal with easy WOB, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with good tone. NNP ordered IVto be weaned by 1cc/h if DS>60. MAE, sucking on pacifier forcomfort. Abdomen soft, nondistended, normal active bowel sounds. P:Cont to assess.#3 O: Mom phoned for update. No murmur.Wt 3035 up 30. Infant cleaned with betadine and draped in a sterile fashion. PO feeds were20cc/k/d. Lytes & bili drawn. Remains on antibiotics. Abd full butsoft. Abdomen benign. A: Stable. Abd soft withactive bowel sounds & no loops. Stable in RA. Did have x 1 bolus NOC for low ds in additionto the one infant recieved shortly after birth. MAEs, FS&F. Will cont to monitor. ABD EXAM BENIGN. PKU done. NeonatologyDoign well. Abd benign. NPN Discharge note.Resp: RA. Circ site healed. VOIDING AND STOOLING WELL.STOOL GUIAC NEG.CIRCHEALED WELL. Neonatology Attending NoteDay 1RA. Wt 3125. On amp/gent. Cl and = BS. LS clear. REmains in RA. Abdomen soft, nondistended, with normal active bowel sounds. Stable.FEN: MIN 140cc/kg of E24. Passed repeat carseat done today.Parenting. CONTINUE DEVELOPMENTALCARES. Wakesfor feedings. Abd is soft and round with activebs.2. TF=min 140cc/k/dayBM24/E24. NPN 2300-07001. Abdomen benign.Ready for dcPMD to be contact.PAssed car seat and hearing. AGA. Willcontinue to offer bottle Q4hours, and gavage remainder untilstamina improves.G/D: Continues to have stable temps in open crib, activeand alert with cares, sleeps well between cares. Stable.CV: Pink, no murmur. is coordinated withfeeding, tired toward end of feeding. Aware infant can go home today. Voiding at 3.2. On radiant warmer.A/P:abx pending clinical course and cx resultsmonitor d/s closely, wean GFR as allowedinitiate enteral feeds Abd soft, +BS no loops or distention, vdg/stlgqs. HR 130-160s. D/C order in chart. Recent femoral line placement. Infant d/c home with . AGA.3. NPO. Info/copies given to . The bowel gas pattern is normal. The bowel gas pattern is normal. d/s 83,93,70. Voiding and stooling with eachdiaper change. HR 160-170's. Line adjustment. NPN DAYSALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON MINOF 130CC/K/D OF E24. Mother called x 2 and updated. 0.4CC. A: feeds improving. Equal air entry with clear breath sounds bilaterally. Good po intake, gaining wt.DEV: Temp stable in open crib. | 68 | [
{
"category": "Nursing/other",
"chartdate": "2127-05-30 00:00:00.000",
"description": "Report",
"row_id": 1836698,
"text": "Admission Note\nOb-\nPedi-unknown\n\n boy is the 3125 gram product of a 33 week gestation (EDC ) born to a 33 yo G1 P0 mom with PNS O+ antibody negative/ RPR NR/Rubella Immune/ Hep B negative/GBS negative\n\nPregnancy complicated by by hypertension.\n\nThe infant was born by emergent C-section because of NRFHR after a trial of induction of labor. He had Apgar scores of 4 (1min) 8 (5min). Mom was given general anestheia. He needed to have PPV in the delivery room for the first minute and a half of life.\n\nHe was brought to the NICU for further evaluation.\n\nExam-infant large for gestational age.\nweigth 2125 grams (>90%) HC 32.75 cm (90%) Length 48 cm (90%)\nTemp 98 HR 160 RR 44 sat 98% BP 86/37 mean 53\nHEENT-normocepahlic atraumatic ant font open flat red reflex present bilaterally\nneck supple\nlungs clear bilaterally\nCV regular rate and rhythm no murmur femoral pulses 2+ bilaterally\nAbd soft with active bowel sound no masses or distention\nEXt warm well perfused feet smooth c/w with a premature infant.\nAnus normally placed patent\nSpine midline\nHips stable\nClavicles intact\nNeuro good tone moved all extremities equally\n\nImp-infant LGA who is acting and more mature than his stated age.\nCV-stable currently will monitor\nRESP-in stable condition currently\nFEN-initial D-stick 7 repeat during the bolus 27 and after IVF started was 44. Will continue to monitor blood sugar.\nID-CBC and blood culture pending. Will not start ABX because no sepsis risk factors. Hypoglycemial likely due to LGA status\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-30 00:00:00.000",
"description": "Report",
"row_id": 1836699,
"text": "Admission Note\nInfant is a former 33 week male born to a 33 yr old G1 P0->1 female. Mom had h/o diabetes, mild PIH, and PROM since 0300 today. Mom was transferred in this am and was induced. C/S for nrfht under GA. Infant emerged floppy and required PPV briefly. Apgars = 4 and 8. Infant was shown to Dad in waiting room and was transported to NICU. Infant was placed on warmer and monitor. VSS. Breathing comfortably. CBC with diff and bld cx sent. D/S = 7. IV started. Infant then rec'd 6cc D10 bolus. IVF started at 60cc/k/day = 7.8cc/hr. Repeat d/s was 44. Attending aware. meds given.\nResp: Infant is in RA with RR=40-70's. LS clear. No retractions.\nCV: BP stable. HR= 150-160's. Pink.\nFEN: BW: 3125gms. TF=60cc/k/day. D/S = 7, 27, 44. No void or stool yet. Active bs. Check d/s per protocol.\nG&D: Temps stable nested in sheepskin on servo warmer. Very active and alert.\nParents: Dad held infant briefly. Mom has not been in yet.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-05 00:00:00.000",
"description": "Report",
"row_id": 1836732,
"text": "Attending Note\nDay of life 6 PMA 34 \nin room air RR 40-60 sat above 92% no brady or desats\nHR 120-140 BP 71/48 mean 56\nweight 2925 up 15 on min 140 cc/kg/day if po or min 150 cc/kg/day if pg PE or BM 20 cal/oz\nvoiding and stooling heme negative\nattempted breast but did not do well\ncirc healing well\nawakes for feeds\n visiting\n\nImp-stable doing well\nwill have a minimum of 140 cc/kg/day\nwill advance to 24 cal/oz feeds\nwill change to enfamil 24 cal/oz\nWill consider discharge early next week\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-07 00:00:00.000",
"description": "Report",
"row_id": 1836742,
"text": "NPN days\n\n\nFEN: infant on MIN of 130cc/k/d of E24/BM24, PO fed with\neach care, taking 35-75cc, gavaged remainder of feeding when\nunable to meet minimum. Abdomen is soft, pink, active bowel\nsounds, no loops. Voiding and stooling guiac neg yellow\nstools. No spits. Minimal residuals. Tolerating feeds\nwell. Bottling well, coordination is good, tires at end of\nfeeds. Will continue to offer po feeds Q4.\n\nG/D: Open crib, swaddled, temps are stable. Active and\nalert with cares, wakes and demands feedings. MAE, brings\nhands to mouth, sucks on hands and pacifier for comfort.\nAGA. Will continue to support developmental needs.\n\n: no contact with family today. will continue to\nupdate and support family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-05 00:00:00.000",
"description": "Report",
"row_id": 1836733,
"text": "NICU Fellow Physical Exam\nPlease see attending note for clinical course and plan.\n\nAsleep, supine\n2925g up 15 p120-140 71/48 mean 56 r40-60 RA\n\nanterior fontanelle soft, open and flat. Equal air entry with clear breath sounds bilaterally. Regular rhythm with normal rate, no murmur. Abdomen soft, nondistended, normal active bowel sounds. Warm, pink. 2+ femoral pulses bilaterally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-05 00:00:00.000",
"description": "Report",
"row_id": 1836734,
"text": "NPN days\n\n\nFEN: Total fluids Min of 140cc/k/d of PE24/BM24(increased\ncals/oz. today), bottling at each feeding. Min of 73cc\nQ4hours is needed to meet min Infant has been taking\nbetween 60-75cc via bottle , remainder gavaged via NGT.\nAbdomen is soft, pink, active bowel sounds, no loops,\nvoiding and stooling guiac neg stools. Bottles well,\ncoordinated, no choking or spitting. Residuals minimal.\nTolerating feeds, will continue with current feeding plan,\nand monitor for signs or symptoms of feeding intolerance.\n\nG&D: Infant is in an open air crib, swaddled, maintains\ntemperatures. Alert and active with cares, sleeps well\nbetween and wakes/ demands feedings ~4hours. MAE, brings\nhands to face, sucks on pacifier/hands for comfort. AGA.\nwill continue to support developmental needs.\n\n: no contact with family today, will continue to\nsupport and update family.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-06 00:00:00.000",
"description": "Report",
"row_id": 1836735,
"text": "#1FEN\nWt 2.965 up 40g. waking q 3h. Checked with NNP. TF now\nmin 120c/kg. bottled 65 at . Awake at 2330 and took\n43cc. At 0230 took 55cc. Abd soft active bowel sounds. Void.\nLiquidy yellow stool which was heme neg. Min asp. No spits.\nDstick 73 prior to feed at 0230.\nA. Bottling all feeds. Monitoring to see if can make\nthe min 120cc/kg. Adequate dstick\nP. Cont to monitor po feed ability. Monitor weight gain on\n24 cals.\n#2Dev\nTemp stable in an open crib. awakening q3-3.5 hours.\n#3Parenst\nMom called for an update. Pleased with progress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-06 00:00:00.000",
"description": "Report",
"row_id": 1836736,
"text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable apeparing.\n\nWt 2965 up 40. Tolerating feeds at ad lib. Requiring gavage this am for not making mins..A bdomen benign.\n\nSL jaundiced. Bili to be checked.\n\nContinue as at presentwhile awaiting maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-06 00:00:00.000",
"description": "Report",
"row_id": 1836737,
"text": "NICU Fellow physical exam\nPlease see attending note for hospital course and plan\n\nsupine in open crib\n\n2965g p140-150 mean 58 r30-60 RA\nanterior fontanelle soft open and flat. Equal air entry with clear breath sounds bilaterally, no distress. Regular rhythm with normal rate, no murmur. ABdomen soft, normal active bowel sounds. Normal circumcised phallus with testes descended. Warm, pink. 2+ femoral pulses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-04 00:00:00.000",
"description": "Report",
"row_id": 1836730,
"text": "NPN DAYS\n\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON MIN\nO F 140C/K/D WHEN BOTTLING FULL FEEDS 73CC, AND 150CC WHEN\nNEEDS TO BE GAVAGED 78CC, OF PE20. ABD EXAM BENIGN. NO\nLOOPS, NO SPITS. VOIDING AND STOOLING WELL. STOOL GUAIC NEG.\nD/S TODAY 77. BOTTLED 45CC AT 8AM, THE REST OF FEEDING\nGAVAGED. BOTTLED 73CC AT 12PM. WILL OFFER BOTTLE AGAIN AT\n4PM. CONTINUE CURRENT FEEDING PLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nSUCKS ON PACIFER. WAKING AND DEMANDING SOME FEEDS. CONTINUE\nDEVELOPEMNTAL CARES. WILL DO HEARING SCREEN WHEN IS ALL\nPO.\n\nALT IN PARENTING:MOM CALLED FOR UPDATE THIS MORNING. SHE\nWILL BE IN TO VISIT LATER TODAY, BUT DOES NOT KNOW WHEN.\nCONTINUE TO SUPPORT AND UPDATE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-05 00:00:00.000",
"description": "Report",
"row_id": 1836731,
"text": "NPN Nights 7pm-7am\n\n\n#1 O: Wgt 2925g, ^15g. TF min of 140 (150 if needing\ngavage), BM 20 or Pe 20. Infant went to breast for the\n time this evening - lathced on briefly with minimal\nsucking then bottled 30cc, with remainder of volume gavaged.\n At 12am feeding infant bottled well and took 75cc. Abd\nremains soft, +bs, no loops. Voiding adeq amts. Large\nstool heme neg. Circ site intact, no redness or bleeding\nnoted, exudate noted and vaseline applied. A: bottling well\ntonight, needing some gavage. P: Continue to encourage po\nintake and moniter circ site.\n#2 O: Infant alert and active with cares. Waking self for\ncares at ~ 4 hours. Temp stable in open crib. Bottling\nwell tonight and went to breast for the first time tonight.\nA: AGA, working on po feeding skills.\n#3 O: Infant's were in during the evening portion of\nthe shift. RN showed them how to take infant's temp and\ndemonstrated circ care. mom with breastfeeding and\nhelped dad with positioning of infant for bottling. \nasked appr. questions. Given circ care handout, Back to\nSleep Brochure and written Breast Milk and Pumpimg info.\nA: involved and invested . P: Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836717,
"text": "nicu fellow physical exam\nplease see attending note for clinical course and plan\n\n2925g down 10g\np130-160 r30-40 RA\n\nanterior fontanelle soft open and flat. Equal air entry with clear breath sounds bilaterally. Regular rhythm and normal rate, no murmur. Abdomen soft, nondistended. Circumcised. 2+ femoral pulses. Warm, pink.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-03 00:00:00.000",
"description": "Report",
"row_id": 1836722,
"text": "SOCIAL WORK\nFamily meeting held today with , nnp, nursing and social work. Infant's current status reviewed, care plan and criteria for d/c discussed. asked several appropriate questions and appear to have good understanding of information offered to them. Mum being d/c'd today, feeling positive about the care her is receiving. informed about parking stickers available to them. They are adjusting well to premature delivery which requires current admission. Will remain available to them. Please call should additional questions arise.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-03 00:00:00.000",
"description": "Report",
"row_id": 1836723,
"text": "Nursing Progress Note:\n#1 - F&N: TF at min of 140cc/kilo = 73cc's q 4 hours of\nBM/PE20. IVF shut off this afternoon at ~11am. Bottled\n65cc, 72cc then 50cc's thus far today. Occassionally waking\nearly. Abdominal exam benign. Soft and round. Voiding and\nstooling. Guaic neg. Dsticks today 75 and 70. If unable to\nmake min - or dropping dstick consider NGT.\n\n#2 - G&D: Temps stable in open crib. Alert and active with\ncares. MAE. AFSF. bottling all feeds. Waking for feeds.\n\n#3 - : Mom and Dad in today. Updated at the bedside.\nAlso had family meeting. Mom discharged home today.\nPumping. Plan to call to let us know when they will be in.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-03 00:00:00.000",
"description": "Report",
"row_id": 1836724,
"text": "Neonatology-NNP PRogress Note\n\nPE: remains in his open cirb, in room air, bbs cl=, rrr s1s2no murmur, abd soft, nontender, V&S, afso, active, piv in place\n\nSee attending note for plan\n\nTeam met with to review clinical issues and expected NICU course. are quiet pleased with and his progress, will continue to keep informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836718,
"text": "NPN\n\n\nInfant currently on TF 140cc/kg/day. At present infant is\nreceiving 80cc/kg via po feeds, SC20, 41ml q4 hours. Tol\nvolume well. Small spit x1. PIV in left hand infusing D10W\nw/lytes @ 60cc/kg/day. Order written to inc po feeds by\n15cc/kg . Next due at 20:30. AC D/S 59 and 74 while still\non D12W. Fluid changed at 1500. Will cont to check ac D/S as\nordered. Voiding large amts but volume inaccurate d/t\npassing mec stool as well. Abd soft. Active bowel sounds.\nWill cont to monitor D/S ac and po feed as tol.\nInfant stable in OAC. Sleeping well between feeds. Active\nand alert w/cares. Coordinated suck/swallow pattern. Brief\nQSR drifts in O2 sats x2 while feeding. No color change or\nHR drop. Infant had circ this am. Tol procedure well. Site\nnoted to have small amt bright red bleeding. Vaseline gauze\napplied. Tylenol ordered prn for discomfort.\nCont to monitor site for excessive bleeding. Assess pain.\nNo contact from thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836719,
"text": "NPN\nAddendum to earlier note.\n and MGM in for visit. Instructed on temp taking and diaper changing. were also shown circ care. Mom is for daycare provider but of older children. Requested reenforcement of teaching needs. Mom held and fed infant. Infant fed well. Dad held infant pc. Sleeping at present.\nCont to support and prepare for discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-03 00:00:00.000",
"description": "Report",
"row_id": 1836720,
"text": "NPN:\n\nRESP: Sats 93-98% n RA. RR=40-50s w/SC retraction. BBS =/clear. No spontaneous desats or A&Bs thus far tonight; no A&Bs over past 24 h. Occasional mild desats (84-85) w/bottle feeds.\n\nCV: No murmur. HR=150-160s. BP=88/51 (65). Color pink w/jaundice. Perfusion good.\n\nFEN: Wt=2910g (- 15g). TF=140cc/kg/d. Enteral feeds @ 95cc/kg/d; IV of D-10-W w/NaCl 1mEq, KCl 1mEq/100cc @ 45cc/kg/d. Bottling well w/good coordination for 49cc SC-20 q 4 h. Feedings increased 15cc/kg as tolerated. Abd benign. U/O=2.7cc/kg/h over 24-h period yesterdat; voiding well tonight. Green stool. Dx=69. Elec: 144/ 4.7/ 107/ 21.\n\nBILI: Bili 10.5/ 0.3/ 10.2 (up from 10.2).\n\nG&D: CGA=34 wk. Temp stable in crib. Active and alert w/good tone. Waking for feeds and bottling well. Vaseline applied to circ site w/each diaper change; circ site healing well. Swaddled, nested and resting well.\n\nSOCIAL: No contact w/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-03 00:00:00.000",
"description": "Report",
"row_id": 1836721,
"text": "Neonatology\nDoing well. Remains in RA. COmfortable appearing. No evidence of PDA. Occasional sats in sats noted. No intervention required.\n\nWt 2910 down 15. Tolerating feeds at 110 out of TF 140 cc/k/d. Abdomen benign. Lytes in good range. Feeding volume advance to be continued.\nWill allow ad lib feeds.\n\nBili in 10 range. WIll recheck in two days or earlier as needed.\n\nSpoke with family at bedside yesterday. Will arrange family meeting.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-04 00:00:00.000",
"description": "Report",
"row_id": 1836725,
"text": "NPN:\n\nRESP: Sats 92-98% in RA. RR=40-50s w/SC retraction. BBS =/clear. Occasional mild desats (80s) w/bottle feeds - quick recovery. No spontaneous desats or A&Bs over past 24 h.\n\nCV: No murmur. HR=160-170. BP=83/43 (55). Color pink w/jaundice. Perfusion good.\n\nFEN: Wt=2900g (- 10g). TF=min 140cc/kg/d (= 73cc q 4 h). NG placed due to inability to take minimum volume last eve. Bottled well w/good coordination x 1 for 73cc. No spits. Abd benign. Voiding and stooling.\n\nBILI: Bili 10.5/0.3 (); to recheck in ~ 2 days.\n\nG&D: CGA=34 wk. Temp stable in crib. Waking for most feeds. Active and alert w/good tone. Swaddled, nested and resting well.\n\nSOCIAL: No contact w/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-04 00:00:00.000",
"description": "Report",
"row_id": 1836726,
"text": "Neonatology\nFamily meeting held yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-04 00:00:00.000",
"description": "Report",
"row_id": 1836727,
"text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable apeparing\nContinues with drifts in saturations during bottling.\n\nWt 2900 down 10 . Tolerating feeds at ad lib. Good intake through day. required NG feeds last night and this am.\n\nBili 10.5 range yesterday.\n\nHBV given yesterday.\n\nCOntinue to await maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-04 00:00:00.000",
"description": "Report",
"row_id": 1836728,
"text": "Neonatology\nFamily meeting held yesterday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-04 00:00:00.000",
"description": "Report",
"row_id": 1836729,
"text": "NICU fellow physical exam\nPlease see attending note for clinical course and plan.\n\nAwake, alert\n140-170 50/42 man 47 r40-60 RA\nanterior fontanelle soft, open and flat. Equal air entry with clear breath sounds bilaterally. REgular rhythm with normal rate, no murmur. ABdomen soft, nondistended, normal active bowel sounds. 2+ femoral pulses bilaterally. Circumcised phallus, testes downgoing. Warm, pink.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-01 00:00:00.000",
"description": "Report",
"row_id": 1836710,
"text": "NPN days\n\n\nFEN: total fluids increased to 120cc/k/d , IVF currently at\n70cc/k/d of D12.5 (changed from D15 at 2pm) with 1/2 u\nheparin per cc infusing via single lumen UVC, and PO feeds\nat 50cc/k/d of SC20 or BM. Taking all feeds PO via bottle.\n28-30cc today. Coordinated with feedings, no choking or\nspits, no desats with feedings. Abdomen is soft,\npink,round, no loops, active bowel sounds, no spits. AG is\nstable at 29cm. D- Sticks today 76,90,68 . Voiding (urine\noutput 2.9cc/k/hour over last 12hours, but no stool since\ndelivery. Tolerating feeds well. Dsticks stable. Plan to\nincrease Po/Pg feeds by 15cc/k/ and decrease IVF and\nmonitor Dsticks closely - keep above 60. will continue with\ncurrent plan and monitor closely.\n\nG/D: Infant is currently on open radiant warmer nested,\ntemps are stable, infant is alert and active with cares,\nbeginning to wake/demand feeds. Sleeps well between cares.\nSucks on pacifier for comfort. will continue to suppport\ndevelopmental needs.\n\n: Father upx1, updated at bedside, Will continue to\nsupport and update family.\n\nPOt. SEpsis: infant has recieved 48hours of antibiotic\ntherapy, BC pending, will check for growth and if none will\ndc antibiotics per orders. No signs of infection noted.\nwill continue to monitor.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836711,
"text": "NP NOTE\nProcedure Note:\nUVC removal: centralaccess no longer needed. Procedureal time out observed. PIV established for running IVF.\nCord tie removed, edematous tissue surrounding cord stump. UVC removed without incident. hemostasis achieved with pressure for 30 seconds. Infant tolerated procedure well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836712,
"text": "#4 SEPSIS\ns/o:blood cx neg at 48 hrs. Ampi and gent d/c'd. A/P:REsolve\n#3 PARENT\ns/o:Both up-- mom held son. Each asking appropriate\nquestions. A: Invested . P: Cont support.\n#2 G&D\ns/o: Transistioned to open crib. Maintaining temp. TOne\ngood. Alert with care. Bottles well. A: 34 + wks. P: Cont\ndev supportive care.\n#1 FEN\ns/o: DS 84, 57, 69 ac this shift. TF remain at 120cc/k/d.\nIVF of D12.5 at 55 cc/k/d while enteral feeds advanced to\n65 cc/k/d-- all bottle. Taking SC 20 well- no emesis. Benign\nabd exam. VOid and stool qs. UVC removed without incident by\nNNP at 4 aM. A: DS stable P: Cont to mtr as advancement of\nfeeds progress.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836713,
"text": "Neonatology\nLytes to be checked in am to fu on NA 147.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836714,
"text": "Neonatology\nREmains in RA. No spells. Comfortable apeparing.\n\nWt 2925 down 10. Tolerating feeds at 80 cc/k/d out of TF 120 cc/k/d. BS in 80s this am. Abdomen benign. Taking enteral voluems all po. Will increase to 140 cc/k/d and increase feeds as tolerated to full volumes. BS to be followed.\n\nBili 10.2 this am. Not under phtoorx. WIll follow.\n\nOff abx after 48 h r/o.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836715,
"text": "Neonatology\nLytes to be checked in am to fu on NA 147.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-02 00:00:00.000",
"description": "Report",
"row_id": 1836716,
"text": "Case Management Note\nChart has been reviewed and events noted. I have placed EIP & VNA options in record. I will cont to follow and assist w/any d'c needs w/team and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-10 00:00:00.000",
"description": "Report",
"row_id": 1836753,
"text": "npn 1900-0700\n\n\n1: fen\ncurrent weight 3070gms up 20gms. total fluids remain at\n150cc/kilo/day of bm/e24 cals. infant waking q 3-4 hours.\ninfant taking 60-70cc thus far this shift. infant voiding,\nno stool. no spits. abd soft with no loops. continue to\nencourage po feedings.\n\n2: g/d\ntemps stable in an oac. alert and active with cares. sleeps\nwell inbetween. brings hands to face. wakes for feedings.\nsucks vigorously on pacifier. aga. continue to monitor for\ndevelopmental milestones. infant failing car seat test this\nshift. infant had a prolonged dsat to 84%.\n\n3: \nmom and dad in for visit. fed infant. discharge\nteaching done with . asking appropriate questions.\nupdated by this rn. continue to support family needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-10 00:00:00.000",
"description": "Report",
"row_id": 1836754,
"text": "Neonatology Note\nDol 11 CGA 35 \n\nResp: in room air, bbs Cl=, no apnea or bradycardia No murmur.\n\nWT 3070 up 20. Tolerating feeds at ad lib. 24 cal. Abdomen benign.\n\nFailed car seat test last night. Will repeat.\nPassed hearing.\n\nPotential for dc home in am if continues to take po well.\n\nCOntineu as at present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-10 00:00:00.000",
"description": "Report",
"row_id": 1836755,
"text": "Nursing Progress Note:\n\nFEN:\nO: Infant receiving 150cc/kg of BM/E 24 with enfamil powder,\n(=78cc q4h, 59cc q3h). Infant has been waking about every\n3-4 hours. Taking 70-90cc with each feed. Infant presents\nwith a strong suck reflex, and is eager to feed. Well\ncoordinated. No spits noted so far this shift. Abdominal\nexam benign; soft, +BS. Infant voiding and passing some\ntrace + stool. Stool yellow, seedy, with each care. No frank\nblood. ? Fissure.\nA: Infant tolerating feeds well. No signs of distress.\nP: Continue to advance po feeds as tolerated by infant.\nContinue to test stool for trace +.\n\nDEV:\nO: Infant temp stable; swaddled in an OAC. Font s/f. Infant\nalert and active with cares; waking for all feeds. Tone\nwithin normal limits. Infant brings hands to face and\nattempts to hold pacifier in mouth. Sleeps well between\ncares.\nA: Appropriate behavior for gestational age.\nP: Continue to support development. Repeat carseat test\ntonight. Pending discharge tomorrow.\n\nSOC:\nO: Mom called x1 this shift. Updated by RN regarding\ninfant's status and plan of care. Due in at 1600. Aware of\npending d/c tomorrow.\nA: Mom involved in infant care.\nP: Continue to support, and keep informed. Continue d/c\nteaching/ planning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-10 00:00:00.000",
"description": "Report",
"row_id": 1836756,
"text": "Nursing Progress Note\n\n\nAgree with above note written by Co, worker. This\nRN examined infant.\nMother called, briefly updated over phone. Informed mother\nthat infant may be able to go home tomorrow if he continues\nto eat well. Informed mother of failed car seat test.\nMother aware that infant will need repeat car seat testing\nnad possible need for car bed. Also, mother aware that\ninfant should not be in bouncy chair/swing when unattended\nat home d/t failure of car seat testing.\nCalled , case manager to place referral for VNA.\nStarted VNA, placed in d/c section of chart.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-10 00:00:00.000",
"description": "Report",
"row_id": 1836757,
"text": "Nursing Progress Note\nInfant has guiac positive stools, notified MD . No visible break down on bottom. Will cont to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-31 00:00:00.000",
"description": "Report",
"row_id": 1836706,
"text": "NPN days\n\n\nFEN: Total fluids increased to 100cc/k/d, IVF remains at\n80cc/k/d = 10.4cc/hour, D15 with heparing 0.5u/cc via UVC.\nEnteral feeds started at 1300, at 20cc/k/d of SC20/BM20 =\n11cc Q4hours , bottled full amt - infant was coordinated\nwith feeding, no choking, no spiting, no desats. Abdomen is\nsoft, pink,with active bowel sounds, no loops. Voiding , no\nstool as yet. Urine output 5cc/k/hour over last 8hrs.\nDStick this am 70 and 83 at 1300. Will continue to monitor\nclosely. Plan to obtain 24hour lytes and DS with next\ncares. Monitor for signs or symptoms of feeding\nintolerance, or low glucose.\n\nG/D: Infant with stable temps on radiant warmer, nested.\nActive and alert with cares. MAE, sucking on pacifier for\ncomfort. Brings hands to face. Fontonelles are soft and\nflat. AGA. Will continue to support developmental needs.\n\n: mother and father up for visit today, updated at\nbedside. Asking appropriate ?'s. mother plans to start\npumping today. Involved and loving family. will continue to\nsupport and update family.\n\nPot. sepsis: Continues on amp and gent for 48hour rule out\nsepsis. BC pending, no signs or symptoms of infection.\nwill continue to monitor, and check BC results.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-01 00:00:00.000",
"description": "Report",
"row_id": 1836707,
"text": "Nursing progress note\n\n\n#1 O: Received on total fluids of 100cc/k/d. UVC of\nD15W w/hep was infusing at 80cc/k/d. PO feeds were\n20cc/k/d. Initial ds was 67. PO taken well. NNP ordered IV\nto be weaned by 1cc/h if DS>60. DS has been 70 & 79. UVC is\npresently at 57cc/k/d & po feeds are at 43cc/k/d. Wgt is\ndown 195 gms. UOP was 4.2cc/k/h. No stool. Abd soft with\nactive bowel sounds & no loops. Lytes & bili drawn. A:\nResolving hypoglycemia. P: Cont to wean UVC as ordered.\n#2 O: Remains nested on warmer. Temp stable. Alert with\ncares. PO feeds taken well with yel nipple. A: Stable. P:\nCont to assess.\n#3 O: Mom phoned for update. A: Appropriate concerns. P:\nSupport.\n#4 O: Blood cultures neg to date. Remains on antibiotics. A:\nSepsis suspect. P: Antibiotics as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-08 00:00:00.000",
"description": "Report",
"row_id": 1836747,
"text": "NPN Days\nADDENDUM:\nParenting: mother in for 4p cares, infant bathed (keeping umbilical cord dry) hair washed etc, with mother. Mother breastfed infant with good latch and suck, infant tired after 10min, bottled by mother after this, and remainder gavaged. Mother continues to have trouble with breast pump at home (not strong enough). Told mother that she should speak to a lactation consultant monday and perhaps change types of breastpump that she has at home. She will follow up tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-09 00:00:00.000",
"description": "Report",
"row_id": 1836748,
"text": "NPN\n\n\n#1 FEN:\nO: Wt, 3.050 (+ 30 gms) On 150cc/k/d BM 24/ E24. Abd. soft,\nactive BS, No loops. Bottled all feeds well, no spits.\nVoiding qs, no stools\nA: Adequate nutritional support for wt gain\nP: Cont to feed and offer po.pg prn\n\n#2 G@D:\nO: Temps stable in open crib, MAE, AFSOF. wakng for cares.\nA/P: Cont to support dev.\n\n#3 :\nO: no contact this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-09 00:00:00.000",
"description": "Report",
"row_id": 1836749,
"text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable apeparing. No murmur.\n\nWt 3035 up 30. Tolereating feeds at 150 cc/k/d of 24 cal. Abdomen benign. requiring some gavage. Not quite able to maintain full inatke. Will follow over coming days.\n\nContinue to await maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-09 00:00:00.000",
"description": "Report",
"row_id": 1836750,
"text": "NICU Fellow Physical Exam\nPlease see attending note for clinical events and plan\n\nSupine in open crib\n3035g up 30g hr 160s 70/47 mean 61 r40-50 RA\n\nanterior fontanelle soft open and flat. Equal air entry with clear breath sounds bilaterally, no retractions. Regular rhythm with normal rate, no murmur. Abdomen soft, nondistended, normal active bowel sounds. 2+ femoral pulses, warm, pink. Normal tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-09 00:00:00.000",
"description": "Report",
"row_id": 1836751,
"text": "Nursing Progress Note\n\n\nFEN: Infant is bottling ~ 150cc/kg/d E24. Tolerating\nfeedings, no spits. Infant takes about 45 min to finish\nbottle. Infant is waking about every 3.5 hrs for feedings.\nAbd exam benign. Voiding QS, passing stools. Plan to cont\nto encourage PO feedings, monitor for need to replace feding\ntube (feeding tube out on arrival).\n\nG/D: Temps stable swaddled in crib. Infant is waking for\nfeedings. infant is active and alert with cares and\nsleeping well btn feedings. Passed hearing screen. Will\ncont to support dev needs.\n\n: Father called, updated over phone. Informed\nfather that feeding tube has been out since last night.\n father of times infant has been eating. Father\nasking if infant eats at night. Informed father that infant\nfeeds at leas every 4 hrs, about feedings a day but at\nhome could go for a max of 5 hrs at night (for now). Father\nstated that mother would be in for 1200 cares but she did\nnot come. Father called from work. D/C teaching to be done\nwhen visit.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-09 00:00:00.000",
"description": "Report",
"row_id": 1836752,
"text": "Nursing Progress Note\nAddendum:\nMother in for 1600 cares, visiting with her twin brothers and her sister-in-law. Difficult to do much teaching with visitors. Mother plans to visit again at 2000cares. Demonstrated mixing 24 calorie milk, mother returned . Started d/c teaching with mother. cont to educate and support. Informed mother that infant may possibly go home this week if he continues to eat well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-30 00:00:00.000",
"description": "Report",
"row_id": 1836700,
"text": "1 FEN\n2 G&D\n3 Parents\n\nREVISIONS TO PATHWAY:\n\n 1 FEN; added\n Start date: \n 2 G&D; added\n Start date: \n 3 Parents; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-31 00:00:00.000",
"description": "Report",
"row_id": 1836701,
"text": "procedure note\nProcedure UVC placement\nIndication need for central access because of hypoglycemia\nTime out to make sure correct patient and procedure\nInfant identified with two forms of ID\nCVR monitor and oximeter. Infant cleaned with betadine and draped in a sterile fashion. A 3.5 Fr single lumen UVC placed. Sutured in place a 10 cm. X-ray obtained showed line in good position. Infant tolerated procedure well with minimal blood loss. No complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-01 00:00:00.000",
"description": "Report",
"row_id": 1836708,
"text": "Neonatology Attending Progress Note\n\nNow day of life 2, CA weeks.\nRR 40-60s, in RA.\n1 episode of brief desaturation with feeding noted overnight.\nNo apnea and bradycardia noted.\nHR 120-140s BP 66/43 50\n\nWt. 2935 down 190gm on 100ml/kg/d TF - 50ml/kg/d of D15W and 50ml/kg/d of SSC20 - DS 76-90 most recently\nNormal urine output - 4.2ml/kg/hr.\n\nLytes - 147 5.4 110 22\n\nID - on ampicillin and gentamicin - blood culture is no growth so far\n\nBili 8.5/0.2\n\nAssessment/plan:\nPremature infant with history of hypoglycemia now resolved with IV dextrose treatment. Will wean IV dextrose and DC UV line later today if tolerated. Total fluids increased to 120ml/kg/d.\nWill encourage PO feedings breast and bottle.\n\nFU bili to checked tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-01 00:00:00.000",
"description": "Report",
"row_id": 1836709,
"text": "NNP Physical Exam\nPE: pink, jaundiced, AFOF, sutures override, breath sounds clear/equal with easy WOB, RRR, no murmur, normal pulses and perfusion, abd soft, non distended, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-08 00:00:00.000",
"description": "Report",
"row_id": 1836743,
"text": "NPN\n\n\n1. FEN: Wt 3.020kg ,up 20gr. On min. TF of 130cc/kg (68cc\nq4hr)of BM/Enf 24 cals, taking 35-50cc overnight the rest\ngiven gavage. Waking hungry prior to feeds, tiring towards\nend of feed, also needing some chin support to maintain\neffective sucking. Abd soft, benign, no spits, no aspirates,\nvoiding and stooling q diaper, heme neg.\nA/P; Tolerating feeds, having feeding immaturity, cont to\nwork on Po's/BF.\n\n2. G&D: Infant active and alert, waking prior to feeds,\nvigorously sucking on pacifier. Swaddled in crib, temps WNL,\nsleeping in between feeds.\nA/P: AGA, cont to suport developmental needs.\n\n3. : in this eve, holding , anxious for\nhim to come home. understand he needs to work on\neating better. Also, encouraged mom to come in for feeds and\nbreast feed. Pumping q3hrs, resting and drinking plenty of\nfluids was encouraged to promote better milk production.\nA/P; Informed first time , cont to support, provide\ninfo.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-08 00:00:00.000",
"description": "Report",
"row_id": 1836744,
"text": "Neonatology Attending Note\nDOL #9, CGA 35 wks.\n\nCVR: Remains in RA. No desats/spells, overall comfortable. Hemodynamically stable. No murmur.\n\nFEN: BW 3125. CW 3020 grams, up 20. TF 130 cc/kg/day, E24, PO/PG. Voiding/stooling.\n\nDEV: In open crib.\n\nPE: comfortable, active and interactive with exam. Skin warm and dry. Fontanelles soft and flat. Chest clear, no g/f/r. Cardiac RRR, no m. Abdomen soft, no HSM. Tone and activity grossly normal.\n\nIMP: Overall stable former 33+ wk infant, doing well. Stable in RA. Tolerating feeds, but still requiring PG feeds.\n\nPLANS:\n- Increase TF to 150.\n- Continue PG feeds as needed, advance PO as able.\n- Monitor for spells.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-31 00:00:00.000",
"description": "Report",
"row_id": 1836702,
"text": "NPN 7a7p\n\n\nFEN\nInfant remains NPO. DS NOC borderline, see careview. Umbi\nline began and infant presently on 80 cc/k/d of D15. Last 2\nds 83 and 93. Did have x 1 bolus NOC for low ds in addition\nto the one infant recieved shortly after birth. Abd full but\nsoft. Some bowel sounds present. Voiding but not stooled.\nMonitor ds.\nG/D\nInfant on open warmer. Temps are stable. Had been bathed and\nswaddled earlier in shift in anticipation of him going into\na crib. Back under open warmer since UVC placed. Alert and\nirritated with cares. Sucks on pacifier. MAEs, FS&F. Infant\nlooks and behaves older then 33/6. AGA. Monitor and support\nG/D.\n\nHave had no contact from this shift.\nsepsis\nInfant began on amp and gent near MN because of persistant\nlow ds at less then 24hrs old. No other risk factors noted.\nCBC resent after placement of UVC in lieu of mod bloody ooze\nat umbi site. HCT and plts in careview, WNL. Monitor for S&S\nof infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-31 00:00:00.000",
"description": "Report",
"row_id": 1836703,
"text": "4 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 4 Infant with Potential Sepsis; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-31 00:00:00.000",
"description": "Report",
"row_id": 1836704,
"text": "NNP Physical Exam\nPE: LGA preterm infant, pink, mild jaundice, AFOF, sutures apposed, breath sounds clear/equal with mild subcostal retracting, RRR, no murmur, normal perfusion, abd soft, non distended, UVC in place, + bowel sounds, normal penis, testes descended bilaterally, mild fullness surrounding scrotum, active with preterm tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-05-31 00:00:00.000",
"description": "Report",
"row_id": 1836705,
"text": "Neonatology Attending Note\nDay 1\n\nRA. RR50-70s. Cl and = BS. No rtxns. Ruddy. HR 130-160s. No murmur. BP 67/41, 52. On amp/gent. Wt 3125. TF80 D15 via UVC. NPO. d/s 83,93,70. Voiding at 3.2. No stool yet. On radiant warmer.\n\nA/P:\nabx pending clinical course and cx results\nmonitor d/s closely, wean GFR as allowed\ninitiate enteral feeds\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-08 00:00:00.000",
"description": "Report",
"row_id": 1836745,
"text": "NPN Days\n\n\nFEN: TF increased to 150cc/k/d of E24/BM24, bottling with\neach feeding Q4hours, Taking 51-68cc, gavaging remainder of\nfeeding (total 78cc/Q4). is coordinated with\nfeeding, tired toward end of feeding. Abdomen is soft,\npink, active bowel sounds, no loops, voiding and stooling\nguiac neg yellow stools. Tolerating feeds well, coordinated\nfeeding, unable to take full volumes at each feeding. Will\ncontinue to offer bottle Q4hours, and gavage remainder until\nstamina improves.\n\nG/D: Continues to have stable temps in open crib, active\nand alert with cares, sleeps well between cares. MAE,\nbrings hands to face, sucks on pacifier and hands. Wakes\nfor feedings. Will continue to support developmental needs.\n\n: Father called this morning - updated, mother and\nfather plan to come in this afternoon, Will continue to\nsupport and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-08 00:00:00.000",
"description": "Report",
"row_id": 1836746,
"text": "NPN Days\nADDENDUM:\nParenting: mother in for 4p cares, infant bathed (keeping umbilical cord dry) hair washed etc, with mother. Mother breastfed infant with good latch and suck, infant tired after 10min, bottled by mother after this, and remainder gavaged. Mother continues to have trouble with breast pump at home (not strong enough). Told mother that she should speak to a lactation consultant monday and perhaps change types of breastpump that she has at home. She will follow up tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-06 00:00:00.000",
"description": "Report",
"row_id": 1836738,
"text": "NPN DAYS\n\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON MIN\nOF 130CC/K/D OF E24. ABD EXAM BENIGN. NO LOOPS, NO SPITS.\nASP. 0.4CC. VOIDING AND STOOLING WELL.STOOL GUIAC NEG.CIRC\nHEALED WELL. BOTTLED 30CC AT 8AM AND 12PM. GAVAGED 43C AFTER\nEACH FEEDING TO MAKE UP TO 140CC/K/D. CONTINUE CURRENT\nFEEDING PLAN.\n\nALT IN GROWTH AND DEVELOPMENT D/ :ALERT AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN OPEN CRIB.\nWAKING AND DEMANDING FEEDS Q4HRS. CONTINUE DEVELOPMENTAL\nCARES. WILL DO HEARING SCREEN WHEN ALL BOTTLES AND GAVAGE\nTUBE IS OUT.\n\nALT IN PARENTING:MOM CALLED ONCE THIS AFTERNOON FOR UPDATE.\nSHE WILL BE IN LATER TODAY TO VISIT, BUT DOES NOT KNOW WHEN.\nCONTINUE TO SUPPORT AND UPDATE, AND REVIEW D/C TEACHING.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-07 00:00:00.000",
"description": "Report",
"row_id": 1836739,
"text": "NPN\n\n\n#1 has fed better this shift taking 30cc, 50cc and\n73cc BM/E24. Abd soft, +BS no loops or distention, vdg/stlg\nqs. A: feeds improving. P: no change\n#2 stable in open crib, waking for feeds, sucks very well on\npacifier, pretty calm with cares. A: AGA P: cont to support\ndevelopment.\n#3 mom and dad visited and held . Pleased that he is\ndoing well, anxious to get him home. A: involved family P:\ncont to support and inform\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-07 00:00:00.000",
"description": "Report",
"row_id": 1836740,
"text": "Neonatology Attending\nDOL 8 / PMA 34-6/7 weeks\n\nRemains in room air with no cardiorespiratory events.\n\nNo murmur. BP 85/36 (58).\n\nBilirubin last night 5.3/0.2 (spontaneously decreasing, not under phototherapy).\n\nWt 3000 (+35) on TFI 130 cc/kg/day min with oral intake approximately with remainder by gavage. Voiding and stooling normally.\n\nA&P\n33-5/7 week GA infant with feeding immaturity, resolving hyperbilirubinemia\n-Continue to encourage development of oral feeding skills\n-No other changes in management as detailed above\n-Discharge planning in progress\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-07 00:00:00.000",
"description": "Report",
"row_id": 1836741,
"text": "Neonatology-NNP Progress Note\n\nPE: remains in his open crib, swaddled, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, V&S, afso, active , gavage in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-10 00:00:00.000",
"description": "Report",
"row_id": 1836758,
"text": "nicu fellow physical exam\nplease see attending note for clinical events and plan\n\nsupine in open crib\n3080g up 35g p150-170 r30-60 RA\nAnterior fontanelle soft open and flat. Equal air entry with clear breath sounds bilaterally. Regular rhythm with normal rate, no murmur. Abdomen soft, nondistended, with normal active bowel sounds. Normal male genitalia. 2+ femoral pulses bilaterally. WArm, pink.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-11 00:00:00.000",
"description": "Report",
"row_id": 1836759,
"text": "NPN 2300-0700\n\n\n1. FEN: WT=3115gms (up 45gms). TF=min 140cc/k/day\nBM24/E24. Bottled 70cc and 60cc this shift. Total intake\nyesterday was 146cc/kg. Voiding and stooling with each\ndiaper change. No spits. Abd is soft and round with active\nbs.\n\n2. G&D: Infant is alert and active with cares. Sleeps\nvery well between cares. Uses pacifier to comfort self.\nTemps stable swaddled in open crib. AFSF. AGA.\n\n3. : No contact this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-11 00:00:00.000",
"description": "Report",
"row_id": 1836760,
"text": "NeonatologyDoign well. REmains in RA. NO spells\n\nWt 3115 up 45. Tolerating ad lib feeds with good intake of 24 cal. Abdomen benign.\n\n\nReady for dc\nPMD to be contact.\nPAssed car seat and hearing.\n HBV given\n\nPMD appt to be arranged for am.\n\n\nDC prep time 35 minutes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-11 00:00:00.000",
"description": "Report",
"row_id": 1836761,
"text": "Neonatology NP Dicharge Physical\nswaddled in open crib\nvigorous, nondysmorphic, term male\nAFOF, sutures approximated\n+ bilateral red reflex, no eye drainage\noral mucosa without lesions, palate intact\nneck supple and without lesions\nclavicles intact\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused, femoral pulses strong\nabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry, no HSM\ntestes descended bilaterally, healing circumcision\nstable hip exam\nno sacral anomalies,\nmoving all extremities, normal digits and creases\nmongolian spot over buttocks\nsymmetric tone and reflexes, normal strength and activity\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-11 00:00:00.000",
"description": "Report",
"row_id": 1836762,
"text": "NPN Discharge note.\naddendum: in at 1830 to take infant home. Reviewed d/c paperwork. Info/copies given to . D/C order in chart. Infant d/c home with .\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-06-11 00:00:00.000",
"description": "Report",
"row_id": 1836763,
"text": "NPN Discharge note.\nResp: RA. LS clear. No spells. Stable.\n\nCV: Pink, no murmur. HR 160-170's. Stable.\n\nFEN: MIN 140cc/kg of E24. Bottling 3 1/2-4hrs. Bottles well 60-85cc. No spits. Abd benign. Circ site healed. Voiding and stooling. Good po intake, gaining wt.\n\nDEV: Temp stable in open crib. Waking on own for feedings. Active and alert with cares. PKU done. AGA. Passed repeat carseat done today.\n\nParenting. Mother called x 2 and updated. Pleased that infant passed carseat test. Aware infant can go home today. Mother stated that she would be in after 3pm, waiting for ride from husband.\n\nVNA called and updated that infant would be going home tonight. Pedi appt set for Friday am, VNA to visit tomorrow. Need to fax referral when d/c'd home. D/C home with tonight.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-05-31 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 868709,
"text": " 12:55 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: UVC placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with persistent hypoglycemia\n REASON FOR THIS EXAMINATION:\n UVC placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hypoglycemia. Recent femoral line placement.\n\n There are no prior studies for comparison. The lungs are clear. The bowel\n gas pattern is normal. A left femoral catheter tip terminates in the region\n of the infradiaphragmatic inferior vena cava.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-05-31 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 868712,
"text": " 2:32 AM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # \n Reason: UVC placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with persistent hypoglycemia\n REASON FOR THIS EXAMINATION:\n UVC placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Hypoglycemia. Line adjustment.\n\n Compared to the examination earlier the same day, the left femoral line has\n been readjusted so that the tip is now in the lower right atrium. The lungs\n remain clear. The bowel gas pattern is normal. No bony abnormalities are\n identified.\n\n\n"
}
] |
1,331 | 114,467 | 1) Sepsis/disseminated infection: Patient was transferred from OSH for sepsis thought secondary to a hand infection. An initial incision and drainage of the right hand abscess had been performed at the OSH. Here, she was started on vancomycin with gentamycin at synergistic dosing for gram positive cocci on outside hospital cultures. She was aggressively resuscitated with IV fluids, with Levophed for additional pressure support. She received a course of Xigris and stress dose steroids. When cultures showed MSSA on HD #2, vancomycin was changed to nafcillin. Gentamycin was stopped after 5 days of synergistic dosing. She was weaned off of pressor support by HD #4 and remained hemodynamically stable thereafter, although she remained intubated on mechanical ventilation to facilitate operative debridement of her right hand osteomyelitis. . Although she subsequently remained hemodynamically stable, she continued to be febrile. There was concern for line infection. Her chronic PICC for home TPN was removed at the outside hospital. Left and right internal jugular central catheters placed since admission were removed, as well as her arterial line. A new left subclavian catheter was placed. However, she continued to remain febrile. . A transesophageal echocardiogram was performed, which showed no evidence of endocarditis. A chest X-ray showed pulmonary nodules, prompting a follow up CT of the chest. This showed nodular opacities consistent with septic emboli. In addition, it showed two fluid collections, one involving the vertebral bodies of T8-T10, and another in the left paraspinal muscles extending inferiorly from C7. A CT of the abdomen and pelvis showed a left iliopsoas abscess. . The orthopaedic spine team was consulted, and an MRI of the spine was obtained for further delineation of these lesions. The MRI confirmed osteomyelitis of the T9 vertebra, and showed a fluid collection abutting the spine in addition to a fluid collection subcutaneously on the back. The orthopaedic spine service recommended a conservative approach with CT guided drainage of the paraspinal fluid collection. The infectious diseases team agreed with a strategy of attempting to treat each locus of infection discretely and attempt drainage. However at this point, the infection appeared fairly disseminated and there was some concern that the infection would be difficult to eradicate. The pulmonary nodules were felt to not be accessible by bronchoscopy, and not large enough for percutaneous drainage. The left iliopsoas abscess was likewise felt not to be amenable to drainage. These concerns were shared with the patient and the family. The patient underwent successful CT guided drainage of the superficial abscess on the back, in addition to the paraspinal fluid collection (with a pigtail catheter left in place for drainage). . She was called out to the floor where she continued to be febrile. Plans were made for CT guided drainage of the parascapular abscess. However, the scan showed no drainable fluid in the parascapular region. The T8-T10 paraspinal fluid collection was persistent, but slightly improved. Incidentally, however, it showed bilateral shoulder effusion. Orthopaedics performed a joint aspirate, which returned grossly cloudy fluid, with 41k WBCs and a negative gram stain. She was taken to the operating room for bilateral shoulder washouts, which she tolerated well. . She subsequently defervesced, and was afebrile x 1 week prior to discharge. She was discharged with plans for an indefinite course of nafcillin. . 2. Pain control: She was initially placed on a morphine PCA for pain control, but had difficulty operating the PCA. She was changed to a fentanyl patch with IV Dilaudid boluses for breakthrough. IV Dilaudid was transitioned to PO Dilaudid prior to discharge. On discharge, her pain was well controlled on 25 mcg/hr fentanyl patch with 8mg PO Dilaudid Q2h for breakthrough pain. . 3. Respiratory failure: The patient had developed respiratory failure at the OSH and arrived on mechanical ventilation. This was thought secondary to non-cardiogenic pulmonary edema in the setting of sepsis. Her ventilator settings were weaned, and she was clinically ready for extubation several days after admission. However, she remained intubated for an additional days because of planned hand surgery by plastic surgery. She was extubated successfully on the following day, although her respiratory status remained tenuous. She was reintubated on for a TEE and again successfully extubated on after the TEE. Her respiratory status was stable through the remainder of her course on the floor. . 4. Crohns: She was given a short course of stress dose steroids on arrival, as described above, and subsequently put on 4mg IV Solu-Medrol QD. She was transitioned back to her home regimen of prednisone 5 mg PO QD prior to discharge. She was maintained on TPN throughout her hospitalization for short gut syndrome. It was initially run by continuous infusion, but was transitioned to a cycled regimen over 12 hours prior to discharge. Her Crohns was otherwise stable, without any complaints of abdominal pain. 5. Cardiac: She had a mild troponin T leak ~ 0.7, with a peak CK-MB of 95. This was felt to be demand related in the setting of sepsis. An initial TTE showed a depressed EF. However, this recovered on subsequent TEEs. . 6. Anemia: Patient had a stable anemia with iron studies consistent with chronic inflammation. . 7. Tachycardia: Patient was noted to be persistently tachycardic during hospitalization. This was confirmed to be sinus by ECG, and thought most likely multifactorial from anxiety, pain, and her hypermetabolic state from infection. In addition to treatment of her underlying infection and pain control described above, she was given anxiolytics as needed. CT was negative for PE. . 8. Acidosis/hyperkalemia: The patient was noted to have a metabolic acidosis on admission. This corrected spontaneously over the subsequent several days. However, as the acidosis resolved, she developed a significant hypokalemia, with potassium levels down to 2.4. There were no ECG changes. Potassium was repleted aggressively over the following several days, with subsequent resolution. . Prophylaxis: She received heparin in her TPN for DVT prophylaxis. . Code status was confirmed to be full. | Interstitial markings are prominent indicating degree of cardiac failure, which is unchanged, as are bilateral pleural effusions. Normal regional LV systolic function.Low normal LVEF.RIGHT VENTRICLE: RV not well seen.AORTA: No atheroma in aortic arch. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Should read left paraspinal multiloculaed fluid collection extends inferiorly from C7 and not C1 as transcribed. Cannot assess LVEF.RIGHT VENTRICLE: Normal RV chamber size.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) MR. LV inflowpattern c/w impaired relaxation.TRICUSPID VALVE: Mild [1+] TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:1. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. A right-sided internal jugular approach central venous line is present, seen to terminate overlying the SVC at a level 2 cm below the carina. 5) Left adrenal nodule which cannot be further characterized on this examination. No gas is present within this effusion but The vertebral bodies at this level (probable T8.9 and 10) demonstrate a mixed sclerotic/ lytic pattern and findings are concerning for osteomyelitis. No TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Previously reported interstitial edema has resolved. FINDINGS: AP single view of the chest obtained with the patient in supine position demonstrates the presence of an ETT and an NG tube. No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV cavity size. The superior extent of this abnormality is roughly at the level of C7 and it extends into the thoracic region, located just to the left of midline in the posterior subcutaneous musculature. There are simple atheroma in the descending thoracic aorta.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion. There is a small right pleural effusion with associated atelectatis. Views of the thoracic spine demonstrate compression deformities of T7, T8, T9, and to a mild degree T10. Mild subluxation of the first proximal interphalangeal joint. IMPRESSION: Unchanged position of indwelling lines and tubes. Right-sided pleural effusion with associated atelectasis. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 65Weight (lb): 125BSA (m2): 1.62 m2BP (mm Hg): 95/54HR (bpm): 76Status: InpatientDate/Time: at 15:54Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV cavity size. In the region of the lower thoracic spine there is an apparent encapsulated prevertebral fluid collection adjacent to the right pleural effusion, and with low but slightly higher density than the free pleual effusion. Right central venous line and left central venous line in good position, as well as endotracheal tube and nasogastric tube. Mild (1+) mitralregurgitation is seen. These densities are consistent with ARDS, appear to have regressed mildly. Various lines and tubes have been removed in the interval with a residual indwelling left subclavian vascular catheter terminating in the superior vena cava. There has been removal of the previously seen left-sided subclavian central venous catheter. A small right-sided paraspinal drainage catheter is now present at that level, the tip of the catheter ending within the phlegmon. Interval size reduction of the right pleural effusion and underlying atelectasis. A 0.018-inch guidewire was advanced through the PICC and the PICC was repositioned into the superior vena cava, however, it appeared to be short. Final limited chest radiograph confirmed catheter tip position in the superior vena cava. There has been interval improvement of previously seen small right-sided pleural effusion. Again seen is a paraspinal abscess collection anterior to the mid thoracic region. Final limited chest radiograph confirmed catheter tip position at the superior vena cava. Previously described posterior deep cervical multiloculated fluid collection at the level of C7 is no longer evident - ? There is right basilar atelectasis and a tiny right pleural effusion. CT OF THE ABDOMEN AFTER THE ADMINISTRATION OF ORAL AND IV CONTRAST: A small right pleural effusion, which is decreased in size. Note is made in the midline, close to where the patient's report stoma is of a fixed loop of bowel that does not appear to peristalse much but by its morphology would appear to be small bowel. FINDINGS: Comparison is made with prior MR thoracic spine of . It does not have a normal appearance, and correlation with clinical history and possibly CT examination is recommended. Small area of enhancement again noted within the left psoas muscle, previously described as abscess, not significantly changed from (Over) 5:45 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: r/o PE Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) prior study. PICC noted to be malpositioned on chest x-ray after removal of central line. FINDINGS: Grayscale and Doppler son of both common femoral, superficial femoral, and popliteal veins were performed. A small-bore catheter is now seen along the right posterior paraspinal soft tissue posteriorly, with its tip ending at the T8/T9 anterolateral paraspinal soft tissues. Small amount of air is noted within the bladder, correlate with recent catheterization. small subcutaneous fluid collection posterior to the right inferior epigastric artery of unclear significance. | 40 | [
{
"category": "Echo",
"chartdate": "2125-04-05 00:00:00.000",
"description": "Report",
"row_id": 99023,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 125\nBSA (m2): 1.62 m2\nBP (mm Hg): 95/54\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 15:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Depressed LVEF. Cannot assess LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\n1. The left ventricular cavity size is normal. LV systolic function appears\ndepressed. Overall left ventricular systolic function cannot be reliably\nassessed.\n2. The aortic valve leaflets (3) are mildly thickened.\n3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-04-17 00:00:00.000",
"description": "Report",
"row_id": 99021,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 65\nWeight (lb): 121\nBSA (m2): 1.60 m2\nBP (mm Hg): 107/67\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 16:51\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was intubated by an anesthesiologist before beginning the\nprocedure. The patient was administered propofol 65 mg IV and fentanyl 100 mcg\nIV during the procedure. The probe was not passed beyond the GE junction\nsecondary to resistance.\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: No spontaneous echo contrast in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of\nthe RA. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: No atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No aortic valve abscess. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. No mitral valve abscess. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. No abscess of tricuspid valve. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. No TEE related\ncomplications. Echocardiographic results were reviewed with the houseofficer\ncaring for the patient.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium or right\natrium. No atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function appears preserved (LVEF>55%), however\ntransgastic views were not obtained. Right ventricular systolic function also\nappears preserved. There are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No masses or vegetations are seen on the aortic valve. No aortic\nvalve abscess is seen. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. No mass or vegetation is seen on the mitral\nvalve. No mitral valve abscess is seen. Trivial mitral regurgitation is seen.\nThere is no abscess of the tricuspid valve. No vegetation/mass is seen on the\npulmonic valve.\n\nCompared with the prior study (images reviewed) of , the valve\nleaflets appear similar and no vegetation is seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-04-06 00:00:00.000",
"description": "Report",
"row_id": 99022,
"text": "PATIENT/TEST INFORMATION:\nIndication: Septic shock with prolonging QT interval on ECG. Evaluate for endocarditis/abscess.\nHeight: (in) 65\nWeight (lb): 121\nBSA (m2): 1.60 m2\nBP (mm Hg): 100/60\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 16:44\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was intubated and sedated in the MICU with monitoring by the ICU\nnurse throughout the TEE. She received a total of 100 mcg of IV Fentanyl, 6 mg\nof IV midazolam, and 0.2 mg of IV glycopyrrolate in addition to the\nintravenous midazolam (2 mg/hr) and intravenous Fentanyl (100 mcg/hr) she was\nreceiving.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function.\nLow normal LVEF.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: No atheroma in aortic arch. No atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No aortic valve abscess. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient appears to be\nin sinus rhythm. The house officer caring for the patient was notified of the\nresults by text page.\n\nConclusions:\n1.The left ventricular cavity size is normal. Regional left ventricular wall\nmotion is normal. Overall left ventricular systolic function is low normal\n(LVEF 50-55%).\n2. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n3. No evidence of endocarditis seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-04-16 00:00:00.000",
"description": "Report",
"row_id": 279399,
"text": "Sinus tachycardia\nNonspecific anterolateral T wave abnormalities\nSince previous tracing of , sinus tachycardia present\n\n"
},
{
"category": "ECG",
"chartdate": "2125-04-10 00:00:00.000",
"description": "Report",
"row_id": 279400,
"text": "Sinus rhythm. Other than more rapid rate, there is no significant change\ncompared to the previous tracing of .\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-04-09 00:00:00.000",
"description": "Report",
"row_id": 279401,
"text": "Sinus rhythm. Since the previous tracing of the axis is now more\nrightward and the rate is somewhat faster. There is otherwise, no diagnostic\nchange.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-04-06 00:00:00.000",
"description": "Report",
"row_id": 279402,
"text": "Sinus rhythm. The QTc interval is prolonged. There is a late transition\nconsistent with possible prior anterior wall myocardial infarction. Diffuse\nnon-specific ST-T wave changes. Compared to the previous tracing late\ntransition is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-04-05 00:00:00.000",
"description": "Report",
"row_id": 279403,
"text": "Normal sinus rhythm. T wave inversions in leads V1-V3 suggesting possible\nanteroseptal ischemia. Prolonged Q-T interval. Borderline low limb lead\nvoltage. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 909946,
"text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow pulm parenchyma\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman w/ARDS\n REASON FOR THIS EXAMINATION:\n follow pulm parenchyma\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: ARDS.\n\n Endotracheal tube and right internal jugular vascular catheter remain in\n standard position. Left internal jugular catheter continues to terminate in\n the superior vena cava but the tip is directed laterally in close proximity to\n the wall of this vessel. Heart size is normal. Bilateral hazy and reticular\n areas of lung opacification show marked interval improvement compared to , . As compared to the more recent study, the overall severity of lung\n opacification is probably not changed, but the distribution is slightly\n different with slight worsening at the bases but slight improvement in the\n upper zones bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 909755,
"text": " 3:08 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval line placement, ptx\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p L IJ placement\n REASON FOR THIS EXAMINATION:\n eval line placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP single view.\n\n INDICATION: Central venous line placement.\n\n FINDINGS: AP single view of the chest obtained with the patient in supine\n position demonstrates the presence of an ETT and an NG tube. A right-sided\n internal jugular approach central venous line is present, seen to terminate\n overlying the SVC at a level 2 cm below the carina. No pneumothorax is\n identified. Bilaterally, there exist widespread and partially confluencing\n parenchymal densities of similar appearance as identified on the preceding\n examinations beginning with the first chest study of when the patient\n was transferred from another institution. These densities are consistent with\n ARDS, appear to have regressed mildly. No new parenchymal infiltrates are\n identified, and the lateral pleural sinus remains free. Heart size is within\n normal limits, and there is no evidence of pulmonary vascular congestion.\n\n IMPRESSION: Unchanged position of indwelling lines and tubes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 911061,
"text": " 10:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with crohn's on immunosupression with fevers\n\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: .\n\n INDICATION: Fever.\n\n Various lines and tubes have been removed in the interval with a residual\n indwelling left subclavian vascular catheter terminating in the superior vena\n cava. Heart size is normal. There has been improved aeration of the lungs\n with residual patchy right lower lobe opacity and poorly defined peripheral\n left mid and right upper lobe opacities. Previously reported interstitial\n edema has resolved.\n\n IMPRESSION: Poorly defined nodular opacities in right upper and left mid lung\n zones, concerning for septic emboli or fungal infection. Findings\n communicated by telephone to Dr. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 909634,
"text": " 6:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? IJ POSITION AND OGT PLACEMENT\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p R IJ pullback.\n REASON FOR THIS EXAMINATION:\n ?IJ position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old female with right IJ pulled back.\n\n COMPARISON: at 7:38 p.m.\n\n AP UPRIGHT CHEST RADIOGRAPH: Right-sided internal jugular central venous\n catheter tip now resides in the superior vena cava. The nasogastric tube has\n been advanced beyond the limits of the examination. There is no evidence of\n pneumothorax. Otherwise, the examination is unchanged compared to the prior\n study performed one hour earlier.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 910551,
"text": " 4:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess placement of OG tube\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with crohn's on immunosupression with sepsis with OG tube\n placement\n REASON FOR THIS EXAMINATION:\n assess placement of OG tube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:36 P.M, .\n\n HISTORY: Crohn disease, immunosuppressed, OG tube placed.\n\n IMPRESSION: AP chest compared to and and 3.\n\n Interstitial pulmonary edema persists. Small right pleural effusion has\n decreased, left lower lobe atelectasis has improved. No definite\n pneumothorax. ET tube and bilateral internal jugular vascular lines are in\n standard placements. Heart size normal, mediastinum midline.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-04 00:00:00.000",
"description": "RP HAND (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 909627,
"text": " 5:21 PM\n HAND (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: r/o osteo\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with ARDS and on pressor support with gross infection of\n right hand with + cultures\n REASON FOR THIS EXAMINATION:\n r/o osteo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old with ARDS on pressor support and gross infection of\n the right hand with positive cultures.\n\n No prior studies for comparison.\n\n THREE VIEWS OF RIGHT HAND: There is marked swelling of the soft tissues of\n the right first digit. Significant amount of subcutaneous air is seen at the\n proximal interphalangeal joint. A vague opacity adjacent to the PIP joint may\n represent a foreign body if there is history of trauma. There is no\n definitive disruption of the cortex. There is subluxation at the first\n proximal interphalangeal joint. There is no evidence of fracture. The\n remainder of the joints is well preserved. There is normal mineralization.\n\n IMPRESSION: Marked soft tissue swelling and subcutaneous air in the soft\n tissues of the first digit. No definitive evidence of osteomyelitis. Mild\n subluxation of the first proximal interphalangeal joint. Vague opacity\n adjacent to the PIP joint may represent a foreing body.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 910708,
"text": " 7:36 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with crohn's on immunosupression with sepsis with OG tube\n s/p new L SC CVL placement\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New central venous line placement.\n\n AP SUPINE PORTABLE CHEST: Comparison with . Right central venous\n line and left central venous line in good position, as well as endotracheal\n tube and nasogastric tube. Interstitial markings are prominent indicating\n degree of cardiac failure, which is unchanged, as are bilateral pleural\n effusions. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-17 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 911164,
"text": " 2:47 AM\n CT HEAD W/ & W/O CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Eval brain parenchyma for septic emboli.\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with septic emboli and altered MS.\n FOR THIS EXAMINATION:\n Eval brain parenchyma for septic emboli.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate brain parenchyma for septic emboli.\n\n COMPARISONS: None.\n\n TECHNIQUE: CT of the head was performed prior to and following administration\n of IV contrast.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage or shift of\n normally midline structures, or hydrocephalus. -white differentiation\n appears preserved. No abnormal enhancing lesions are seen on post-contrast\n images. Surrounding osseous and soft tissue structures appear unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage or shift of normally\n midline structures. No abnormal enhancing lesions seen on post-contrast\n images.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-17 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 911268,
"text": " 3:10 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: ?abscess; characterize for surgery\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with paraspinal abscess visualized on ct.\n REASON FOR THIS EXAMINATION:\n ?abscess; characterize for surgery\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL AND THORACIC SPINE\n\n INDICATION: 55-year-old woman with paraspinal abscess visualized on CT,\n assess and characterize for surgery.\n\n TECHNIQUE: Sagittal and axial T1- and T2-weighted scans of the cervical and\n thoracic spine were obtained, and post-gadolinium sagittal and axial T1-\n weighted scans are included.\n Comparison is made to a CT of the body performed two days earlier.\n\n FINDINGS:\n\n Sagittal images of the cervical spine demonstrate normal vertebral alignment.\n Vertebral body height and signal is maintained. There is thickening of the\n soft tissues of the C1-2 joint space. This may be degenerative in nature, but\n infection cannot be excluded, as there is enhancement in this location.\n However, there is no clear evidence of abnormal epidural enhancement in the\n cervical spinal canal.\n\n There was identified and is again seen, a posterior cervical deep soft tissue\n multiloculated collection with a thickly enhancing rim. The superior extent\n of this abnormality is roughly at the level of C7 and it extends into the\n thoracic region, located just to the left of midline in the posterior\n subcutaneous musculature. The craniocaudal length of this area of enhancing\n abnormal fluid is roughly 8 cm.\n\n Otherwise, the cervical spinal canal is not stenotic. The cervical spinal\n cord is normal in caliber.\n\n Views of the thoracic spine demonstrate compression deformities of T7, T8, T9,\n and to a mild degree T10. The T9 vertebral body is markedly abnormal with\n decreased T1 signal and irregularly increased T2 signal throughout this\n vertebra and involving the adjacent disc spaces. There is also a prevertebral\n T2 hyperintense mass extending anterior to the vertebral body and encompassing\n adjacent disc spaces. This is indenting the posterior mediastinum. There is\n irregular enhancement of the T9 vertebral body and the margins of the\n prevertebral abnormality, suggesting that it is an abscess with associated\n peripheral inflammatory change. There is also a right pleural effusion which\n exhibits some enhancement along its margins and is associated with atelectasis\n of the adjacent lung. Additionally, within the spinal canal, primarily at the\n (Over)\n\n 3:10 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: ?abscess; characterize for surgery\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n T9 level, but also slightly above and below, there is abnormal circumferential\n epidural enhancement. This is suspicious for infection in the epidural space.\n The spinal canal is mildly narrowed at the T9 level due to the compression\n deformity of the bone and epidural abnormality. There is no cord compression.\n\n IMPRESSION: There are signs of extensive osseous abnormality of the mid\n thoracic spine with a prevertebral collection associated with bone and\n interspace abnormality. This is most suspicious for infection and abscess\n formation. There is also an adjacent pleural effusion, and extension of an\n infectious process into this space should be considered.\n\n An area suspicious for large abscess collection is also identified in the\n subcutaneous musculature of the posterior back extending from roughly C7, 8 cm\n inferiorly into the thoracic region, to about T5.\n\n Abnormality at the C1-2 junction is also identified and though this could\n represent degenerative change, but infection cannot be excluded in this\n location.\n\n Findings and concern about purulent collections in the mid thoracic region and\n upper cervical soft tissues were discussed with Dr. at 3 p.m. on\n .\n Subsequently, the Infectious Disease Service reviewed and discussed the\n findings of the study with this radiologist.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-16 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 911121,
"text": " 4:44 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: eval pulmonary nodules seen on CXR, ? septic emboli\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Field of view: 30 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL ADDENDUM\n Please note error in transcribed report. Should read left paraspinal\n multiloculaed fluid collection extends inferiorly from C7 and not C1 as\n transcribed.\n\n\n 4:44 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: eval pulmonary nodules seen on CXR, ? septic emboli\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Field of view: 30 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with MSSA bacteremia, now with tachycardia, new fevers, and\n new pulmonary nodules seen on CXR\n REASON FOR THIS EXAMINATION:\n eval pulmonary nodules seen on CXR, ? septic emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old with MSA bacteremia, now with tachycardia and fever\n and question pulmonary emboli seen on CT examination.\n\n Comparison is made to the chest x-ray of .\n\n TECHNIQUE: MDCT axial images of the chest were obtained after the\n administration of 100 cc of IV Optiray contrast.\n\n FINDINGS: The heart and great vessels are unremarkable. A single right\n axillary lymph node measures 1 cm. There are no other pathologically enlarged\n mediastinal lymph nodes. The airways are patent bilaterally. There is a\n small right pleural effusion with associated atelectatis. Lung windows revea\n severe emphysematous changes. There are multiple bilateral, scattered varying-\n sized rounded and irregular non-cavitating focal pulmonary opacities,\n predominantly with a peripheral location. In the left posterior paraspinal\n musculature just deep to the trapezius muscle extending inferiorly from the C1\n level , there is a rim enhancing multiloculated fluid collection concerning\n for abscess. In the region of the lower thoracic spine there is an\n apparent encapsulated prevertebral fluid collection adjacent to the right\n pleural effusion, and with low but slightly higher density than the free\n pleual effusion. No gas is present within this effusion but The vertebral\n bodies at this level (probable T8.9 and 10) demonstrate a mixed sclerotic/\n lytic pattern and findings are concerning for osteomyelitis.\n\n IMPRESSION:\n 1. Multiple bilateral predominantly peripheral focal opacities consistent\n with septic emboli.( The differential diagnosis includes atypical infection,\n cryptogenic organizing pneumonia, vasculitis and much less likely pulmonary\n metastases.)\n 2. Right-sided pleural effusion with associated atelectasis.\n 3. Left cervical paraspinal rim- enhancing fluid collection concerning for\n abscess.\n 4. Apparent encapsulated prevertebral fluid collection atlower thoracic spine\n level with mixed lytic/ sclerotic process involving vetebral bodies (probably\n 8,9 and 10) concerning for osteomyelitis MR exam may be helpful if clinically\n indicated to better evaluate the spine.\n 5) Left adrenal nodule which cannot be further characterized on this\n examination.\n\n (Over)\n\n 4:44 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: eval pulmonary nodules seen on CXR, ? septic emboli\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Field of view: 30 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Multiplanar reformatted images will be performed and the report addended.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 909629,
"text": " 5:21 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p R IJ placement.\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old female status post right IJ placement, evaluate for\n pneumothorax.\n\n COMPARISON: at 1456.\n\n APUPRIGHT CHEST RADIOGRAPHS: A right-sided internal jugular central venous\n catheter tip terminates in the IVC. A nasogastric tube terminates in the\n esophagus. An endotracheal tube is in appropriate position. There is no\n evidence of pneumothorax. The cardiomediastinal silhouette is unchanged.\n There has been interval decrease in the degree of alveolar opacity in both mid\n lung zones. There has been increase in alveolar opacity in the right lower\n lung zone.\n\n IMPRESSION:\n 1. ARDS; Interval decrease in degree of midlung zone alveolar opacity.\n Increase in alveolar opacity in the right lower lung zone.\n 2. Cystic lucencies at both bases, which may be due to pneumatoceles as\n previously described.\n 3. No definite evidence of pneumothorax.\n 4. Right internal jugular central venous line is in the IVC.\n 5. Nasogastric tube in the esophagus.\n\n Findings were conveyed to the house to Dr. at 6:10 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-17 00:00:00.000",
"description": "MR T-SPINE W &W/O CONTRAST",
"row_id": 915163,
"text": " 11:05 AM\n MR W &W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: eval size of abscesses - please include imaging of parascapu\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with paraspinal abscess s/p pigtail drain and parascapular\n abscess\n REASON FOR THIS EXAMINATION:\n eval size of abscesses - please include imaging of parascapular abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with paraspinals abscess, status post drainage.\n Evaluate abscess.\n\n TECHNIQUE: T1- and T2-weighted images of the cervical spine with the\n administration of intravenous contrast .\n\n COMPARISON: MRI dated .\n\n FINDINGS: Again note is made of compression fracture of T7-9, with increased\n signal intensity of the disc and vertebral bodies, surrounded by T2\n hypointense fluid collection anterior to the vertebral body, representing\n abscess, not significantly changed compared to the prior study. There is no\n evidence of progression of compression fracture or no evidence of significant\n increase in the size of the abscess. Again note is made of bilateral pleural\n effusions at this level. No abnormal fluid collection within the spinal canal\n is noted.\n\n The axial images in the upper portion of the left scapula is obtained, and was\n reviewed with Dr. and Dr. . There is no definite fluid\n collection. There is small area of enhancement within the adjacent muscle\n posterior to the scapula. Please note that the inferior portion of the\n scapula is not completely imaged.\n\n There is a drainage catheter in the subcutaneous area of right upper back,\n however, the tip is not confidently identified.\n\n IMPRESSION:\n 1. Persistent compression fracture from T7-9, with surrounding paraspinal\n abscess and discitis, without significant progression compared to the prior\n study. Persistent small pleural effusion.\n 2. Small area of enhancement within the muscles posterior to the left\n scapula, however, no definite fluid collection is identified. Please note the\n evaluation of the left scapula is limited and includes only the upper portion\n of the scapula.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915025,
"text": " 12:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with crohn's on immunosupression with fevers, admitted for\n multiple abscesses, persistently febrile\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Crohn's on immunosuppression with fevers, admitted for multiple\n abscesses.\n\n COMPARISON: .\n\n FINDINGS: A new left-sided PICC line is present with the tip terminating in\n the SVC. Note is made that the catheter loops along its course within the\n region of the junction of the left brachiocephalic vein and left subclavian. A\n drainage catheter is also noted projecting over the left upper hemithorax.\n Persistent widening of the right paraspinal line is again consistent with\n patient's known paraspinal collection. The appearance of the lungs are not\n significantly changed with again note of poorly defined bilateral nodular\n opacities. No new areas of focal consolidation or effusion are identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-22 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 915819,
"text": " 5:45 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: r/o PE\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 y/o F w/MSSA bacteremia, numerous abscesses, pulmonary septic emboli, now\n s/p 6 weeks of antibiotics with tachycardia and increasing ESR, ? PE\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia, numerous abscesses, pulmonary septic emboli, status\n post antibiotics, now with tachycardia.\n\n COMPARISON: Chest CT , CT of the abdomen and pelvis .\n\n TECHNIQUE: MDCT acquired axial images of the chest, abdomen and pelvis were\n obtained with IV contrast. Multiplanar reformatted images were also\n displayed.\n\n CT OF THE CHEST WITH IV CONTRAST: Pulmonary arteries appear well opacified\n and there is no evidence of acute pulmonary embolism. Heart and great vessels\n appear unremarkable. Again seen are several mediastinal lymph nodes, however,\n none appear to meet CT criteria for pathological enlargement. There is no\n evidence of pathologically enlarged hilar or axillary lymphadenopathy. There\n has been interval improvement of previously seen small right-sided pleural\n effusion. Again seen are diffuse emphysematous bullous changes bilaterally.\n Three poorly-defined peripheral opacities are present in the right lung. The\n opacity seen on series 3, image 39, does not appear significantly changed from\n prior study. New linear/nodular opacities seen on series 2, image 34, possibly\n represents atelectasis. Also seen is a smaller irregular peripheral opacity,\n best seen on series 3, image 55. Peripheral opacity in the left lung (series\n 3, image 49) appears improved compared to prior study. Again seen is a\n paraspinal abscess collection anterior to the mid thoracic region. Small\n amount of fluid is again seen, decreased compared to . Compared to , the fluid collection is likely not significantly changed to slightly\n larger in size. Soft tissue inflammation is also seen in this area. Again\n seen is destruction of the T7 through T9 vertebral bodies.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, pancreas, spleen, adrenal\n glands, and kidneys appear unchanged. The bile duct measures 9 mm, not\n changed from prior study. There is no evidence of free fluid or free air\n within the abdomen. Scattered mesenteric lymph nodes again seen, however,\n none appear to meet CT criteria for pathologic enlargement.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid appear\n unremarkable. Small amount of air is noted within the bladder, correlate with\n recent catheterization. Small area of enhancement again noted within the left\n psoas muscle, previously described as abscess, not significantly changed from\n (Over)\n\n 5:45 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: r/o PE\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior study.\n\n BONE WINDOWS: Again seen is destruction of the T7 through T9 vertebral\n bodies. Degenerative changes also again noted within the spine, most notably\n at the L5 level.\n\n Multiplanar reformatted images confirm the axial findings.\n\n IMPRESSION:\n\n 1. No evidence of acute pulmonary embolism.\n\n 2. Multiple peripheral densities again seen within both lungs. There is\n improvement of the density in the left lung consistent with improving septic\n emboli. New linear nodular opacity in the right lung, possibly represents\n atelectasis.\n\n 3. Again seen is paraspinal abscess with soft tissue inflammatory changes in\n the mid thoracic spine, not significantly changed to slightly increased in\n size compared to , however, decreased in size compared to .\n Destruction of T7 through T9 vertebral body is again seen.\n\n 4. No significant change in the small area of enhancement seen within the\n left iliopsoas muscle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-18 00:00:00.000",
"description": "REPOSITION CATHETER",
"row_id": 915329,
"text": " 1:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please adjust PICC (loops around)\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with bacteremia on IV abx, PICC placed in IR has now coiled\n on itself\n REASON FOR THIS EXAMINATION:\n please adjust PICC (loops around)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Malpositioned PICC.\n\n RADIOLOGISTS: and , with Dr. (the Attending\n Radiologist), being present and supervising the procedure.\n\n The left arm and in situ PICC were prepped and draped in standard sterile\n fashion. A 0.018-inch guidewire was advanced through the red lumen of the\n PICC and the tip was repositioned into the superior vena cava from the left\n brachiocephalic vein, under fluoroscopic guidance. Both lumens of the\n catheter flushed and aspirated well, were capped and heplocked. The catheter\n was fixed in place with a StatLock device and a sterile transparent dressing\n was applied. Final limited chest radiograph confirmed catheter tip position in\n the superior vena cava. The catheter can be used immediately. There were no\n immediate complications.\n\n IMPRESSION: Successful repositioning of the left-sided PICC from the\n subclavian vein to the superior vena cava. The catheter can be used\n immediately.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 912483,
"text": " 3:47 PM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for effusion/empyema\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with multiple MSSA abscesses, septic emboli, spiking through\n Abx\n REASON FOR THIS EXAMINATION:\n Please assess for effusion/empyema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Assessment for effusion or infiltrate in a patient\n with known multiple MSSA abscesses and spiking fever.\n\n PA and lateral upright chest radiograph was reviewed and compared to the\n previous chest CT and portable chest from .\n\n The heart size is normal. Mediastinum has normal position, width, and shape.\n There is a left subclavian vein catheter inserted with its tip in the distal\n superior vena cava. The patient is status post insertion of the subcutaneous\n drain in the right hemithorax. There is no evidence of congestive heart\n failure. There are several discoid atelectases or small consolidations in\n both lower lobes with no change in comparison to the previous film. There is\n no pleural effusion.\n\n IMPRESSION:\n 1. Multiple discoid atelectases and/or small consolidations, stable.\n 2. No evidence of congestive heart failure or significant amount of pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-02 00:00:00.000",
"description": "R CT UP EXT W/C RIGHT",
"row_id": 913250,
"text": " 11:55 AM\n CT UP EXT W/C RIGHT; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please assess for abscess in R hand\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with known abscess in R hand, s/p I&D, now spiking fevers,\n with worsening swelling and erythema in hand.\n REASON FOR THIS EXAMINATION:\n Please assess for abscess in R hand\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Known abscess in the right hand, now status post I&D with spiking\n fevers.\n\n TECHNIQUE: Contiguous axial images were obtained through the right hand after\n the administration of 80 cc Optiray. Nonionic contrast was used secondary to\n patient allergies. Multiplanar reformations were performed.\n\n COMPARISON: Radiographs from .\n\n FINDINGS:\n\n\n The intrnsic soft tissue contrast on this examinaiton is limited due to\n inherent limitations of contrast-enhanced CT for evaluaiton of soft tissues.\n Moreover, there are post-oiperative changes in the region of the thenar\n eminence, with what may represent descreased enhancment of muscles in the\n surgical bed. There is a small, tubular rim- enhancing focus along the volar\n aspect of the hand, adjacent to the flexor tendons. Overall, this measures\n approximately 22 x 7 mm and is best appreciated on the coronal reformatted\n images. Given the patient's history, this could represent a residual\n collection. A thrombosed vessel is considered less likely. Otherwise, no\n obviuos fluid collection is identified.\n\n There are advanced degenerative changes of the first metacarpophalangeal\n joint. There is joint space narrowing, and subluxation is also present. Small\n calcific densities are seen which may represent loose bodies or fragmentation\n at the joint. The osseous structures are otherwise unremarkable in\n appearance.\n\n Evaluation of the flexor and extensor tendons are grossly unremarkable.\n\n IMPRESSION:\n\n 1. Small rim-enhancing tubular structure seen along the volar aspect of the\n hand -- ? tiny residual abcess or less likely thrombosed vessel. Allowing for\n limitations, no more extensive abcess is identified. If clinically indicated,\n ultrasound or MRI might help to further characterize the soft tissue\n findings.\n\n (Over)\n\n 11:55 AM\n CT UP EXT W/C RIGHT; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please assess for abscess in R hand\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Degenerative changes of the first metacarpophalangeal joint.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-03 00:00:00.000",
"description": "IN-111 WHITE BLOOD CELL STUDY",
"row_id": 913223,
"text": "IN-111 WHITE BLOOD CELL STUDY Clip # \n Reason: MULTIPLE ABCESSESS ANY NEW LOCALIZING AREAS?\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 488.0 uCi In-111 WBCs;\n History: inpatient with multiple abscesses, assess for new areas of active\n infection\n\n REPORT:\n\n FINDINGS: Following the injection of autologous white blood cells labeled with\n In-111, images of the whole body were obtained at 24 hours. There is a focus of\n increased uptake in the upper left back. There is a subtle focus of uptake in\n the radial aspect of the hand, the site of recent surgery. There is decreased\n tracer accumulation in a number of mid-thoracic vertebrae, most consistent with\n reported compression abnormalities in T7-T9. Diffuse uptake in the soft tissues\n of the right knee is mildly increased compared to the left knee.\n\n DECISION: SPECT of the chest was performed to better characterize uptake in the\n left upper back.\n\n SPECT FINDINGS: There is a moderate focus of activity in the left back at the\n level of the upper aspect of the left scapula.\n\n CORRELATION is made with a chest CT performed , which shows a left\n paraspinal abscess extending from C7 down to the level of the scapula.\n\n IMPRESSION:\n Increased accumulation of white blood cells near the left scapula, which\n correlates with the region of a previously identified paraspinal abscess.\n\n\n , M.D.\n , M.D. Approved: TUE 4:41 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-23 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 911936,
"text": " 9:19 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Evaluate for cholecystitis, CBD dilatation.\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 yo F with Crohns admitted to MICU with PICC infection c/b septic pulmonary\n nodules, multiple absceses with elevated LFTs, AP and GGT.\n REASON FOR THIS EXAMINATION:\n Evaluate for cholecystitis, CBD dilatation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated LFTs, AP and GGT. Evaluate for cholecystitis, common\n bile duct dilatation, the patient is status post cholecystectomy.\n\n Comparison is made to prior ultrasound of .\n\n FINDINGS: The liver is normal in appearance without focal or textural\n abnormalities. No intrahepatic or extrahepatic biliary dilatation is seen.\n The common bile duct measures 3 mm. The patient is status post\n cholecystectomy. Main portal vein is patent. Spleen appears normal. The\n right kidney measures 10.1 cm in length. The left kidney measures 11.0 cm in\n length. The aorta is normal in diameter. The pancreas appears unremarkable.\n No ascites is seen.\n\n IMPRESSION: Patient is status post cholecystectomy. No intra- or extra-\n hepatic biliary dilatation is seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-30 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 912932,
"text": " 9:47 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please assess for DVTs\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with multiple abscesses with persistent fevers through Abx\n REASON FOR THIS EXAMINATION:\n Please assess for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with multiple abscesses and persistent fevers\n through antibiotics.\n\n FINDINGS: Grayscale and Doppler son of both common femoral, superficial\n femoral, and popliteal veins were performed. Normal flow, augmentation,\n compressibility, and waveforms are demonstrated. Intraluminal thrombus is not\n identified.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-28 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 912756,
"text": " 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Assess iliopsoas abscesses for growth\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with Crohns, septic emboli, persistent fevers.\n\n REASON FOR THIS EXAMINATION:\n Assess iliopsoas abscesses for growth\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old with Crohn disease, septic emboli, paraspinal\n abscess. Assess for interval change.\n\n TECHNIQUE: MDCT images of the abdomen and pelvis after the administration of\n oral and IV contrast. Multiplanar reformatted images were obtained.\n\n COMPARISON: CT thoracentesis and CT abdomen and pelvis, both performed .\n\n CT OF THE ABDOMEN AFTER THE ADMINISTRATION OF ORAL AND IV CONTRAST: A small\n right pleural effusion, which is decreased in size. Atelectatic changes are\n seen at both lung bases. Imaging is performed from the level of the main\n pulmonary artery through the lung bases. The paraspinal abscess collection\n seen anterior to T9-10 is markedly smaller in size. A small amount of fluid\n persists. A right paraspinal drainage catheter remains in place with its tip\n in the posterolateral aspect of this collection. Soft tissue inflammatory\n changes persist in the right paraspinal muscles posterior to T9 through T11.\n The visualized heart, pericardium, and great vessels are normal. Numerous\n nodular opacities in both lung fields are smaller in size consistent with\n improving septic emboli.\n\n The liver, spleen, pancreas, adrenals, kidneys, and intra-abdominal large and\n small bowel are normal in appearance. The common bile duct measures 9 mm, not\n significantly changed from the prior study. There is no free fluid. A few\n small mesenteric lymph nodes are identified, not pathologically enlarged.\n\n CT OF THE PELVIS WITH IV AND ORAL CONTRAST: A Foley catheter is present\n within the bladder. An ileostomy is seen in the right lower quadrant. The\n uterus and visualized small bowel are normal in appearance. No free fluid is\n present within the pelvis. There is no significant lymphadenopathy in the\n pelvis or inguinal regions. There is a tiny left iliopsoas muscle abscess,\n which is unchanged from the prior study measuring 1.3 cm in greatest AP\n dimension.\n\n Osseous structures again demonstrate destruction of the T7 through 9 vertebral\n bodies. Degenerative changes with marked Schmorl nodes are seen in L5 and\n T12.\n\n (Over)\n\n 3:39 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Assess iliopsoas abscesses for growth\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Multiplanar reformatted images confirm the above findings.\n\n IMPRESSION:\n\n 1. Interval decrease in the size of the paraspinal abscess with a drainage\n catheter seen in the posterolateral aspect of the collection.\n\n 2. No change in the size of the left iliopsoas muscle abscess.\n\n 3. Improved appearance of multiple nodular densities seen within both lung\n fields consistent with improving septic emboli.\n\n 4. Destruction of the T7 through 9 vertebral bodies. For additional details,\n please refer to report from the thoracic and cervical spine MRI performed\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 913006,
"text": " 4:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm PICC remains in place after removal of same-s\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with crohn's on immunosupression with fevers, s/p d/c of\n L TLC shortly after placement of L PICC\n REASON FOR THIS EXAMINATION:\n Please confirm PICC remains in place after removal of same-sided TLC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Crohn's, on immunosuppression with fevers, status post PICC line\n and removal of triple lumen catheter.\n\n COMPARISON: and .\n\n FINDINGS: There has been interval placement of a left-sided PICC line with\n the tip malpositioned in the left neck. There has been removal of the\n previously seen left-sided subclavian central venous catheter. A right-sided\n subcutaneous drainage catheter is unchanged. There are poorly defined\n bilateral nodular pulmonary opacities, which are slightly less pronounced than\n the prior study. There is also persistent widening of the right paraspinal\n line consistent with the known paraspinal collection. No new focal areas of\n consolidation or effusion are identified.\n\n IMPRESSION:\n 1. Malpositioned left-sided PICC line.\n 2. Bilateral poorly defined nodular opacities, slightly less pronounced than\n the prior study.\n\n Results were discussed with Dr. at 5:00 p.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-30 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 912941,
"text": " 10:19 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Requesting IR-guided PICC placement in pt with notoriously d\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with known MSSA abscesses on nafcillin, negative blood\n cultures since , though having fevers, moist likely known abscesses\n REASON FOR THIS EXAMINATION:\n Requesting IR-guided PICC placement in pt with notoriously difficult access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with methicillin-sensitive Staphylococcus\n aureus abscesses with negative blood cultures with fevers. Difficult\n intravenous access. Need for long-term antibiotics and total parenteral\n nutrition.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , the\n attending radiologist, was present and supervising for the duration of the\n procedure.\n\n PROCEDURE/FINDINGS: Using ultrasound guidance, the left basilic vein was\n identified and confirmed to be compressible and patent. The left arm was\n prepped and draped in the standard sterile fashion. Using ultrasound\n guidance, the left basilic vein was entered with a 21-gauge introducer needle.\n Hard copy ultrasound images were obtained before and after venous access\n documenting vessel patency. A 0.018 guide wire was passed through the needle\n into the superior vena cava under fluoroscopic guidance. The needle was\n exchanged for a 5 French sheath. Based on the markings on the wire, a length\n of 38 cm was found to be appropriate for the PICC. The PICC was trimmed to\n this length and passed over the wire into the superior vena cava. A final\n fluoroscopic image obtained confirming the tip positioned in the SVC. The\n catheter was secured to the skin using a StatLock device and covered with\n sterile Tegaderm. Both ports flushed easily.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n MEDICATIONS: 1% lidocaine for local anesthesia.\n\n IMPRESSION: Successful placement of a double lumen 38 cm PICC via the left\n basilic vein terminating in the superior vena cava. The line is ready for\n use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-30 00:00:00.000",
"description": "REPOSITION CATHETER",
"row_id": 913013,
"text": " 5:20 PM\n PIC CHECK/REPO Clip # \n Reason: Requesting repositioning of L PICC\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with known MSSA abscesses on nafcillin, negative blood\n cultures since , though having fevers, moist likely known abscesses.\n PICC placed by IR today moved after removing TLC on same side\n REASON FOR THIS EXAMINATION:\n Requesting repositioning of L PICC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with known MSSA abscesses. PICC noted to be\n malpositioned on chest x-ray after removal of central line.\n\n PROCEDURE: performed the procedure with Dr. ,\n the attending radiologist, present and supervising.\n\n The patient was positioned supine on the angiography table. The left upper\n extremity and in situ PICC was prepped and draped in standard sterile fashion.\n Initial scout fluoroscopic radiograph demonstrated the tip of the PICC to be\n within the expected region of the left internal jugular vein. A 0.018-inch\n guidewire was advanced through the PICC and the PICC was repositioned into the\n superior vena cava, however, it appeared to be short. Therefore, the PICC was\n exchanged for a new 5-French double-lumen PICC that was cut to a length of 45\n cm based on the markers on the guidewire. Guidewire was removed. Both lumens\n of the new catheter flushed and aspirated well, were capped and hep-locked.\n The catheter was fixed in place with a StatLock device and a sterile\n transparent dressing was applied. Final limited chest radiograph confirmed\n catheter tip position at the superior vena cava. The catheter can be used\n immediately. There were no immediate complications.\n\n The catheter that was removed measured 38 cm, as was reported on the prior\n insertion.\n\n IMPRESSION: Successful replacement of the in situ 38-cm double-lumen PICC for\n a new 45-cm 5-French double-lumen PICC with tip in the superior vena cava.\n The catheter can be used immediately.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-26 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 912447,
"text": " 12:28 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: eval for residual fluid collection prior to removal of drain\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with paraspinal abscesses s/p pigtail drain placement, drain\n with zero output\n REASON FOR THIS EXAMINATION:\n eval for residual fluid collection prior to removal of drain. pls perform with\n and without contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR CERVICAL AND THORACIC SPINE\n\n CLINICAL INFORMATION: Paraspinal abscess. Status post pigtail drainage\n placement. No output. ? residual fluid collection.\n\n TECHNIQUE: Pre- and post-contrast multiplanar, multisequence MRI of the\n thoracic and cervical spine.\n\n FINDINGS: Comparison is made with prior MR thoracic spine of .\n\n A small-bore catheter is now seen along the right posterior paraspinal soft\n tissue posteriorly, with its tip ending at the T8/T9 anterolateral paraspinal\n soft tissues. Again, there are extensive compression deformities involving\n the T7, T8, and T9 vertebral bodies, with raised T2 signal within the T9\n vertebra and the adjacent intervertebral disks. The prevertebral enhancing T2\n hyperintense soft tissue thickening/mass has slightly decreased in size and\n extent since . The post-contrast images again demonstrate a thin\n sliver of non-enhancing component within this soft tissue abnormality (series\n 17, image 240), stable since the prior study, and a small amount of fluid\n cannot be excluded.\n\n No intrinsic cord signal abnormality is detected. Spinal canal and neural\n foramina are otherwise capacious throughout the thoracic spine.\n\n The previously described right-sided pleural effusion and adjacent atelectasis\n have reduced in extent since the prior study.\n\n Scans of the cervical spine again demonstrate soft tissue thickening related\n to the C1/C2 joint space (series 19, image 270), likely degenerative in\n nature. This remained unchanged in appearance. The previously described\n posterior deep cervical soft tissue multiloculated fluid collection is no\n longer evident on today's study - ? drained. Alignment of the cervical\n vertebrae and the craniocervical junction appears normal. Spinal canal and\n neural foramina are capacious at all levels within the cervical spine.\n\n CONCLUSION:\n\n 1. Extensive bone marrow signal abnormality within the T9 vertebral body,\n (Over)\n\n 12:28 PM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: eval for residual fluid collection prior to removal of drain\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with compression deformity. Prevertebral soft tissue thickening,\n demonstrating enhancement and T2 hyperintense signal has slightly reduced in\n size and extent at that level. A small sliver of fluid within this soft\n tissue abnormality cannot be excluded.\n\n 2. A small right-sided paraspinal drainage catheter is now present at that\n level, the tip of the catheter ending within the phlegmon.\n\n 3. No convincing epidural encroachment or abscess is identified.\n\n 4. Persistent T2 hyperintense signal within the T8/T9 and T9/T10\n intervertebral disks. Compression deformities at T7 and T8 vertebral bodies,\n also altered in appearance.\n\n 5. Previously described posterior deep cervical multiloculated fluid\n collection at the level of C7 is no longer evident - ? drained.\n\n 6. Interval size reduction of the right pleural effusion and underlying\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-05-08 00:00:00.000",
"description": "B CT UP EXT W/C BILAT",
"row_id": 913953,
"text": " 10:08 AM\n CT UP EXT W/C BILAT; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Requesting CT-guided drainage of parascapular abscess\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with known parascapular abscess, from which 1cc was drained\n by IR under CT-guidance previously. Recent wbc scan done persistent fevers,\n still lighting up this region\n REASON FOR THIS EXAMINATION:\n Requesting CT-guided drainage of parascapular abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT scan of the chest performed on .\n\n HISTORY: 55-year-old woman with known left parascapular abscess. Status post\n prior drainage in . Recent WBC scan demonstrated increased uptake\n in this region. Evaluate for persistent collection.\n\n FINDINGS: Comparison is made to the prior WBC scan report from as\n well as CT scan from and CT thoracentesis study from .\n\n The enhancing collection in the left periscapular area extending at the level\n of C7 down for approximately 8 cm is not well seen on today's study. No\n enhancing fluid collection in this region is identified. There is some soft\n tissue stranding and some mild increased density in this area. No drainable\n collection is noted.\n\n There is again seen marked destructive changes, seen of several mid thoracic\n vertebral bodies likely the T8, T9, and T10 vertebral bodies. There is a\n epidural fluid collection which is persistent, however, it is slightly\n decreased when compared to the prior studies.\n\n Several nodular opacities seen throughout both lung fields, which are\n peripherally based. These lesions appear similar to the previous study and\n again may represent either septic emboli or infectious etiology. Overall, the\n appearance of the lungs are unchanged. There are emphysematous changes with\n multiple bullae noted bilaterally. There is a small right-sided pleural\n effusion, which has remained stable in the interim.\n\n There is no axillary, mediastinal, or definite hilar lymphadenopathy. Limited\n images of the upper abdomen are grossly within normal limits. There are joint\n effusions in bilateral shoulders.\n\n IMPRESSION:\n\n 1. There is soft tissue irregularity in the left paraspinal region with no\n discrete enhancing collection. This likely due to improvement of the\n collection; however, due to the early timing of the imaging study with the\n contrast bolus, a rim enhancing collection maybe less apparent.\n\n (Over)\n\n 10:08 AM\n CT UP EXT W/C BILAT; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Requesting CT-guided drainage of parascapular abscess\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Extensive osteomyelitic changes noted of the mid thoracic spine with a\n persistent epidural fluid collection. The collection has decreased slightly\n when compared to the prior study.\n\n 3. Multiple peripherally based nodular opacities throughout both lung fields.\n These can be secondary to septic emboli, however, other infectious etiologies\n should also be considered.\n\n 4. There are bilateral effusion in both shoulder joints.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-05 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 909688,
"text": " 9:39 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: please eval liver/GB for cholestatis/obstruction/thrombosis.\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with septic shock and elevated LFTs/bili.\n REASON FOR THIS EXAMINATION:\n please eval liver/GB for cholestatis/obstruction/thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with septic shock.\n\n TECHNIQUE: scale imaging of the abdomen was performed.\n\n COMPARISON: None.\n\n REPORT.\n\n The liver appears slightly echogenic. No focal intrahepatic mass is seen.\n Portal veins also appear distended suggesting degree of either fluid overload\n or right-sided heart failure. Minimal ascites is seen. The gallbladder is\n not seen. There is no intra or extrahepatic biliary dilatation. Views of the\n midline pancreas are somewhat limited. Note is made in the midline, close to\n where the patient's report stoma is of a fixed loop of bowel that does not\n appear to peristalse much but by its morphology would appear to be small\n bowel. It's diameter measures approximately 3-4 cm. It does not have a\n normal appearance, and correlation with clinical history and possibly CT\n examination is recommended. Both kidneys are normal in size, shape, and\n echotexture. Normal spleen.\n\n CONCLUSION:\n\n 1) No gallbladder seen, presumed surgically absent.\n\n 2) No intra or extrahepatic biliary dilatation. Normal LFTs.\n\n 3) Dilated, aperistaltic loop of midline abnormal appearing bowel. Correlate\n with history and CT. Findings discussed with Dr. at time of\n reporting, approximately 3:00 p.m. on .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-18 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 911417,
"text": " 4:42 PM\n CT CHEST W/O CONTRAST; CT GUIDED NEEDLE PLACTMENT Clip # \n CT THORACENTESIS W/TUBE PLACMENT\n Reason: EVAL FOR HEPATOSPLENIC ABSCESS, DRAIN ABSCESS ON BACK WITHIN PARASPINAL MUSCLES\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n PRELIMINARY ADDENDUM\n\n\n DR. \n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n\n 4:42 PM\n CT CHEST W/O CONTRAST; CT GUIDED NEEDLE PLACTMENT Clip # \n CT THORACENTESIS W/TUBE PLACMENT\n Reason: EVAL FOR HEPATOSPLENIC ABSCESS, DRAIN ABSCESS ON BACK WITHIN PARASPINAL MUSCLES\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with Crohns, septic emboli and altered MS.\n\n REASON FOR THIS EXAMINATION:\n r/o hepatosplenic abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE OF PARAVERTEBRAL COLLECTION AT THE LEVEL OF THE MID\n THORACIC SPINE AND FLUID COLLECTION IN THE MUSCULAR PLANES OF THE POSTERIOR\n BACK\n\n CHEST CT:\n\n Confirmed the presence of a fluid collection within the musculature in the\n periscapular region in the left side situated at the level of C7, extending\n caudally for aproximately 8 cm..\n\n There is redemonstration of a paravertebral collection indenting the posterior\n mediastinum at the level of the mid thoracic spine.\n\n There is pleural thickening in the right hemithorax. There is no pleural\n effusion in the current study.\n\n The airways are patent. There is a small subsegmental atelectasis in the\n right lower lobe. There are also emphysematous changes. Unchanged multiple\n bilateral, predominantly peripheral irregular focal pulmonary opacities\n consistent with septic emboli. Mid thoracic vertebral bodies show mixed\n sclerotic and lytic areas concerning for osteomyelitis, please refer to\n complete description done in recent MR and recent chest CT performed and\n .\n\n PROCEDURE: The risks and benefits of the procedure were explained to the\n patient. Written informed consent was obtained. Preprocedure timeout was\n called to confirm the identity of the patient and the procedure to be\n performed.\n\n With the patient in right lateral decubitus. The patient was prepped and\n draped in the usual sterile fashion. Under continuous CT fluoroscopic\n guidance, after local anesthesia was infiltrated, a 20-gauge needle was\n inserted into the periscapular/cervical collection, 1 cc of hematic material\n was aspirated and sent for microbiology.\n\n After CT localization of paravertebral mid thoracic fluid collection and local\n anesthesia infiltrated into the soft tissue, a 5-French TLA needle was\n inserted into the collection under continious flouroscopic guidance. With\n Seldinger technique, an 8-French catheter was placed into the\n (Over)\n\n 4:42 PM\n CT CHEST W/O CONTRAST; CT GUIDED NEEDLE PLACTMENT Clip # \n CT THORACENTESIS W/TUBE PLACMENT\n Reason: EVAL FOR HEPATOSPLENIC ABSCESS, DRAIN ABSCESS ON BACK WITHIN PARASPINAL MUSCLES\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n collection.\n\n The pigtail was formed and the catheter was secured in place.\n\n Approximately 10 cc of purulent/seropurulent material was obtained and sent\n for microbiology.\n\n There were no complications. The patient tolerated well the procedure.\n\n The attending radiologist, Dr. , was present throughout the procedure.\n\n IMPRESSION: Successful ultrasound-guided placement of a 8-French \n catheter within an anterior paraspinal fluid collection.\n\n Successful CT-guided drainage of subcutaneous periscapular fluid collection.\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-18 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 911419,
"text": " 4:55 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for septic emboli\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with Crohns, septic emboli and altered MS.\n FOR THIS EXAMINATION:\n eval for septic emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JCT WED 5:45 PM\n no hepatosplenic abscess or other acute intraabdominal pathology seen.\n\n small subcutaneous fluid collection posterior to the right inferior epigastric\n artery of unclear significance.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old woman with Crohn disease, septic emboli, and altered\n mental status.\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n with IV contrast. Coronal and sagittal reformatted images were obtained.\n\n CT ABDOMEN: Small rounded opacities are observed at the lung bases consistent\n with patient's known septic emboli. There is right basilar atelectasis and a\n tiny right pleural effusion. The liver, pancreas, spleen, adrenal glands and\n kidneys are unremarkable. There is no free air or free fluid. No mesenteric\n or retroperitoneal lymphadenopathy is identified.\n\n CT PELVIS: The bladder, uterus, adnexa and rectal remnant are unremarkable.\n Right lower quadrant ostomy is unremarkable. There is a small focus of rim\n enhancement and decreased central attenuation measuring approximately 5 mm\n consistent with a psoas abscess. The left iliacus muscle is also somewhat\n symmetric and there is a rounded focus of decreased attenuation. This is also\n concerning for a developing abscess. In the right anterior pelvis\n subcutaneous tissues, there is a 19 x 9 mm cystic collection with rim\n enhancement just posterior to the right inferior epigastric artery.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Irregularity at the inferior endplate of L5 is likely degenerative in nature.\n The disc height appears largely preserved.\n\n IMPRESSION:\n 1. Tiny left psoas and left iliacus abscesses, which are too small to be\n percutaneously drained.\n 2. Small fluid collection in the right anterior pelvic subcutaneous tissues.\n It is unclear whether this is infectious. If this is to be sampled\n percutaneously, caution should be paid to the overlying inferior epigastric\n artery.\n 3. No hepatic or splenic abscess is identified.\n (Over)\n\n 4:55 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for septic emboli\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n These findings were discussed with Dr. at 1:30 p.m. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 909604,
"text": " 2:37 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ?PTX, ?ARDS\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman s/p failed R subclav placement. Intubated w/ARDS per OSH.\n REASON FOR THIS EXAMINATION:\n ?PTX, ?ARDS\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST at 14:56:\n\n INDICATION: Failed right subclavian line placement. Question pneumothorax.\n\n There are no prior films for comparison.\n\n There are subtle cystic lucencies at both lung bases along the diaphragm\n contour. The radiographic appearance favors pneumatoceles related to the\n provided history of ARDS over pneumothoraces, but additional decubitus\n radiographs could be obtained to confirm this impression and to exclude\n basilar pneumothorax if warranted clinically. Nasogastric tube terminates\n approximately 4 1/2 cm above the thoracoabdominal junction. Cardiac\n silhouette is normal in size. There is a bilateral combined alveolar and\n interstitial pattern with the alveolar opacities most prominent in the mid\n lung zone regions.\n\n IMPRESSION: Proximal location of nasogastric tube as communicated by\n telephone to Dr. on .\n\n 2) Cystic lucencies at both lung bases, which may be due to pneumatoceles from\n the provided history of ARDS, but additional decubitus views may be considered\n to exclude basilar pneumothorax given recent intervention. 3) Combined\n alveolar and interstitial opacities which may be due to ARDS but superimposed\n infection is not excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 910501,
"text": " 10:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o new infiltrate\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with crohn's on immunosupression with sepsis resp failure\n now with new fever\n REASON FOR THIS EXAMINATION:\n r/o new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n INDICATION: Sepsis and respiratory failure. Now new fever.\n Immunosuppressed.\n\n FINDINGS: Compared with , there has been further interval clearing of\n the CHF. Bibasilar opacities with air bronchograms consistent with\n atelectasis and/or consolidation, in addition to the right greater than left\n effusions. These findings in the lung bases are new/worse compared with the\n prior study of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 910166,
"text": " 3:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ACUTE RESPIRATORY DISTRESS SYNDROME\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman w/ARDS\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:11 A.M., .\n\n IMPRESSION: AP chest compared to and 29:\n\n Mild pulmonary edema, which improved substantially between and 27 is\n unchanged, but small moderate of bilateral pleural effusions and mediastinal\n vascular engorgement are increasing, indicating that most of the abnormalities\n appeared cardiogenic edema, not ARDS. The cystic quality of the abnormality\n is probably due to coexistent emphysema, though some interstitial lung disease\n cannot be excluded.\n\n Tip of the ET tube at the upper margin of the clavicles is acceptable.\n Bilateral central venous jugular lines end in the upper SVC. There is no\n pneumothorax.\n\n\n"
}
] |
21,202 | 155,154 | 55 year h/o AML, s/p BMT w/ chronic GVHD to skin and liver, on steroids, presenting with hypoxic respiratory failure secondary to parainfluenza infection. # Hypoxic Respiratory Failure - Pt admitted to the ICU with fever, SOB, productive cough, and O2 sat of 86% on RA, improving to 94% on non-rebreather. CTA negative for PE, hypoxia out of proportion to imaging findings of scattered tree-in- opacities. Rapid viral screen returned positive for parainfluenza. Sputum gram stain demonstrated GPCs and GNRs. Sputum culture (prelim) demonstrated commensal flora, yeast, negative PCP. only mildly elevated. No evidence of meningismus. Started on vancomycin/aztreonam empirically for pneumonia as allergic to cipro and cefepime. Doxycycline also added for mycoplasma coverage but this was D/Ced after parainfluenza diagnosis. Patient was gradually weaned from a non rebreather to NC supp O2. He was able to ambulate and maintain O2 sat >90% on RA though still required 2-3L NC O2 to maintain sat >90% while seated in bed. Baseline O2 sat is around 94% RA. He was transferred to the floor for furhter management. Oxygen was continued on a prn basis. Scheduled nebulizers were continued. Mr. developed a rash and vancomycin and aztreonam were discontinued. Oxygen requirement was intermittant. Due to continued malaise and oxygen requirement, Ig levels were drawn and Mr. was determined to be IgG deficient. He recieved IVIG and prednisone was increased to 15 mg daily. His oxygen status improved within 48 hours of these changes. On day of discharge, ambulatory oxygen saturation was 90% and oxygen saturation at rest was 94-96%. He was discharged home to follow-up with Dr. on Monday, . # Abnormal EKG/Lateral ST-depressions and T-wave inversions - Has had similar EKG changes in setting of physiologic stress. ECHO showed EF >55%, borderline pulm HTN, could not rule out WMA due to poor quality of study. Patient was ruled out for MI with negative cardiac enzymes, no further symptoms or EKG changes. . # Hypotension - Responded to IVF and has since remained normotensive. Received stress dose steroids in clinic and on ICU Day 1, given diagnosis of steroid-induced adrenal insufficieny on last hospital admission, but decreased to his home dose the following morning. # Acute Renal Failure - Baseline 0.9-1, 1.5 on presentation. Likely prerenal in etiology given poor po, nausea/vomiting, and hypotension. Rapidly resolved with IV hydration. | Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Noted b/p low for patient 90/60 and tachycardic 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%, cultured and vanco given and brought to ED. Noted b/p low for patient 90/60 and tachycardic 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%, cultured and vanco given and brought to ED. Noted b/p low for patient 90/60 and tachycardic 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%, cultured and vanco given and brought to ED. Noted b/p low for patient 90/60 and tachycardic 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%, cultured and vanco given and brought to ED. Noted b/p low for patient 90/60 and tachycardic 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%, cultured and vanco given and brought to ED. Noted b/p low for patient 90/60 and tachycardic 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%, cultured and vanco given and brought to ED. Pneumonia, bacterial, community acquired (CAP) Assessment: Received the pt on NRB mask,sats 92-97%,diffuse ronchorous breath sounds, productive cough,RR teens Action: Contd droplet precautions,receiving IV vanco/doxy/aztrenam anad acyclovir,received a total of 1L fluid bolus,also receving manitaince fluid at 75cc/hr Response: Ongoing. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Pt reports left sided chest pain, medicated w/1mg dilaudid IV. Allergies: Cefepime Rash; Cipro (Oral) (Ciprofloxacin Hcl) Rash; Last dose of Antibiotics: Doxycycline - 10:05 AM Vancomycin - 08:00 PM Aztreonam - 12:00 AM Acyclovir - 06:00 AM Infusions: Other ICU medications: Heparin Sodium (Prophylaxis) - 08:37 AM Pantoprazole (Protonix) - 08:00 PM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 07:49 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since AM Tmax: 36.2C (97.2 Tcurrent: 36.1C (97 HR: 73 (63 - 95) bpm BP: 156/94(110) {112/67(82) - 156/94(110)} mmHg RR: 10 (9 - 18) insp/min SpO2: 93% Heart rhythm: SR (Sinus Rhythm) Height: 71 Inch Total In: 2,080 mL 177 mL PO: 840 mL TF: IVF: 1,000 mL 177 mL Blood products: Total out: 1,300 mL 725 mL Urine: 1,300 mL 725 mL NG: Stool: Drains: Balance: 780 mL -549 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 93% ABG: ///30/ Physical Examination General: Sleeping but easily arousable, no acute distress, speaking in full sentences without increased respiratory effort Lungs: Good air movement bilaterally; End-inspiratory crackles at R lung base; no wheezes or ronchi Cardiac: RRR; nl S1, S2; no murmurs; distant heart sounds Abd: soft, NT, obesely distended Extr: WWP; 2+ DP on R; 1+ DP on L Labs / Radiology 147 K/uL 14.1 g/dL 96 mg/dL 0.8 mg/dL 30 mEq/L 4.0 mEq/L 16 mg/dL 103 mEq/L 141 mEq/L 41.9 % 6.3 K/uL [image002.jpg] 05:10 PM 08:26 PM 09:05 PM 04:43 AM 05:16 AM 05:36 AM WBC 5.4 6.5 7.9 6.3 Hct 42.8 42.7 43.9 41.9 Plt 113 117 139 147 Cr 1.1 0.8 0.9 0.8 TropT <0.01 <0.01 TCO2 25 Glucose 189 175 113 96 Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB / Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2, Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L, Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL Assessment and Plan Parainfluenza Infection ICU Care Nutrition: Diabetic diet Glycemic Control: See above Lines: 22 Gauge - 12:00 AM Prophylaxis: DVT: Pneumoboots, Subcutaneous heparin Stress ulcer: PPI Comments: Communication: Comments: Wife , cell d Code status: Full code Disposition: c/o to BMT Cardiac: RRR; nl S1, S2; no murmurs Abd: soft, obesely distended, non-tender to palpation Extr: WWP; DPs 2+ on R, 1+ on L Allergies: Cefepime Rash; Cipro (Oral) (Ciprofloxacin Hcl) Rash; Last dose of Antibiotics: Acyclovir - 09:30 PM Vancomycin - 08:19 AM Doxycycline - 11:00 AM Aztreonam - 12:00 AM Infusions: Other ICU medications: Pantoprazole (Protonix) - 08:40 PM Heparin Sodium (Prophylaxis) - 08:40 PM Other medications: Bactrim Folic Acid Vitamin D Budesonide Insulin NPH and Humalog SS Ondansetron PRN Oxycodone Hydromorphone PRN Colace + Senna Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 07:53 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since AM Tmax: 36.5C (97.7 Tcurrent: 36.1C (96.9 HR: 68 (64 - 86) bpm BP: 137/88(100) {106/70(77) - 144/96(107)} mmHg RR: 10 (7 - 18) insp/min SpO2: 93% Heart rhythm: SR (Sinus Rhythm) Height: 71 Inch Total In: 4,021 mL 590 mL PO: 840 mL 240 mL TF: IVF: 3,181 mL 350 mL Blood products: Total out: 2,480 mL 250 mL Urine: 2,480 mL 250 mL NG: Stool: Drains: Balance: 1,541 mL 340 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 93% ABG: ///26/ Physical Examination See above. | 42 | [
{
"category": "Physician ",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402371,
"text": "Chief Complaint: Hypoxia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with hypoxia, fever, and hypotension following 2 days of\n productive cough and lethargy.\n 24 Hour Events:\n No acute events overnight.\n For hypoxia, pt maintained on non rebreather mask overnight, with O2\n sat between 93-98%. On attempt to lower FiO2 this morning, O2 sat\n dropped to 85% on RA, 88% on 6L NC, and 88% on 35% FiO2 via Venti mask.\n Pt was switched back to the non rebreather, then transitioned to a cool\n nebulizer, with O2 sat maintained at approx 95%.\n Pt remained afebrile and hemodynamically stable overnight. He received\n a 1L NS bolus and was started on maintenance fluids, given no PO\n intake.\n Cardiac enzymes #2 and #3 returned negative.\n This morning, pt reports feeling much better, though he woke up\n drenched in sweat. He reports increased productive cough but denies\n dyspnea, chest pain (including pleurisy), nausea, abd pain, dizziness,\n palpitations, headache. His chronic LUE pain is well controlled. He\n expressed an interest in breakfast.\n On exam:\n General: Less somnolent than last night, easily arousable and\n appropriately interactive; oriented x3; no acute distress; able to\n speak in full sentences without increased respiratory effort\n HEENT: Sclera anicteric, conjunctive non-injected, MMM, oropharynx\n clear w/o exudates or lesions, no bulging tonsils\n Neck: Thick, supple, JVP not elevated\n Lungs: Good air movement on L; poor air movement on R; scattered ronchi\n and crackles at both lung bases\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, obesely distended, no rebound tenderness or guarding,\n no organomegaly\n GU: No foley\n Ext: Warm, well perfused; DPs present (1+ on L, 2+ on R), no clubbing,\n cyanosis or edema; bruising on arms and legs\n Neuro: No focal deficits. No pronator drift; finger tapping intact\n bilaterally; 5/5 strength in lower extremities.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendCefepime\n ;\n Cipro (Oral) (Ciprofloxacin Hcl)\n ;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Acyclovir - 09:30 PM\n Doxycycline - 10:30 PM\n Aztreonam - 11:52 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Pantoprazole (Protonix) - 09:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 70 (70 - 95) bpm\n BP: 120/82(90) {97/69(75) - 152/102(104)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,619 mL\n 1,530 mL\n PO:\n TF:\n IVF:\n 619 mL\n 1,530 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,050 mL\n Urine:\n 800 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: 7.43/37/80./22/0\n PaO2 / FiO2: 80\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 117 K/uL\n 14.8 g/dL\n 175 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 13 mg/dL\n 105 mEq/L\n 138 mEq/L\n 42.7 %\n 6.5 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n WBC\n 5.4\n 6.5\n Hct\n 42.8\n 42.7\n Plt\n 113\n 117\n Cr\n 1.1\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n Other labs: PT / PTT / INR:11.7/31.7/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with profound hypoxia, fever, and productive cough, likely\n secondary to community-acquired pneumonia.\n #) Hypoxic Respiratory Failure: Several possible explanations, but\n infectious process is most likely, given fever and productive cough in\n a susceptible host, with CXR demonstrating areas of infiltrate at bases\n bilaterally (R>L), and CT demonstrating scattered GGOs and areas of\n nodularity in both lung fields. Atypical vs typical etiology.\n Legionella ruled out by negative urinary antigen. PCP unlikely, given\n LDH and current ppx regimen. Infection superimposed on\n underlying lung disease (possibly GVHD to lung, less likely pulmonary\n hypertension untreated OSA or emphysematous changes) might account\n for why the patient's hypoxia appears out of proportion to the findings\n on CT. At baseline, pt\ns DLCO is 50% and RA O2 sat is low-to-mid 90s.\n Possible, though less likely, that the patient has an intracardiac\n shunt (e.g. PFO) contributing to hypoxia in the setting of increased\n R-sided pressures from infection-driven hypoxia-induced\n vasoconstriction, which may be reflected in the RV strain pattern on\n EKG. No evidence of hypercarbic respiratory failure on ABG. PE ruled\n out by the CT angiogram. No prior history or exam/imaging findings to\n support diagnosis of CHF or COPD exacerbation.\n -Attempt to lower FiO2\n -Consider a trial of mask ventilation if O2 Sat < 90% on non rebreather\n -Vancomycin 1g IV Q12H (Day 1 is ) for Gram positive coverage\n -Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram negative coverage,\n given allergy to cephalosporins and quinolones\n -Doxycycline 100mg IV Q12H (Day 1 is ) for mycoplasma coverage\n -f/u blood cultures, CMV viral load\n -f/u Viral DFA panel\n -f/u Sputum culture and gram stain, including fungal cx and PCP stain\n off on Echo with bubble study to r/o intracardiac shunt/PFO,\n given infectious etiology most likely explanation for hypoxia\n -TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Hypotension: dehydration, fluid responsive, now resolved.\n Initially concerning for sepsis vs adrenal insufficiency.\n -D/C stress-dose steroids\n -Resume home steroid regimen of 10mg prednisone PO daily\n -Advance diet\n -D/C maintenance fluids\n -Infectious work-up, as above\n #) EKG Changes: ST-segment depressions and T-wave inversions initially\n concerning for demand ischemia in the setting of infection, but the\n ST-segment changes are an exaggeration of a baseline abnormality, and\n the patient ruled out for MI.\n -Repeat EKG today\n #) Thrombocytopenia: Plt count 140s on admission, then 113 last night,\n down from 220s in . Plt count stable in 110s this morning. Most\n likely explanation is medication side effect. Both sulfa drugs and\n vancomycin can cause thrombocytopenia, though the time course is not\n right for either. Another possible explanation is HIT Type 1, although\n the patient's plt count was down from baseline prior to administration\n of subcutaneous heparin on the floor. ITP always possible, though this\n would be a diagnosis of exclusion.\n -Trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Pt has been maintaining BS in 130s with 12\n units NPH in AM. No PO intake in past three days. Despite this,\n inpatient BS are 170s-180s, most likely stress-dose steroids.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that GVHD to the lung is contributing to\n the patient\ns hypoxia, as discussed above, though this is not a\n diagnosis we would make in the inpatient setting.\n -Continue steroids, as above\n -TMP-SMX 1 Tab DS Daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) : Pre-renal picture, now resolved. Creatinine 1.5 on admission,\n up from baseline of 0.9-1.0, with return to baseline following\n hydration.\n -Trend creatinine\n #) Nausea: Pt has 3-month hx of nausea/vomiting. GI work-up was\n essentially unrevealing. Barium swallow indicated mild esophagitis. EGD\n noted small hiatal hernia; biopsies were negative. H pylori studies\n were negative. Gastric emptying studying was normal. Hospital admission\n in for this CC concluded that DDX included GERD vs adrenal\n insufficiency.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Start bowel regimen: Colace + Senna\n #) Headache: Resolved. Pt was somnolent last night but had normal\n mental status otherwise. Concern would be for meningeal infection,\n though pt continues to have no focal neuro deficits or meningeal signs\n on exam.\n -LP if meningeal signs or neuro deficit develops, or headache returns\n and becomes unresponsive to pain meds\n -Acetaminophen PRN for pain\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n ICU Care\n Nutrition: Diabetic diet, as tolerated\n Glycemic Control: See above\n Lines:\n 18 Gauge - 06:51 PM\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: on PPI, as above\n VAP:\n Comments:\n Communication: Comments: Patient, patient's wife (cell\n )\n Code status: Full code\n Disposition: Pending improvement in hypoxia, ability to maintain O2 sat\n >93% on NC O2\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402373,
"text": "Chief Complaint: Hypoxia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with hypoxia, fever, and hypotension following 2 days of\n productive cough and lethargy.\n 24 Hour Events:\n No acute events overnight.\n For hypoxia, pt maintained on non rebreather mask overnight, with O2\n sat between 93-98%. On attempt to lower FiO2 this morning, O2 sat\n dropped to 85% on RA, 88% on 6L NC, and 88% on 35% FiO2 via Venti mask.\n Pt was switched back to the non rebreather, then transitioned to a cool\n nebulizer, with O2 sat maintained at approx 95%.\n For hypotension, pt received a 1L NS bolus last night and was started\n on maintenance fluids, given no PO intake. He remained afebrile and\n hemodynamically stable overnight.\n Cardiac enzyme sets 2 and 3 returned negative. Repeat EKG @ 8pm\n demonstrated NSR @ 86bpm; 1mm ST-segment depression in V4=V5,\n persistent T-wave inversions in V2-V6.\n This morning, pt reports feeling much better, though he woke up\n drenched in sweat. He reports increased productive cough but denies\n dyspnea, chest pain (including pleurisy), nausea, abd pain, dizziness,\n palpitations, headache. His chronic LUE pain is well controlled. He\n expressed an interest in breakfast.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendCefepime\n ;\n Cipro (Oral) (Ciprofloxacin Hcl)\n ;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Acyclovir - 09:30 PM\n Doxycycline - 10:30 PM\n Aztreonam - 11:52 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Pantoprazole (Protonix) - 09:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 70 (70 - 95) bpm\n BP: 120/82(90) {97/69(75) - 152/102(104)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,619 mL\n 1,530 mL\n PO:\n TF:\n IVF:\n 619 mL\n 1,530 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,050 mL\n Urine:\n 800 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: Cool nebulizer\n SpO2: 95%\n ABG: 7.43/37/80./22/0\n PaO2 / FiO2: 80\n Physical Examination\n General: Less somnolent than last night, easily arousable and\n appropriately interactive; oriented x3; no acute distress; able to\n speak in full sentences without increased respiratory effort\n HEENT: Sclera anicteric, conjunctive non-injected, MMM, oropharynx\n clear w/o exudates or lesions, no bulging tonsils\n Neck: Thick, supple, JVP not elevated\n Lungs: Good air movement on L; poor air movement on R; scattered ronchi\n and crackles at both lung bases\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Soft, obesely distended, no rebound tenderness or guarding,\n no organomegaly.\n GU: No foley.\n Ext: Warm, well perfused; DPs present (1+ on L, 2+ on R), no clubbing,\n cyanosis or edema; bruising on arms and legs\n Neuro: No focal deficits. No pronator drift; finger tapping intact\n bilaterally; 5/5 strength in lower extremities.\n Labs / Radiology\n 117 K/uL\n 14.8 g/dL\n 175 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 13 mg/dL\n 105 mEq/L\n 138 mEq/L\n 42.7 %\n 6.5 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n WBC\n 5.4\n 6.5\n Hct\n 42.8\n 42.7\n Plt\n 113\n 117\n Cr\n 1.1\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n Other labs: PT / PTT / INR:11.7/31.7/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n CXR : Area of opacification at R medial lung base.\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with profound hypoxia, fever, and productive cough, likely\n secondary to community-acquired pneumonia.\n #) Hypoxic Respiratory Failure CAP: Several possible explanations,\n but infectious process is most likely, given fever and productive cough\n in a susceptible host, with CXR demonstrating areas of opacification at\n lung bases bilaterally (R>L), and CT demonstrating scattered GGOs and\n areas of nodularity in both lung fields. Atypical vs typical etiology.\n Legionella ruled out by negative urinary antigen. PCP unlikely, given\n LDH and current ppx regimen. Infection superimposed on\n underlying lung disease (possibly GVHD to lung, less likely pulmonary\n hypertension untreated OSA or emphysematous changes) might account\n for why the patient's hypoxia appears out of proportion to the findings\n on CT. At baseline, pt\ns DLCO is 50% and RA O2 sat is low-to-mid 90s.\n Possible, though less likely, that the patient has an intracardiac\n shunt (e.g. PFO) contributing to hypoxia in the setting of increased\n R-sided pressures from infection-driven hypoxia-induced\n vasoconstriction, which may be reflected in the RV strain pattern on\n EKG. No evidence of hypercarbic respiratory failure on ABG. PE ruled\n out by the CT angiogram. No prior history or exam/imaging findings to\n support diagnosis of CHF or COPD exacerbation.\n -Attempt to lower FiO2\n -Consider a trial of mask ventilation if O2 Sat < 90% on non rebreather\n -Vancomycin 1g IV Q12H (Day 1 is ) for Gram positive coverage\n -Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram negative coverage,\n given allergy to cephalosporins and quinolones\n -Doxycycline 100mg IV Q12H (Day 1 is ) for mycoplasma coverage\n -f/u blood cultures, CMV viral load\n -f/u Viral DFA panel\n -f/u Sputum culture and gram stain, including fungal cx and PCP stain\n off on Echo with bubble study to r/o intracardiac shunt/PFO,\n given infectious etiology most likely explanation for hypoxia\n -TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n -PA/Lateral CXR tomorrow\n #) Hypotension: dehydration, fluid responsive, now resolved.\n Initially concerning for sepsis vs adrenal insufficiency.\n -D/C stress-dose steroids\n -Resume home steroid regimen of 10mg prednisone PO daily\n -Advance diet\n -D/C maintenance fluids\n -Infectious work-up, as above\n #) EKG Changes: ST-segment depressions and T-wave inversions initially\n concerning for demand ischemia in the setting of infection, but the\n ST-segment changes are an exaggeration of a baseline abnormality, and\n the patient ruled out for MI.\n -Repeat EKG today\n #) Thrombocytopenia: Plt count 140s on admission, then 113 last night,\n down from 220s in . Plt count stable in 110s this morning. Most\n likely explanation is medication side effect. Sulfa drugs, vancomycin,\n and pantoprazole can cause thrombocytopenia, though the time course is\n not right for any of these medications. Another possible explanation is\n HIT Type 1, although the patient's plt count was down from baseline\n prior to administration of subcutaneous heparin on the floor. ITP\n always possible, though this would be a diagnosis of exclusion.\n -Trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Pt has been maintaining BS in 130s with 12\n units NPH in AM. No PO intake in past three days. Despite this,\n inpatient BS are 170s-180s, most likely stress-dose steroids.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that GVHD to the lung is contributing to\n the patient\ns hypoxia, as discussed above, though this is not a\n diagnosis we would make in the inpatient setting.\n -Continue steroids, as above\n -TMP-SMX 1 Tab DS Daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) : Pre-renal picture, now resolved. Creatinine 1.5 on admission,\n up from baseline of 0.9-1.0, with return to baseline following\n hydration.\n -Trend creatinine\n #) Nausea: Pt has 3-month hx of nausea/vomiting. GI work-up was\n essentially unrevealing. Barium swallow indicated mild esophagitis. EGD\n noted small hiatal hernia; biopsies were negative. H pylori studies\n were negative. Gastric emptying studying was normal. Hospital admission\n in for this CC concluded that DDX included GERD vs adrenal\n insufficiency.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Start bowel regimen: Colace + Senna\n #) Headache: Resolved. Pt was somnolent last night but had normal MS\n otherwise. Concern is for meningeal infection, though pt continues to\n have no focal neuro deficits or meningeal signs on exam.\n -LP if meningeal signs or neuro deficit develops, or headache returns\n and becomes unresponsive to pain meds\n -Acetaminophen PRN for pain\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n #) Electrolyes: Calcium of 8.1 converts to 8.8 when corrected for\n albumin of 3.5.\n -Trend Calcium\n -Replete lytes as necessary\n ICU Care\n Nutrition: Diabetic diet, as tolerated\n Glycemic Control: See above\n Lines:\n 18 Gauge - 06:51 PM\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: on PPI, as above\n VAP:\n Comments:\n Communication: Comments: Patient, patient's wife (cell\n )\n Code status: Full code\n Disposition: Pending improvement in hypoxia, ability to maintain O2 sat\n >93% on NC O2\n"
},
{
"category": "ECG",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Report",
"row_id": 226012,
"text": "Sinus rhythm. Diffuse ST-T wave abnormalities are non-specific but clinical\ncorrelation is suggested. Since the previous tracing of the rate is\nslower and ST-T wave changes appear slightly less prominent but there may be no\nsignificant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Report",
"row_id": 226013,
"text": "Sinus rhythm. Diffuse ST-T wave abnormalities are non-specific but cannot\nexclude myocardial ischemia. Clinical correlation is suggested. Since the\nprevious tracing of same date sinus tachycardia is absent and ST-T wave\nabnormalities have decreased.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Report",
"row_id": 226014,
"text": "Sinus tachycardia. Diffuse ST-T wave abnormalities may be due to myocardial\nischemia. Clinical correlation is suggested. Since the previous tracing\nof sinus tachycardia rate is faster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Report",
"row_id": 226015,
"text": "Sinus tachycardia. Diffuse ST-T wave changes in the anterolateral leads may be\ndue to myocardial ischemia or drug or metabolic effect. Clinical correlation\nis suggested. Compared to the previous tracing of the ST segment\nchanges are more accentuated on the current tracing.\n\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402430,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n course involved maintenance on NRB mask overnight initially with\n sat range 93-98. Attempt at titrating O2 down after 24 hours with sats\n dropping to 85% on RA. Course involved cool neb mask, back to NRB and\n eventual titration to NC yesterday.\n Pneumonia, bacterial, community acquired (CAP) hypoxia\n Assessment:\n Lungs with some scattered rhonchi, decreased to bases. Sats >93%.\n Congested productive cough.\n r/o for influenza\n+paraflu. Afebrile.\n Action:\n Titrated from 6L NC to 3L NC without event.\n Response:\n Maintaining good sats with nc-though when NC off, pt did desat to\n 89-90. Able to illicit strong cough. Tol PO\n Plan:\n -Continue to encourage cough and deep breathe\n -OOB as tolerates\n ** Medicated ATC for chronic pain and also requested x 1 dilaudid po\n for breakthrough pain.\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 402431,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n course involved maintenance on NRB mask overnight initially with\n sat range 93-98. Attempt at titrating O2 down after 24 hours with sats\n dropping to 85% on RA. Course involved cool neb mask, back to NRB and\n eventual titration to NC yesterday.\n Pneumonia, bacterial, community acquired (CAP) hypoxia\n Assessment:\n Lungs with some scattered rhonchi, decreased to bases. Sats >93%.\n Congested productive cough.\n r/o for influenza\n+paraflu. Afebrile.\n Action:\n Titrated from 6L NC to 3L NC without event.\n Response:\n Maintaining good sats with nc-though when NC off, pt did desat to\n 89-90. Able to illicit strong cough. Tol PO\n Plan:\n -Continue to encourage cough and deep breathe\n -OOB as tolerates\n ** Medicated ATC for chronic pain and also requested x 1 dilaudid po\n for breakthrough pain.\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402630,
"text": "Chief Complaint: Parainfluenza Infection\n 55yM with h/x of AML, s/p allogenic BMT in complicated by GVHD to\n skin and lung, on steroids, presenting with hypoxic respiratory failure\n secondary to parainfluenza type 1 infection.\n 24 Hour Events:\n CALLED OUT\n Afebrile. Hemodynamically stable. Able to ambulate around pod\n maintaining O2 sat >90% on RA. On 2L NC while in bed, switched to 3L NC\n overnight after O2 sat <90%. This AM: on 3L NC, with O2 sat 97%. Per\n patient, he was wheezing overnight, but not this AM. No cough, SOB, CP.\n Preliminary sputum cx\n commensal flora. Antibiotics were continued\n despite low suspicion for bacterial superinfection, given pt is s/p\n BMT.\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Doxycycline - 10:05 AM\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:37 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Vitamin D\n Folic Acid\n Oxycodone SR\n Budesonide\n Insulin, NPH and Humalog SS\n Hydromorphone PRN\n Ondansetron PRN\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 95) bpm\n BP: 156/94(110) {112/67(82) - 156/94(110)} mmHg\n RR: 10 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,080 mL\n 177 mL\n PO:\n 840 mL\n TF:\n IVF:\n 1,000 mL\n 177 mL\n Blood products:\n Total out:\n 1,300 mL\n 725 mL\n Urine:\n 1,300 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///30/\n Physical Examination\n General: Sleeping but easily arousable, no acute distress, speaking in\n full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally; End-inspiratory crackles at R\n lung base; no wheezes on 8am exam, but end-inspiratory wheezes present\n bilaterally on 12noon team rounds.\n Cardiac: RRR; nl S1, S2; no murmurs; distant heart sounds\n Abd: soft, NT, obesely distended\n Extr: WWP; 2+ DP on R; 1+ DP on L\n Labs / Radiology\n 147 K/uL\n 14.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 41.9 %\n 6.3 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n 05:36 AM\n WBC\n 5.4\n 6.5\n 7.9\n 6.3\n Hct\n 42.8\n 42.7\n 43.9\n 41.9\n Plt\n 113\n 117\n 139\n 147\n Cr\n 1.1\n 0.8\n 0.9\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n 96\n Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL\n Microbiology\n Sputum culture (preliminary)\n Heavy growth of commensal flora\n Fungal culture (preliminary)\n Yeast\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n #) Hypoxic Respiratory Failure parainfluenza infection: Clinically\n improved, though now with symptomatic bronchoconstriction \n infection. Able to maintain O2 sat >90% on RA while ambulating but not\n while sleeping. Bacterial superinfection unlikely, given growth of\n commensal flora on sputum cx.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue ambulation around floor\n -Nebulizers PRN for wheezing\n -Per BMT: continue abx for now, BMT will make decision about d/c on\n floor\n -f/u final sputum cx and fungal cx\n -f/u blood cx\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Thrombocytopenia: Count dropped to 110s from baseline of 200s on\n this admission but is now recovering and in the 140s today. Explanation\n unclear; likely medication side effect, given that the patient is on\n multiple drugs (Bactrim, PPI, Vanc) that can affect the plt count.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Fingerstick BS were 300 at 12noon and 6pm\n yesterday, respectively. Better control overnight and this morning.\n Possible that AM NPH dose needs to be increased, though this change\n should be made in the outpatient setting.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that pt has GVHD involvement in the lung,\n given hypoxia out of proportion to CXR and CT findings on admission.\n -Continue home dose steroids: Prednisone 10mg PO daily\n -TMP-SMX 1 Tab DS daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) Nausea: Pt currently asymptomatic but has 3-month hx of\n nausea/vomiting attributed to GERD vs esophagitis vs adrenal\n insufficiency vs GVDH involvement in the gut.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID for gut GVHD\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Continue bowel regimen: Colace + Senna\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI\n Comments:\n Communication: Comments: Wife , cell d\n Code status: Full code\n Disposition: c/o to BMT\n ------ Protected Section ------\n Agree with data & plan as above.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402339,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on NRB mask,sats 92-97%,diffuse ronchorous breath\n sounds, productive cough,RR teens\n Action:\n Contd droplet precautions,receiving IV vanco/doxy/aztrenam anad\n acyclovir,received a total of 1L fluid bolus,also receving manitaince\n fluid at 75cc/hr\n Response:\n Ongoing. Sats low to mid 90\ns,no sob. Pt was sweating this am,no chest\n pain,CE were flat, FS 185(as per the pt he had similar episode at\n home)\nattempted to wean to NC but sats dropped to 87%on 6L ,attempted\n vent mask 35% but desats to 88% currently back to NRB\n Plan:\n Continue to follow the resp status,cont abx,Need induce sputum in am.\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402530,
"text": "55 year old AML patient s/p BMT\n07 presented to oncology clinic\n hypoxic, + para influenza, on contact precaution.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received on 3 liters O2 via nasal cannula, denies SOB, lung sounds dim\n at bases; no coughing noted\n Action:\n Doxicycline dc\nd; OOB to chair and ambulate around the unit; O2 wean\n down to 2 lpm\n Response:\n Denies SOB, afebrile, O2 sats > 90% at room air\n Plan:\n Continue vancomycin, acyclovir, aztreonam, bactrim and prednisone\n Oriented x 3, steady gait with walking\n Stable BP 110\ns, NSR\n + bowel sounds, no BM this shift, poor appetite\n Voided 2x total of 650cc clear yellow urine\n Skin intact but several bruises noted on all extremities\n 1 PIV working well\n Patient\ns daughter visited, updates given\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402427,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n course involved maintenance on NRB mask overnight initially with\n sat range 93-98. Attempt at titrating O2 down after 24 hours with sats\n dropping to 85% on RA.\n Pneumonia, bacterial, community acquired (CAP) hypoxia\n Assessment:\n Pt required 100% NRB to maintain sats in 90\ns. rr 20\n Congested productive cough.\n r/o for influenza\n+paraflu\n afebrile\n Action:\n Changed pt to 5l nc while sitting on side of bed\n Response:\n Maintaining good sats with nc\n Plan:\n Continue to encourage cough and deep breathe\n OOB as tolerates\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402334,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on NRB mask,sats 92-97%,diffuse ronchorous breath\n sounds, productive cough,RR teens\n Action:\n Contd droplet precautions,receiving IV vanco/doxy/aztrenam anad\n acyclovir,received a total of 1L fluid bolus,also receving manitaince\n fluid at 75cc/hr\n Response:\n Ongoing. Sats low to mid 90\ns,no sob. Pt was sweating this am,no chest\n pain,CE were flat, FS 185(as per the pt he had similar episode at\n home)\nattempted to wean to NC but sats dropped to 87%on 6L ,back to NRB\n again.\n Plan:\n Continue to follow the resp status,cont abx,possible induce sputum in\n am.\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402426,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt required 100% NRB to maintain sats in 90\ns. rr 20\n Congested productive cough.\n r/o for influenza\n+paraflu\n afebrile\n Action:\n Changed pt to 5l nc while sitting on side of bed\n Response:\n Maintaining good sats with nc\n Plan:\n Continue to encourage cough and deep breathe\n OOB as tolerates\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402523,
"text": "55 year old AML patient s/p BMT\n07 presented to oncology clinic\n hypoxic, + para influenza, on contact precaution.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received on 3 liters O2 via nasal cannula, denies SOB, lung sounds dim\n at bases; no coughing noted\n Action:\n Doxicycline dc\nd; OOB to chair and ambulate around the unit; O2 wean\n down to 2 lpm\n Response:\n Denies SOB, afebrile, O2 sats > 90% at room air\n Plan:\n Continue vancomycin, acyclovir, aztreonam, bactrim and prednisone\n Oriented x 3, steady gait with walking\n Stable BP 110\ns, NSR\n + bowel sounds, no BM this shift, poor appetite\n Voided 2x total of 650cc clear yellow urine\n Skin intact but several bruises noted on all extremities\n 1 PIV working well\n Patient\ns daughter visited\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402600,
"text": "Chief Complaint: Parainfluenza Infection\n 55yM with h/x of AML, s/p allogenic BMT in complicated by GVHD to\n skin and lung, on steroids, presenting with hypoxic respiratory failure\n secondary to parainfluenza type 1 infection.\n 24 Hour Events:\n CALLED OUT\n Afebrile. Hemodynamically stable. Able to ambulate around pod\n maintaining O2 sat >90% on RA. On 2L NC while in bed, switched to 3L NC\n overnight after O2 sat <90%. This AM: on 3L NC, with O2 sat 97%. Per\n patient, he was wheezing overnight, but not this AM. No cough, SOB, CP.\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Doxycycline - 10:05 AM\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:37 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 95) bpm\n BP: 156/94(110) {112/67(82) - 156/94(110)} mmHg\n RR: 10 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,080 mL\n 177 mL\n PO:\n 840 mL\n TF:\n IVF:\n 1,000 mL\n 177 mL\n Blood products:\n Total out:\n 1,300 mL\n 725 mL\n Urine:\n 1,300 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///30/\n Physical Examination\n General: Sleeping but easily arousable, no acute distress, speaking in\n full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally; End-inspiratory crackles at R\n lung base; no wheezes or ronchi\n Cardiac: RRR; nl S1, S2; no murmurs; distant heart sounds\n Abd: soft, NT, obesely distended\n Extr: WWP; 2+ DP on R; 1+ DP on L\n Labs / Radiology\n 147 K/uL\n 14.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 41.9 %\n 6.3 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n 05:36 AM\n WBC\n 5.4\n 6.5\n 7.9\n 6.3\n Hct\n 42.8\n 42.7\n 43.9\n 41.9\n Plt\n 113\n 117\n 139\n 147\n Cr\n 1.1\n 0.8\n 0.9\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n 96\n Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n Parainfluenza Infection\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI\n Comments:\n Communication: Comments: Wife , cell d\n Code status: Full code\n Disposition: c/o to BMT\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402602,
"text": "Chief Complaint: Parainfluenza Infection\n 55yM with h/x of AML, s/p allogenic BMT in complicated by GVHD to\n skin and lung, on steroids, presenting with hypoxic respiratory failure\n secondary to parainfluenza type 1 infection.\n 24 Hour Events:\n CALLED OUT\n Afebrile. Hemodynamically stable. Able to ambulate around pod\n maintaining O2 sat >90% on RA. On 2L NC while in bed, switched to 3L NC\n overnight after O2 sat <90%. This AM: on 3L NC, with O2 sat 97%. Per\n patient, he was wheezing overnight, but not this AM. No cough, SOB, CP.\n Preliminary sputum cx\n commensal flora.\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Doxycycline - 10:05 AM\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:37 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Vitamin D\n Folic Acid\n Oxycodone SR\n Budesonide\n Insulin, NPH and Humalog SS\n Hydromorphone PRN\n Ondansetron PRN\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 95) bpm\n BP: 156/94(110) {112/67(82) - 156/94(110)} mmHg\n RR: 10 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,080 mL\n 177 mL\n PO:\n 840 mL\n TF:\n IVF:\n 1,000 mL\n 177 mL\n Blood products:\n Total out:\n 1,300 mL\n 725 mL\n Urine:\n 1,300 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///30/\n Physical Examination\n General: Sleeping but easily arousable, no acute distress, speaking in\n full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally; End-inspiratory crackles at R\n lung base; no wheezes or ronchi\n Cardiac: RRR; nl S1, S2; no murmurs; distant heart sounds\n Abd: soft, NT, obesely distended\n Extr: WWP; 2+ DP on R; 1+ DP on L\n Labs / Radiology\n 147 K/uL\n 14.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 41.9 %\n 6.3 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n 05:36 AM\n WBC\n 5.4\n 6.5\n 7.9\n 6.3\n Hct\n 42.8\n 42.7\n 43.9\n 41.9\n Plt\n 113\n 117\n 139\n 147\n Cr\n 1.1\n 0.8\n 0.9\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n 96\n Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL\n Microbiology\n Sputum culture (preliminary)\n Heavy growth of commensal flora\n Fungal culture (preliminary)\n Yeast\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n #) Hypoxic Respiratory Failure Parainfluenza infection: Clinically\n improved. Able to maintain O2 sat >90% on RA while ambulating but not\n while sleeping. Bacterial superinfection unlikely, given growth of\n commensal flora on sputum cx, but plan to continue abx until final\n speciation is determined.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue ambulation around floor\n -Continue Vancomycin 1g IV Q12H (Day 1 is ) for Gram pos coverage\n -Continue Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram neg\n coverage\n -f/u final sputum cx and fungal cx\n -f/u blood cx\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Thrombocytopenia: Count dropped to 110s from baseline of 200s on\n this admission but is now recovering and in the 140s today. Explanation\n unclear; likely medication side effect, given that the patient is on\n multiple drugs (Bactrim, PPI, Vanc) that can affect the plt count.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Fingerstick BS were 300 at 12noon and 6pm\n yesterday, respectively. Better control overnight and this morning.\n Possible that AM NPH dose needs to be increased, though this change\n should be made in the outpatient setting.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that pt has GVHD involvement in the lung,\n given hypoxia out of proportion to CXR and CT findings.\n -Continue home dose steroids: Prednisone 10mg PO daily\n -TMP-SMX 1 Tab DS daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) Nausea: Pt currently asymptomatic but has 3-month hx of\n nausea/vomiting attributed to GERD vs esophagitis vs adrenal\n insufficiency vs GVDH involvement in the gut.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID for gut GVHD\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Continue bowel regimen: Colace + Senna\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI\n Comments:\n Communication: Comments: Wife , cell d\n Code status: Full code\n Disposition: c/o to BMT\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402294,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n Access: two #18 guage peripherals\n ALL: cefepime and cipro\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received pt on 100% NRB. LS CTA. Pt has congested productive cough.\n Sats 93-96% on NRB. Sats quickly down to 86% when O2 removed.\n Afebrile. WBC 5.4 upon admission.\n Action:\n Pt being r/o for flu and is on droplet precautions. Ordered for Vanco,\n Acyclovir, Aztreanam and Doxy. Given Vanco.\n Response:\n Ongoing. Currently on 100% NRB with sats of 95%.\n Plan:\n Continue to monitor for s/s infection. Continue to administer abx as\n ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 402295,
"text": "TITLE: Intensivist\n I saw and examined the patient, and was physically present with the ICU\n resident (Dr. for the key portions of the services provided. I\n agree with her note, including the assessment and plan. To that I\n would add the following:\n This is a 55 yo man with h/o of AML s/p BMT\n07, presented to \n clinic today with chest congestion/discomfort and cough x 3 days. SBP\n in 90s, HR in 110s in clinic. EKG with lateral TWIs. Hypoxemic with\n sats of 91% on RA. Sent to ED for eval. Required 100% NRB to maintain\n sats in mid 90s in ED. CTA neg for PE but with groung glass in LUL and\n scattered poorly-formed nodular opacity in RUL/RML. Transferred to ICU\n for further management. Here, pt comfortable, c/o chest congestion but\n breathing comfortable appearing. ABG with significant A-a difference:\n 7.43/37/80 on 100% NRB. Exam with scattered rhonchi L > R.\n A/P: Hypoxemia and pulmonary infiltrate in pt with h/o BMT. There is a\n disconnect between his degree of hypoxemia and the severity of his\n infiltrate\n may be that his infiltrate is evolving and will be more\n prominent on subsequent imaging. Will treat overnight with\n vanc/aztreo/doxy (given cipro, cefepime allergies) and obtain a TTE\n with bubble if no improvement overnight in oxygenation. Cont stress\n dose steroids. Will check induced sputum for PCP\n though LDH is\n normal and pt has been on ppx. HR down, bolus 1 additional liter of\n saline and follow urine output.\n Patient is critically ill. Time spent 40 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402355,
"text": "Chief Complaint: Hypoxia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with hypoxia, fever, and hypotension following 2 days of\n productive cough and lethargy.\n 24 Hour Events:\n No acute events overnight. Pt maintained on non rebreather \n overnight, with O2 sat between 93-98%. This morning, O2 sat dropped to\n 85% on RA, 88% on 6L NC, and 88% on 35% FiO2 via Venti , pt was\n switched back to the non rebreather. Pt remained afebrile overnight.\n He was started on maintenance fluids and also bolused with 1L NS, and\n remained hemodynamically stable. Second and third cardiac enzymes were\n negative.\n This morning, he reports feeling much better, though he woke up\n drenched in sweat. He reports continued productive cough but denies\n dyspnea, chest pain (including pleurisy), nausea, abd pain, dizziness,\n palpitations. His chronic LUE pain is well controlled.\n On exam:\n General: Less somnolent than last night, easily arousable and\n appropriately interactive; oriented x3; no acute distress; able to\n speak in full sentences without increased respiratory effort\n HEENT: Sclera anicteric, conjunctive non-injected, MMM, oropharynx\n clear w/o exudates or lesions, no bulging tonsils\n Neck: thick, supple, JVP not elevated\n Lungs: Good air movement and clear lung sounds on L; poor air movement\n with scattered ronchi and crackles at R base\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, obesely distended, no rebound tenderness or guarding,\n no organomegaly\n GU: No foley\n Ext: Wwarm, well perfused; DPs present (1+ on L, 2+ on R), no clubbing,\n cyanosis or edema; bruising on arms and legs\n Neuro: No focal deficits. No pronator drift; finger tapping intact\n bilaterally; 5/5 strength in lower extremities.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendCefepime\n ;\n Cipro (Oral) (Ciprofloxacin Hcl)\n ;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Acyclovir - 09:30 PM\n Doxycycline - 10:30 PM\n Aztreonam - 11:52 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Pantoprazole (Protonix) - 09:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 70 (70 - 95) bpm\n BP: 120/82(90) {97/69(75) - 152/102(104)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,619 mL\n 1,530 mL\n PO:\n TF:\n IVF:\n 619 mL\n 1,530 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,050 mL\n Urine:\n 800 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 98%\n ABG: 7.43/37/80./22/0\n PaO2 / FiO2: 80\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 117 K/uL\n 14.8 g/dL\n 175 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 13 mg/dL\n 105 mEq/L\n 138 mEq/L\n 42.7 %\n 6.5 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n WBC\n 5.4\n 6.5\n Hct\n 42.8\n 42.7\n Plt\n 113\n 117\n Cr\n 1.1\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n Other labs: PT / PTT / INR:11.7/31.7/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n #) Hypoxia: A-a gradient = 587 on 100% FiO2, indicating severe\n hypoxemia. Several posible explanations: Infection most likely, given\n fever and productive cough in a susceptible host, with a CT scan\n demonstrating scattered GGOs and areas of nodularity in both lung\n fields. This pattern suggests an atypical etiology (virus, mycoplasma,\n chlamydia), although the patient should receive empiric abx coverage\n for typical agents as well. Legionella ruled out by negative urinary\n antigen. PCP unlikely, given LDH and current ppx regimen.\n Infection superimposed on underlying lung disease (e.g. pulmonary\n hypertension untreated OSA) might account for why the patient's\n hypoxia appears out of proportion to the findings on CT. At baseline,\n pt's room air O2 sat is in low-to-mid 90s. Possible, though less\n likely, that the patient has an intracardiac shunt (e.g. PFO)\n contributing to hypoxia in the setting of increased R-sided pressures\n from infection-driven hypoxia-induced vasoconstriction, which may be\n reflected in the RV strain pattern on EKG. No evidence of hypercarbic\n respiratory failure on ABG. PE ruled out by the CT angiogram. Patient\n has no prior history or exam/imaging findings to support diagnosis of\n CHF or COPD exacerbation.\n -Attempt to lower FiO2 via Venti \n -Consider a trial of ventilation if O2 Sat < 90% on non rebreather\n -Vancomycin 1g IV Q12H (Day 1 is ) for Gram positive coverage\n -Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram negative coverage,\n given allergy to cephalosporins and quinolones\n -Doxycycline\n -f/u blood cultures, CMV viral load\n -f/u Viral DFA panel\n -Sputum culture and gram stain, including fungal cx and PCP stain\n Echo with bubble study to r/o intracardiac shunt/PFO\n -TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Hypotension: Initially concerning for sepsis but more likely \n dehydration from poor PO intake, given improvement with 2L NS. Also\n possible that patient's underlying steroid-induced adrenal\n insufficiency, diagnosed by stim testing on last admission, is a\n contributing factor.\n -Continue stress-dose steroids: Methylprednisolone Sodium Succ 100 mg\n IV Q8H\n -75cc/hr NS for maintenance, given poor PO intake\n -Infectious work-up, as above\n #) EKG Changes: The ST-segment depressions and T-wave inversions\n concerning for demand ischemia in setting of infection, but the\n ST-segment changes appear to be an exaggeration of a baseline\n abnormality, and the patient ruled out for MI with 3 sets of negative\n cardiac enzymes. The persistent T-wave inversions may be non-specific.\n The S1Q3T3 pattern apparent on the initial EKG from today suggests\n R-heart strain, possibly increased pulmonary vascular resistance\n from hypoxia-induced vasoconstriction, although the strain pattern was\n less evident on repeat EKG.\n -Hold ASA for thrombocytopenia\n #) Thrombocytopenia: Plt count 140s on admission, then 113 last night,\n down from 220s in . Plt count stable in 110s this morning. Most\n likely explanation is medication side effect, as both sulfa drugs and\n vancomycin can cause thrombocytopenia. Another possible explanation is\n HIT Type 1, although the patient's plt count was down from baseline\n prior to administration of subcutaneous heparin on the floor. ITP\n always possible, though this would be a diagnosis of exclusion.\n -Trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Pt has been maintaining BS in 130s with 12\n units NPH in AM. No PO intake in past three days. Inpatient BS are\n 170s-180s despite poor PO intake stress-dose steroids.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. No evidence that GVHD is contributing to the\n patient's lung process.\n -Continue steroids (home dose of prednisone replaced by stress dose\n steroids in inpt setting, see above)\n -TMP-SMX 1 Tab DS Daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n #) : Creatinine 1.5 on admission, up from baseline of 0.9-1.0, with\n return to baseline following 2L NS, suggesting a pre-renal picture. Pt\n received contrast load in EW for CT angio, though this was preceded by\n the 2L NS, and pt's current lab values are not concerning for a\n contrast-induced ATN.\n -Trend creatinine\n #) Nausea: Pt has 3-month hx of nausea/vomiting. GI work-up was\n essentially unrevealing. Barium swallow indicated mild esophagitis. EGD\n noted small hiatal hernia; biopsies were negative. H pylori studies\n were negative. Gastric emptying studying was normal. Hospital admission\n in for this CC concluded that DDX included GERD vs adrenal\n insufficiency.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Start bowel regimen: Colace + Senna\n #) Headache: Improved with pain medication. Pt is somnolent but has\n normal mental status otherwise. Concern is for meningeal infection,\n though pt has no focal neuro deficits or meningeal signs on exam.\n -Low threshhold for LP if meningeal signs or neuro deficit develops,\n headache becomes unresponsive to pain meds\n -Acetaminophen PRN for pain\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n #) FEN:\n -Replete electrolytes\n -Diabetic diet as tolerated\n #) Prophylaxis: Subutaneous heparin for DVT\n #) Access: 2 peripheral IVs\n #) Code: Full\n #) Communication: Patient, patient's wife (cell )\n #) Disposition: Pending improvement in hypoxia, ability to maintain O2\n sat >93% on NC O2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:51 PM\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 402291,
"text": "Chief Complaint: shortness of breath, weakness, hypotension\n HPI:\n 55 year h/o AML, s/p BMT w/ chronic GVHD of the liver, skin, and eye,\n reporting 3 days of productive cough, malaise, nausea, non-bilious,\n non-bloody vomiting x1 and weakness who was seen in clinic today\n with fever to 101, hypotension 90's/50's, tachy 120's, hypoxia 91% on\n RA, 93-94% on 2 L via NC. An EKG was obtained with showed V4-V6 Twave\n inversions prompting further evaluation in the ED. Prior to leaving the\n clinic he received 1 Liter NS, 60 mg Solumedrol (stress dose as pt on\n chronic steroids), vancomycin 1gm IV with blood cultures sent from\n clinic.\n .\n In the ED, initial vs were: T 101.9 HR 117 BP 107/73 RR 24 POX 89% on\n RA. Improved to 95% on a NRB, then on ventimask 50%. Repeat blood\n cultures and urine culture were sent. Patient was given dilaudid,\n aztreonam 2gm IV, benadryl and prochloperazine for headache/belly ache.\n IV access 2 18g PIVs. CTA negative for PE, but did show scattered tree\n in opacities. EKG was not far from baseline and plan established to\n trend CEs per BMT team, no aspirin given low platelets. VS 90\n 126/78 16 97% on 50% ventimask prior to transfer.\n .\n On the floor, patient denied shortness of breath but did report vague\n diffuse chest discomfort, headache, and nausea. Wife reported recent\n course of azithromycin.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Acyclovir - 09:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Pantoprazole (Protonix) - 09:44 PM\n Other medications:\n Acyclovir 400 mg PO Q8H\n Folic Acid 1 mg PO DAILY\n Prednisone 10 mg PO DAILY\n Pantoprazole 40 mg Tablet PO Q12H\n Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY\n Oxycodone SR (60 mg)QAM , (20 mg) Q2PM, and 60mg QPM\n Ranitidine HCl 150 mg PO HS\n Budesonide 3 mg SR PO three times a day.\n Cholecalciferol (Vitamin D3) 400 unit PO DAILY\n Humulin N Twelve (12) units Subcutaneous twice a day.\n Insulin Lispro QACHS Per sliding scale.\n Past medical history:\n Family history:\n Social History:\n - AML-M7: s/p matched unrelated allogenic transplant on \n - Chronic extensive GVHD of skin and liver, liver biopsy \n consistent with GVHD, managed with cyclosporine, steroids, periodic\n CellCept, and has received 1 cycle of Rituxan.\n .\n Other Past Medical History:\n - Type 2 DM, steroid induced\n - Hyperlipidemia\n - H/o AVN bilateral hips\n - HTN\n - H/o nephrolithiasis, lithotripsy and previous nephrostomy tube and\n emergent surgery to repair ureteral damage\n - h/o left interpolar renal lesion, followed with MRs\n - h/o BCC s/p excision\n - h/o SCC left cheek, s/p Mohs' \n - h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and\n cervical spine fusion (bone graft, no hardware)\n - h/o anterior cervical diskectomy and instrument arthrodesis at C5-C6\n and C6-C7 for degenerative cervical spondylitic disease with spinal\n cord compression and foraminal stenosis at C5-C6 and C6-C7 - Dr.\n \n - Chronic numbness, neuropathic pain in left upper extremity.\n - Multilevel compression fractures T11, T12, L1 and mild\n compression L3 and L4.\n - h/o pulmonary embolism on anticoagulated from \n - h/o RSV requiring ICU admission\n - h/o OSA, on BIPAP followed by \n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his wife, and one of children, worked as a \n technician now retired.\n Tob: previously smoked 1ppd for many years but quit 3 years ago\n EtOH: h/o social use; none recently\n Review of systems:\n (+) Per HPI, has baseline rhinorrhea that is unchanged,\n (-) Denies chills, night sweats, recent weight loss or gain. Denies\n sinus tenderness or congestion. Denied palpitations. Denied diarrhea,\n constipation or abdominal pain. No recent change in bowel or bladder\n habits. No dysuria. Denied arthralgias or myalgias.\n Flowsheet Data as of 10:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 87 (87 - 95) bpm\n BP: 116/75(86) {105/71(80) - 152/102(104)} mmHg\n RR: 16 (14 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,275 mL\n PO:\n TF:\n IVF:\n 275 mL\n Blood products:\n Total out:\n 0 mL\n 900 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,375 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 95%\n ABG: 7.43/37/80./22/0\n PaO2 / FiO2: 80\n Physical Examination\n General: Sleepy but easily arousable, oriented x3, no acute distress,\n speaking in full sentences w/out accessory muscle use\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Scatter crackles, rhonchi at left base, no wheezes, good air\n movement, no stridor\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Obese, distended, soft, non-tender, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU:no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,\n strength intact throughout\n Labs / Radiology\n 113 K/uL\n 14.7 g/dL\n 189 mg/dL\n 1.1 mg/dL\n 13 mg/dL\n 22 mEq/L\n 100 mEq/L\n 4.7 mEq/L\n 134 mEq/L\n 42.8 %\n 5.4 K/uL\n [image002.jpg]\n \n 2:33 A3/1/ 05:10 PM\n \n 10:20 P3/1/ 08:26 PM\n \n 1:20 P3/1/ 09:05 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 5.4\n Hct\n 42.8\n Plt\n 113\n Cr\n 1.1\n TropT\n <0.01\n TC02\n 25\n Glucose\n 189\n Other labs: CK / CKMB / Troponin-T:51//<0.01, Amylase / Lipase:/41,\n Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1 %, Eos:0.1 %, Lactic\n Acid:0.9 mmol/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.9 mg/dL\n Imaging: - CTA - No PE. Scattered tree and opacities\n concerning for atypical infection or inflammatory process. No dense\n consolidation. Mild emphsematous changes.\n Microbiology: Blood Cx - pending\n Urine Cx - pending\n ECG: EKG: NSR at 86, , III, poor transition across precordium, T\n wave inversions V2-V5, V6 flattening\n Assessment and Plan\n 55 year h/o AML, s/p BMT w/ chronic GVHD reporting 3 days of productive\n cough, malaise, nausea, and weakness with fever to 101,\n fluid-responsive hypotension and hypoxia.\n .\n # Fever/Hypoxia - CTA negative for PE, hypoxia out of proportion to\n imaging findings of scattered tree in opacities. LDH not elevated\n and has been on bactrim prophylaxis while on 10mg po prednisone. BNP\n only mildly elevated. No evidence of meningismus.\n - rapid viral screen, droplet precautions\n - f/u blood, urine cx\n - obtain induced sputum to r/o PCP\n repeat CXR in am after additional hydration\n - check \n - continue vanc/aztreonam given allergy profile, add doxcycline for\n atypical coverage\n - check ABG\n - titrate down on O2 as tolerated to eval for possible shunt physiology\n - add on lipase given nausea\n - consider ECHO w/ bubble study if hypoxia continues\n .\n # Chest Pain/Lateral T-wave inversions - Has had previous symptoms and\n EKG changes, ? in setting of physiologic stress. ECHO showed EF\n >55%, borderline pulm HTN, could not rule out WMA due to poor quality\n of study.\n - cycle CEs\n - repeat EKG in am\n - continue telemetry\n .\n # Hypotension - Responded to IVF. Did get stress dose steroids in\n clinic. Per history, poor po intake over last 3 days.\n - continue stress dose steroids\n - IVF over night, prn boluses for hypotension\n .\n # ARF - Baseline 0.9-1, 1.5 on presentation. Likely prerenal in\n etiology given poor po, nausea/vomiting, and hypotension. Did also get\n IV dye load w/ CTA.\n - trend creatinine\n - send urine lytes\n .\n # Steroid-induced DMII\n - while taking poor po, cover with SS, hold long acting\n .\n # AML s/p BMT w/ GVHD\n - continue stress dose steroids in place of prednisone 10mg daily\n - continue acyclovir/bactrim prophylaxis\n - trend cbc\n - continue home pain regimen\n .\n # Thrombocytopenia - Baseline 160-220, mildly low on presentation\n - trend, if remains low, check DIC\n .\n FEN: Maitainence IVF, replete electrolytes, diabetic diet as tolerated,\n continue home PPI\n .\n Prophylaxis: Subutaneous heparin\n .\n Access: peripherals\n .\n Code: Full\n .\n Communication: Patient and wife\n .\n Disposition: pending clinical improvement\n .\n ICU Care\n Nutrition:\n Comments: diabetic diet\n Glycemic Control: Comments: NPH/lispro SS\n Lines:\n 18 Gauge - 06:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-14 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 402293,
"text": "Chief Complaint: shortness of breath, weakness, hypotension\n HPI:\n 55 year h/o AML, s/p BMT w/ chronic GVHD of the liver, skin, and eye,\n reporting 3 days of productive cough, malaise, nausea, non-bilious,\n non-bloody vomiting x1 and weakness who was seen in clinic today\n with fever to 101, hypotension 90's/50's, tachy 120's, hypoxia 91% on\n RA, 93-94% on 2 L via NC. An EKG was obtained with showed V4-V6 Twave\n inversions prompting further evaluation in the ED. Prior to leaving the\n clinic he received 1 Liter NS, 60 mg Solumedrol (stress dose as pt on\n chronic steroids), vancomycin 1gm IV with blood cultures sent from\n clinic.\n .\n In the ED, initial vs were: T 101.9 HR 117 BP 107/73 RR 24 POX 89% on\n RA. Improved to 95% on a NRB, then on ventimask 50%. Repeat blood\n cultures and urine culture were sent. Patient was given dilaudid,\n aztreonam 2gm IV, benadryl and prochloperazine for headache/belly ache.\n IV access 2 18g PIVs. CTA negative for PE, but did show scattered tree\n in opacities. EKG was not far from baseline and plan established to\n trend CEs per BMT team, no aspirin given low platelets. VS 90\n 126/78 16 97% on 50% ventimask prior to transfer.\n .\n On the floor, patient denied shortness of breath but did report vague\n diffuse chest discomfort, headache, and nausea. Wife reported recent\n course of azithromycin. Remote sick contact of college-aged daughter on\n .\n admitted from: ER\n History obtained from Patient, Family / Medical records\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Acyclovir - 09:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Pantoprazole (Protonix) - 09:44 PM\n Other medications:\n Acyclovir 400 mg PO Q8H\n Folic Acid 1 mg PO DAILY\n Prednisone 10 mg PO DAILY\n Pantoprazole 40 mg Tablet PO Q12H\n Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY\n Oxycodone SR (60 mg)QAM , (20 mg) Q2PM, and 60mg QPM\n Ranitidine HCl 150 mg PO HS\n Budesonide 3 mg SR PO three times a day.\n Cholecalciferol (Vitamin D3) 400 unit PO DAILY\n Humulin N Twelve (12) units Subcutaneous twice a day.\n Insulin Lispro QACHS Per sliding scale.\n Past medical history:\n Family history:\n Social History:\n - AML-M7: s/p matched unrelated allogenic transplant on \n - Chronic extensive GVHD of skin and liver, liver biopsy \n consistent with GVHD, managed with cyclosporine, steroids, periodic\n CellCept, and has received 1 cycle of Rituxan.\n .\n Other Past Medical History:\n - Type 2 DM, steroid induced\n - Hyperlipidemia\n - H/o AVN bilateral hips\n - HTN\n - H/o nephrolithiasis, lithotripsy and previous nephrostomy tube and\n emergent surgery to repair ureteral damage\n - h/o left interpolar renal lesion, followed with MRs\n - h/o BCC s/p excision\n - h/o SCC left cheek, s/p Mohs' \n - h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and\n cervical spine fusion (bone graft, no hardware)\n - h/o anterior cervical diskectomy and instrument arthrodesis at C5-C6\n and C6-C7 for degenerative cervical spondylitic disease with spinal\n cord compression and foraminal stenosis at C5-C6 and C6-C7 - Dr.\n \n - Chronic numbness, neuropathic pain in left upper extremity.\n - Multilevel compression fractures T11, T12, L1 and mild\n compression L3 and L4.\n - h/o pulmonary embolism on anticoagulated from \n - h/o RSV requiring ICU admission\n - h/o OSA, on BIPAP followed by \n Non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives with his wife, and one of children, worked as a \n technician now retired.\n Tob: previously smoked 1ppd for many years but quit 3 years ago\n EtOH: h/o social use; none recently\n Review of systems:\n (+) Per HPI, has baseline rhinorrhea that is unchanged,\n (-) Denies chills, night sweats, recent weight loss or gain. Denies\n sinus tenderness or congestion. Denied palpitations. Denied diarrhea,\n constipation or abdominal pain. No recent change in bowel or bladder\n habits. No dysuria. Denied arthralgias or myalgias.\n Flowsheet Data as of 10:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 87 (87 - 95) bpm\n BP: 116/75(86) {105/71(80) - 152/102(104)} mmHg\n RR: 16 (14 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,275 mL\n PO:\n TF:\n IVF:\n 275 mL\n Blood products:\n Total out:\n 0 mL\n 900 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,375 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 95%\n ABG: 7.43/37/80./22/0\n PaO2 / FiO2: 80\n Physical Examination\n General: Sleepy but easily arousable, oriented x3, no acute distress,\n speaking in full sentences w/out accessory muscle use\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Scatter crackles, rhonchi at left base, no wheezes, good air\n movement, no stridor\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Obese, distended, soft, non-tender, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU:no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,\n strength intact throughout\n Labs / Radiology\n 113 K/uL\n 14.7 g/dL\n 189 mg/dL\n 1.1 mg/dL\n 13 mg/dL\n 22 mEq/L\n 100 mEq/L\n 4.7 mEq/L\n 134 mEq/L\n 42.8 %\n 5.4 K/uL\n [image002.jpg]\n \n 2:33 A3/1/ 05:10 PM\n \n 10:20 P3/1/ 08:26 PM\n \n 1:20 P3/1/ 09:05 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 5.4\n Hct\n 42.8\n Plt\n 113\n Cr\n 1.1\n TropT\n <0.01\n TC02\n 25\n Glucose\n 189\n Other labs: CK / CKMB / Troponin-T:51//<0.01, Amylase / Lipase:/41,\n Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1 %, Eos:0.1 %, Lactic\n Acid:0.9 mmol/L, Ca++:8.2 mg/dL, Mg++:1.9 mg/dL, PO4:2.9 mg/dL\n Imaging: - CTA - No PE. Scattered tree and opacities\n concerning for atypical infection or inflammatory process. No dense\n consolidation. Mild emphsematous changes.\n Microbiology: Blood Cx - pending\n Urine Cx - pending\n ECG: EKG: NSR at 86, , III, poor transition across precordium, T\n wave inversions V2-V5, V6 flattening\n Assessment and Plan\n 55 year h/o AML, s/p BMT w/ chronic GVHD reporting 3 days of productive\n cough, malaise, nausea, and weakness with fever to 101,\n fluid-responsive hypotension and hypoxia.\n .\n # Fever/Hypoxia - CTA negative for PE, hypoxia out of proportion to\n imaging findings of scattered tree in opacities. LDH not elevated\n and has been on bactrim prophylaxis while on 10mg po prednisone. BNP\n only mildly elevated. No evidence of meningismus.\n - rapid viral screen, droplet precautions\n - f/u blood, urine cx\n - obtain induced sputum to r/o PCP\n repeat CXR in am after additional hydration\n - check \n - continue vanc/aztreonam given allergy profile, add doxcycline for\n atypical coverage\n - check ABG\n - titrate down on O2 as tolerated to eval for possible shunt physiology\n - add on lipase given nausea\n - consider ECHO w/ bubble study if hypoxia continues\n .\n # Chest Pain/Lateral T-wave inversions - Has had previous symptoms and\n EKG changes, ? in setting of physiologic stress. ECHO showed EF\n >55%, borderline pulm HTN, could not rule out WMA due to poor quality\n of study.\n - cycle CEs\n - repeat EKG in am\n - continue telemetry\n .\n # Hypotension - Responded to IVF. Did get stress dose steroids in\n clinic. Per history, poor po intake over last 3 days.\n - continue stress dose steroids\n - IVF over night, prn boluses for hypotension\n .\n # ARF - Baseline 0.9-1, 1.5 on presentation. Likely prerenal in\n etiology given poor po, nausea/vomiting, and hypotension. Did also get\n IV dye load w/ CTA.\n - trend creatinine\n - send urine lytes\n .\n # Steroid-induced DMII\n - while taking poor po, cover with SS, hold long acting\n .\n # AML s/p BMT w/ GVHD\n - continue stress dose steroids in place of prednisone 10mg daily\n - continue acyclovir/bactrim prophylaxis\n - trend cbc\n - continue home pain regimen\n .\n # Thrombocytopenia - Baseline 160-220, mildly low on presentation\n - trend, if remains low, check DIC\n .\n FEN: Maitainence IVF, replete electrolytes, diabetic diet as tolerated,\n continue home PPI\n .\n Prophylaxis: Subutaneous heparin\n .\n Access: peripherals\n .\n Code: Full\n .\n Communication: Patient and wife\n .\n Disposition: pending clinical improvement\n .\n ICU Care\n Nutrition:\n Comments: diabetic diet\n Glycemic Control: Comments: NPH/lispro SS\n Lines:\n 18 Gauge - 06:51 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Generic Note",
"row_id": 402366,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n mulitdisciplinary rounds this morning. Hypoxia sl improved overnight\n and he is somewhat more comfortable.\n 97.1 70 127/87\n Alert. Comfortable\n Chest\n diffuse bilat mid insp crackles some wheezes\n CV w/o m\n Abd\n obese soft\n WBC 6.5\n Hct 42.7\n CXR\n incr basilar markings R > L\n Still unclear what is responsible for his hypoxia although CXR today\n suggests he may have some incr airspace dis today. Will continue abx\n but I doubt this is bacterial infection. We are ruling out for\n influenza which is not prevalent now. Continuing supplemental oxygen.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402375,
"text": "Chief Complaint: Hypoxia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with hypoxia, fever, and hypotension following 2 days of\n productive cough and lethargy.\n 24 Hour Events:\n No acute events overnight.\n For hypoxia, pt maintained on non rebreather mask overnight, with O2\n sat between 93-98%. On attempt to lower FiO2 this morning, O2 sat\n dropped to 85% on RA, 88% on 6L NC, and 88% on 35% FiO2 via Venti mask.\n Pt was switched back to the non rebreather, then transitioned to a cool\n nebulizer, with O2 sat maintained at approx 95%.\n For hypotension, pt received a 1L NS bolus last night and was started\n on maintenance fluids, given no PO intake. He remained afebrile and\n hemodynamically stable overnight.\n Cardiac enzyme sets 2 and 3 returned negative. Repeat EKG @ 8pm\n demonstrated NSR @ 86bpm; 1mm ST-segment depression in V4=V5,\n persistent T-wave inversions in V2-V6.\n This morning, pt reports feeling much better, though he woke up\n drenched in sweat. He reports increased productive cough but denies\n dyspnea, chest pain (including pleurisy), nausea, abd pain, dizziness,\n palpitations, headache. His chronic LUE pain is well controlled. He\n expressed an interest in breakfast.\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendCefepime\n ;\n Cipro (Oral) (Ciprofloxacin Hcl)\n ;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Acyclovir - 09:30 PM\n Doxycycline - 10:30 PM\n Aztreonam - 11:52 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Pantoprazole (Protonix) - 09:44 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 70 (70 - 95) bpm\n BP: 120/82(90) {97/69(75) - 152/102(104)} mmHg\n RR: 13 (11 - 19) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,619 mL\n 1,530 mL\n PO:\n TF:\n IVF:\n 619 mL\n 1,530 mL\n Blood products:\n Total out:\n 1,350 mL\n 1,050 mL\n Urine:\n 800 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 480 mL\n Respiratory support\n O2 Delivery Device: Cool nebulizer\n SpO2: 95%\n ABG: 7.43/37/80./22/0\n PaO2 / FiO2: 80\n Physical Examination\n General: Less somnolent than last night, easily arousable and\n appropriately interactive; oriented x3; no acute distress; able to\n speak in full sentences without increased respiratory effort\n HEENT: Sclera anicteric, conjunctive non-injected, MMM, oropharynx\n clear w/o exudates or lesions, no bulging tonsils\n Neck: Thick, supple, JVP not elevated\n Lungs: Good air movement on L; poor air movement on R; scattered ronchi\n and crackles at both lung bases\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: Soft, obesely distended, no rebound tenderness or guarding,\n no organomegaly.\n GU: No foley.\n Ext: Warm, well perfused; DPs present (1+ on L, 2+ on R), no clubbing,\n cyanosis or edema; bruising on arms and legs\n Neuro: No focal deficits. No pronator drift; finger tapping intact\n bilaterally; 5/5 strength in lower extremities.\n Labs / Radiology\n 117 K/uL\n 14.8 g/dL\n 175 mg/dL\n 0.8 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 13 mg/dL\n 105 mEq/L\n 138 mEq/L\n 42.7 %\n 6.5 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n WBC\n 5.4\n 6.5\n Hct\n 42.8\n 42.7\n Plt\n 113\n 117\n Cr\n 1.1\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n Other labs: PT / PTT / INR:11.7/31.7/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.7 mg/dL\n CXR : Area of opacification at R medial lung base.\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with profound hypoxia, fever, and productive cough, likely\n secondary to community-acquired pneumonia.\n #) Hypoxic Respiratory Failure CAP: Several possible explanations,\n but infectious process is most likely, given fever and productive cough\n in a susceptible host, with CXR demonstrating areas of opacification at\n lung bases bilaterally (R>L), and CT demonstrating scattered GGOs and\n areas of nodularity in both lung fields. Atypical vs typical etiology.\n Legionella ruled out by negative urinary antigen. PCP unlikely, given\n LDH and current ppx regimen. Infection superimposed on\n underlying lung disease (possibly GVHD to lung, less likely pulmonary\n hypertension untreated OSA or emphysematous changes) might account\n for why the patient's hypoxia appears out of proportion to the findings\n on CT. At baseline, pt\ns DLCO is 50% and RA O2 sat is low-to-mid 90s.\n Possible, though less likely, that the patient has an intracardiac\n shunt (e.g. PFO) contributing to hypoxia in the setting of increased\n R-sided pressures from infection-driven hypoxia-induced\n vasoconstriction, which may be reflected in the RV strain pattern on\n EKG. No evidence of hypercarbic respiratory failure on ABG. PE ruled\n out by the CT angiogram. No prior history or exam/imaging findings to\n support diagnosis of CHF or COPD exacerbation.\n -Attempt to lower FiO2\n -Consider a trial of mask ventilation if O2 Sat < 90% on non rebreather\n -Vancomycin 1g IV Q12H (Day 1 is ) for Gram positive coverage\n -Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram negative coverage,\n given allergy to cephalosporins and quinolones\n -Doxycycline 100mg IV Q12H (Day 1 is ) for mycoplasma coverage\n -f/u blood cultures, CMV viral load\n -f/u Viral DFA panel\n -f/u Sputum culture and gram stain, including fungal cx and PCP stain\n off on Echo with bubble study to r/o intracardiac shunt/PFO,\n given infectious etiology most likely explanation for hypoxia\n -TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n -PA/Lateral CXR tomorrow\n #) Hypotension: dehydration, fluid responsive, now resolved.\n Initially concerning for sepsis vs adrenal insufficiency.\n -D/C stress-dose steroids\n -Resume home steroid regimen of 10mg prednisone PO daily\n -Advance diet\n -D/C maintenance fluids\n -Infectious work-up, as above\n #) EKG Changes: ST-segment depressions and T-wave inversions initially\n concerning for demand ischemia in the setting of infection, but the\n ST-segment changes are an exaggeration of a baseline abnormality, and\n the patient ruled out for MI.\n -Repeat EKG today\n #) Thrombocytopenia: Plt count 140s on admission, then 113 last night,\n down from 220s in . Plt count stable in 110s this morning. Most\n likely explanation is medication side effect. Sulfa drugs, vancomycin,\n and pantoprazole can cause thrombocytopenia, though the time course is\n not right for any of these medications. Another possible explanation is\n HIT Type 1, although the patient's plt count was down from baseline\n prior to administration of subcutaneous heparin on the floor. ITP\n always possible, though this would be a diagnosis of exclusion.\n -Trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Pt has been maintaining BS in 130s with 12\n units NPH in AM. No PO intake in past three days. Despite this,\n inpatient BS are 170s-180s, most likely stress-dose steroids.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that GVHD to the lung is contributing to\n the patient\ns hypoxia, as discussed above, though this is not a\n diagnosis we would make in the inpatient setting.\n -Continue steroids, as above\n -TMP-SMX 1 Tab DS Daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) : Pre-renal picture, now resolved. Creatinine 1.5 on admission,\n up from baseline of 0.9-1.0, with return to baseline following\n hydration.\n -Trend creatinine\n #) Nausea: Pt has 3-month hx of nausea/vomiting. GI work-up was\n essentially unrevealing. Barium swallow indicated mild esophagitis. EGD\n noted small hiatal hernia; biopsies were negative. H pylori studies\n were negative. Gastric emptying studying was normal. Hospital admission\n in for this CC concluded that DDX included GERD vs adrenal\n insufficiency.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Start bowel regimen: Colace + Senna\n #) Headache: Resolved. Pt was somnolent last night but had normal MS\n otherwise. Concern is for meningeal infection, though pt continues to\n have no focal neuro deficits or meningeal signs on exam.\n -LP if meningeal signs or neuro deficit develops, or headache returns\n and becomes unresponsive to pain meds\n -Acetaminophen PRN for pain\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n #) Electrolyes: Calcium of 8.1 converts to 8.8 when corrected for\n albumin of 3.5.\n -Trend Calcium\n -Replete lytes as necessary\n ICU Care\n Nutrition: Diabetic diet, as tolerated\n Glycemic Control: See above\n Lines:\n 18 Gauge - 06:51 PM\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: on PPI, as above\n VAP:\n Comments:\n Communication: Comments: Patient, patient's wife (cell\n )\n Code status: Full code\n Disposition: Pending improvement in hypoxia, ability to maintain O2 sat\n >93% on NC O2\n ------ Protected Section ------\n Patient seen and examined. Patient\ns assessment and plan discussed on\n MICU team rounds. Agree with note as above. Respiratory\n status has stabilized overnight and infiltrates appear to be increasing\n on CXR as well as patient has increased productive cough. Continue abx\n regimen as above and wean O2 as tolerated.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:56 ------\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 402622,
"text": "Chief Complaint: Respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Breathing comfortable\n 24 Hour Events:\n CALLED OUT\n History obtained from Medical records\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Azithromycin - 12:00 AM\n Doxycycline - 10:05 AM\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n Daytime somnolence\n Allergy / Immunology: Immunocompromised, Influenza vaccine\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:16 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.9\nC (96.6\n HR: 69 (63 - 95) bpm\n BP: 125/77(87) {112/67(82) - 156/94(110)} mmHg\n RR: 21 (9 - 21) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,080 mL\n 621 mL\n PO:\n 840 mL\n 400 mL\n TF:\n IVF:\n 1,000 mL\n 221 mL\n Blood products:\n Total out:\n 1,300 mL\n 1,150 mL\n Urine:\n 1,300 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -530 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n Wheezes : diffuse, No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, Rash: GVHD, No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 14.1 g/dL\n 147 K/uL\n 96 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 41.9 %\n 6.3 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n 05:36 AM\n WBC\n 5.4\n 6.5\n 7.9\n 6.3\n Hct\n 42.8\n 42.7\n 43.9\n 41.9\n Plt\n 113\n 117\n 139\n 147\n Cr\n 1.1\n 0.8\n 0.9\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n 96\n Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP) - Parainfluenza\n S/P BMT\n Immunosuppression\n He is slowly improving. Still with an O2 requirement. Will discuss abx\n with BMT but would be inclined to d/c.\n ICU Care\n Nutrition:\n Comments: Fukk\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402624,
"text": "Chief Complaint: Parainfluenza Infection\n 55yM with h/x of AML, s/p allogenic BMT in complicated by GVHD to\n skin and lung, on steroids, presenting with hypoxic respiratory failure\n secondary to parainfluenza type 1 infection.\n 24 Hour Events:\n CALLED OUT\n Afebrile. Hemodynamically stable. Able to ambulate around pod\n maintaining O2 sat >90% on RA. On 2L NC while in bed, switched to 3L NC\n overnight after O2 sat <90%. This AM: on 3L NC, with O2 sat 97%. Per\n patient, he was wheezing overnight, but not this AM. No cough, SOB, CP.\n Preliminary sputum cx\n commensal flora. Antibiotics were continued\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Doxycycline - 10:05 AM\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:37 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Vitamin D\n Folic Acid\n Oxycodone SR\n Budesonide\n Insulin, NPH and Humalog SS\n Hydromorphone PRN\n Ondansetron PRN\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 95) bpm\n BP: 156/94(110) {112/67(82) - 156/94(110)} mmHg\n RR: 10 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,080 mL\n 177 mL\n PO:\n 840 mL\n TF:\n IVF:\n 1,000 mL\n 177 mL\n Blood products:\n Total out:\n 1,300 mL\n 725 mL\n Urine:\n 1,300 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///30/\n Physical Examination\n General: Sleeping but easily arousable, no acute distress, speaking in\n full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally; End-inspiratory crackles at R\n lung base; no wheezes on 8am exam, but end-inspiratory wheezes present\n bilaterally on 12noon team rounds.\n Cardiac: RRR; nl S1, S2; no murmurs; distant heart sounds\n Abd: soft, NT, obesely distended\n Extr: WWP; 2+ DP on R; 1+ DP on L\n Labs / Radiology\n 147 K/uL\n 14.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 41.9 %\n 6.3 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n 05:36 AM\n WBC\n 5.4\n 6.5\n 7.9\n 6.3\n Hct\n 42.8\n 42.7\n 43.9\n 41.9\n Plt\n 113\n 117\n 139\n 147\n Cr\n 1.1\n 0.8\n 0.9\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n 96\n Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL\n Microbiology\n Sputum culture (preliminary)\n Heavy growth of commensal flora\n Fungal culture (preliminary)\n Yeast\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n #) Hypoxic Respiratory Failure parainfluenza infection: Clinically\n improved, though now with symptomatic bronchoconstriction \n infection. Able to maintain O2 sat >90% on RA while ambulating but not\n while sleeping. Bacterial superinfection unlikely, given growth of\n commensal flora on sputum cx.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue ambulation around floor\n -Nebulizers PRN for wheezing\n -Plan to d/c vanc and aztreonam pending BMT attending recs\n -f/u final sputum cx and fungal cx\n -f/u blood cx\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Thrombocytopenia: Count dropped to 110s from baseline of 200s on\n this admission but is now recovering and in the 140s today. Explanation\n unclear; likely medication side effect, given that the patient is on\n multiple drugs (Bactrim, PPI, Vanc) that can affect the plt count.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Fingerstick BS were 300 at 12noon and 6pm\n yesterday, respectively. Better control overnight and this morning.\n Possible that AM NPH dose needs to be increased, though this change\n should be made in the outpatient setting.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that pt has GVHD involvement in the lung,\n given hypoxia out of proportion to CXR and CT findings on admission.\n -Continue home dose steroids: Prednisone 10mg PO daily\n -TMP-SMX 1 Tab DS daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) Nausea: Pt currently asymptomatic but has 3-month hx of\n nausea/vomiting attributed to GERD vs esophagitis vs adrenal\n insufficiency vs GVDH involvement in the gut.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID for gut GVHD\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Continue bowel regimen: Colace + Senna\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI\n Comments:\n Communication: Comments: Wife , cell d\n Code status: Full code\n Disposition: c/o to BMT\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402626,
"text": "Chief Complaint: Parainfluenza Infection\n 55yM with h/x of AML, s/p allogenic BMT in complicated by GVHD to\n skin and lung, on steroids, presenting with hypoxic respiratory failure\n secondary to parainfluenza type 1 infection.\n 24 Hour Events:\n CALLED OUT\n Afebrile. Hemodynamically stable. Able to ambulate around pod\n maintaining O2 sat >90% on RA. On 2L NC while in bed, switched to 3L NC\n overnight after O2 sat <90%. This AM: on 3L NC, with O2 sat 97%. Per\n patient, he was wheezing overnight, but not this AM. No cough, SOB, CP.\n Preliminary sputum cx\n commensal flora. Antibiotics were continued\n despite low suspicion for bacterial superinfection, given pt is s/p\n BMT.\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Doxycycline - 10:05 AM\n Vancomycin - 08:00 PM\n Aztreonam - 12:00 AM\n Acyclovir - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:37 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Vitamin D\n Folic Acid\n Oxycodone SR\n Budesonide\n Insulin, NPH and Humalog SS\n Hydromorphone PRN\n Ondansetron PRN\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (97\n HR: 73 (63 - 95) bpm\n BP: 156/94(110) {112/67(82) - 156/94(110)} mmHg\n RR: 10 (9 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 2,080 mL\n 177 mL\n PO:\n 840 mL\n TF:\n IVF:\n 1,000 mL\n 177 mL\n Blood products:\n Total out:\n 1,300 mL\n 725 mL\n Urine:\n 1,300 mL\n 725 mL\n NG:\n Stool:\n Drains:\n Balance:\n 780 mL\n -549 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///30/\n Physical Examination\n General: Sleeping but easily arousable, no acute distress, speaking in\n full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally; End-inspiratory crackles at R\n lung base; no wheezes on 8am exam, but end-inspiratory wheezes present\n bilaterally on 12noon team rounds.\n Cardiac: RRR; nl S1, S2; no murmurs; distant heart sounds\n Abd: soft, NT, obesely distended\n Extr: WWP; 2+ DP on R; 1+ DP on L\n Labs / Radiology\n 147 K/uL\n 14.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 103 mEq/L\n 141 mEq/L\n 41.9 %\n 6.3 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n 05:36 AM\n WBC\n 5.4\n 6.5\n 7.9\n 6.3\n Hct\n 42.8\n 42.7\n 43.9\n 41.9\n Plt\n 113\n 117\n 139\n 147\n Cr\n 1.1\n 0.8\n 0.9\n 0.8\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n 96\n Other labs: PT / PTT / INR:11.8/39.6/1.0, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:8.9 mg/dL, Mg++:2.0 mg/dL, PO4:2.0 mg/dL\n Microbiology\n Sputum culture (preliminary)\n Heavy growth of commensal flora\n Fungal culture (preliminary)\n Yeast\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n #) Hypoxic Respiratory Failure parainfluenza infection: Clinically\n improved, though now with symptomatic bronchoconstriction \n infection. Able to maintain O2 sat >90% on RA while ambulating but not\n while sleeping. Bacterial superinfection unlikely, given growth of\n commensal flora on sputum cx.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue ambulation around floor\n -Nebulizers PRN for wheezing\n -Per BMT: continue abx for now, BMT will make decision about d/c on\n floor\n -f/u final sputum cx and fungal cx\n -f/u blood cx\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Thrombocytopenia: Count dropped to 110s from baseline of 200s on\n this admission but is now recovering and in the 140s today. Explanation\n unclear; likely medication side effect, given that the patient is on\n multiple drugs (Bactrim, PPI, Vanc) that can affect the plt count.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Fingerstick BS were 300 at 12noon and 6pm\n yesterday, respectively. Better control overnight and this morning.\n Possible that AM NPH dose needs to be increased, though this change\n should be made in the outpatient setting.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that pt has GVHD involvement in the lung,\n given hypoxia out of proportion to CXR and CT findings on admission.\n -Continue home dose steroids: Prednisone 10mg PO daily\n -TMP-SMX 1 Tab DS daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) Nausea: Pt currently asymptomatic but has 3-month hx of\n nausea/vomiting attributed to GERD vs esophagitis vs adrenal\n insufficiency vs GVDH involvement in the gut.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID for gut GVHD\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Continue bowel regimen: Colace + Senna\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI\n Comments:\n Communication: Comments: Wife , cell d\n Code status: Full code\n Disposition: c/o to BMT\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402313,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received the pt on NRB mask,sats 92-97%,diffuse ronchorous breath\n sounds, productive cough,RR teens\n Action:\n Contd droplet precautions,receiving IV vanco/doxy/ztrenam anad\n acyclovir,received a total of 1L fluid bolus,also receving manitaince\n fluid at 75cc/hr\n Response:\n Ongoing. Sats low to mid 90\ns,no sob.\n Plan:\n Continue to follow the resp status,cont abx,possible induce sputum in\n am.\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402511,
"text": "55 year old AML patient s/p BMT\n07 presented to oncology clinic\n hypoxic, + para influenza, on contact precaution.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received on 3 liters O2 via nasal cannula, denies SOB, lung sounds dim\n at bases; no coughing noted\n Action:\n Doxicycline dc\nd; OOB to chair and ambulate around the unit; O2 wean\n off at 1500\n Response:\n Denies SOB, afebrile, O2 sats > 90% at room air\n Plan:\n Continue vancomycin, acyclovir, aztreonam, bactrim and prednisone\n Oriented x 3, steady gait with walking\n Stable BP 110\ns, NSR\n + bowel sounds, no BM this shift, poor appetite\n Voided 2x total of 650cc clear yellow urine\n Skin intact but several bruises noted on all extremities\n 1 PIV working well\n Patient\ns daughter visited\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402497,
"text": "Chief Complaint: Community Acquired Pnemonia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n 24 Hour Events:\n No acute events overnight. Patient remained afebrile and\n hemodynamically stable. His O2 requirement was lowered gradually to 3L\n NC with O2 sats maintained in low-to-mid 90s.\n Relevant microbiology results:\n Parainfluenza Type 1 +\n Sputum Gram Stain revealed 4+ GPCs, 3+ Gram - coccobacilli, and 2+ GNRs\n Given the possibility of bacterial superinfection, antibiotics were\n continued.\n This morning, the patient appears clinically improved. He reports\n feeling better than yesterday, with reduced cough, and no headache,\n SOB, CP, pleurisy, nausea, abd pain, dizziness. He is eating a full\n diet and ambulating to the chair in his room.\n Exam:\n General: Awake, alert, interactive, propped up in bed, oriented x3,\n speaking in full sentences without increased respiratory effort\n HEENT: MMM; oropharynx clear w/o lesions or exudates\n Lungs: Good air movement bilaterally. End-inspiratory crackles at R\n lung base. Otherwise clear. No wheezing or ronchi.\n Cardiac: RRR; nl S1, S2; no murmurs\n Abd: soft, obesely distended, non-tender to palpation\n Extr: WWP; DPs 2+ on R, 1+ on L\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 09:30 PM\n Vancomycin - 08:19 AM\n Doxycycline - 11:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 PM\n Heparin Sodium (Prophylaxis) - 08:40 PM\n Other medications:\n Bactrim\n Folic Acid\n Vitamin D\n Budesonide\n Insulin NPH and Humalog SS\n Ondansetron PRN\n Oxycodone\n Hydromorphone PRN\n Colace + Senna\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 68 (64 - 86) bpm\n BP: 137/88(100) {106/70(77) - 144/96(107)} mmHg\n RR: 10 (7 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 4,021 mL\n 590 mL\n PO:\n 840 mL\n 240 mL\n TF:\n IVF:\n 3,181 mL\n 350 mL\n Blood products:\n Total out:\n 2,480 mL\n 250 mL\n Urine:\n 2,480 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,541 mL\n 340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n See above.\n Labs / Radiology\n 139 K/uL\n 15.1 g/dL\n 113 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 7.9 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n WBC\n 5.4\n 6.5\n 7.9\n Hct\n 42.8\n 42.7\n 43.9\n Plt\n 113\n 117\n 139\n Cr\n 1.1\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n Other labs: PT / PTT / INR:11.3/29.8/0.9, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Fingerstick BS: 258 (afternoon ), 272 (dinner ), 131 (midnight\n )\n Microbiology\n Viral DFA\n positive for parainfluenza type 1\n Sputum Gram Stain: 4+ GPCs, 3+ Gram - coccobacilli, 2+ GNRs\n Sputum Cx\n speciation pending; negative for PCP; fungal cx pending\n MRSA screen\n pending\n Blood Cx\n pending\n Urine Cx\n negative\n CMV viral load\n negative\n EKG: NSR; 0.5-1mm ST-segment depressions and T-wave inversions in V2-V5\n (unchanged from yesterday)\n Assessment and Plan\nParainfluenza Infection\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n #) Hypoxic Respiratory Failure: Significantly improved. Etiology is\n Parainfluenza Type 1 infection. Treatment is supportive care. Given the\n results of the gram stain, there is the possibility of bacterial\n superinfection, therefore continued broad-spectrum antibiotic coverage\n is warranted until speciation results are available.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue Vancomycin 1g IV Q12H (Day 1 is ) for Gram pos coverage\n -Continue Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram neg\n coverage\n -D/C doxycycline\n -f/u sputum cx speciations and sensitivities\n -f/u sputum fungal cx\n -f/u blood cx\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Abnormal EKG: Unchanged from yesterday. ST-depressions are present\n on EKG from prior admission here in . Pt has been ruled out for MI\n and is asymptomatic.\n #) Thrombocytopenia: Count dropped to 110s from baseline of 200s on\n this admission but is now back up to 139. Explanation is unclear;\n likely medication side effect, given that the patient is on multiple\n drugs (Bactrim, PPI, Vanc) that can affect the plt count.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Fingerstick BS were high during the day\n yesterday, likely secondary to stress-dose steroids in the AM and\n increased PO intake throughout the day. Expect lower FS today with\n return to home steroid dose.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that pt has GVHD involvement in the lung,\n given hypoxia out of proportion to CXR and CT findings, though the\n hypoxia has improve\n -Switch to home dose steroids: Prednisone 10mg PO daily\n -TMP-SMX 1 Tab DS daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) Nausea: Pt currently asymptomatic but has 3-month hx of\n nausea/vomiting attributed to GERD vs esophagitis vs adrenal\n insufficiency vs GVDH involvement in the gut.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID for gut GVHD\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Continue bowel regimen: Colace + Senna\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n #) Hypotension: Resolved\n #) : Resolved.\n #) Headache: Resolved.\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI, as above\n Communication: Comments: HCP is wife ()\n Code status: Full code\n Disposition: Plan for call out to BMT service today\n ------ Protected Section ------\n Agree with note as stated above.\n PGY-1 \n ------ Protected Section Addendum Entered By: , MD\n on: 12:47 ------\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402493,
"text": "Chief Complaint: Community Acquired Pnemonia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n 24 Hour Events:\n No acute events overnight. Patient remained afebrile and\n hemodynamically stable. His O2 requirement was lowered gradually to 3L\n NC with O2 sats maintained in low-to-mid 90s.\n Relevant microbiology results:\n Parainfluenza Type 1 +\n Sputum Gram Stain revealed 4+ GPCs, 3+ Gram - coccobacilli, and 2+ GNRs\n Given the possibility of bacterial superinfection, antibiotics were\n continued.\n This morning, the patient appears clinically improved. He reports\n feeling better than yesterday, with reduced cough, and no headache,\n SOB, CP, pleurisy, nausea, abd pain, dizziness. He is eating a full\n diet and ambulating to the chair in his room.\n Exam:\n General: Awake, alert, interactive, propped up in bed, oriented x3,\n speaking in full sentences without increased respiratory effort\n HEENT: MMM; oropharynx clear w/o lesions or exudates\n Lungs: Good air movement bilaterally. End-inspiratory crackles at R\n lung base. Otherwise clear. No wheezing or ronchi.\n Cardiac: RRR; nl S1, S2; no murmurs\n Abd: soft, obesely distended, non-tender to palpation\n Extr: WWP; DPs 2+ on R, 1+ on L\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 09:30 PM\n Vancomycin - 08:19 AM\n Doxycycline - 11:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 PM\n Heparin Sodium (Prophylaxis) - 08:40 PM\n Other medications:\n Bactrim\n Folic Acid\n Vitamin D\n Budesonide\n Insulin NPH and Humalog SS\n Ondansetron PRN\n Oxycodone\n Hydromorphone PRN\n Colace + Senna\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 68 (64 - 86) bpm\n BP: 137/88(100) {106/70(77) - 144/96(107)} mmHg\n RR: 10 (7 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 4,021 mL\n 590 mL\n PO:\n 840 mL\n 240 mL\n TF:\n IVF:\n 3,181 mL\n 350 mL\n Blood products:\n Total out:\n 2,480 mL\n 250 mL\n Urine:\n 2,480 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,541 mL\n 340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n See above.\n Labs / Radiology\n 139 K/uL\n 15.1 g/dL\n 113 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 7.9 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n WBC\n 5.4\n 6.5\n 7.9\n Hct\n 42.8\n 42.7\n 43.9\n Plt\n 113\n 117\n 139\n Cr\n 1.1\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n Other labs: PT / PTT / INR:11.3/29.8/0.9, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Fingerstick BS: 258 (afternoon ), 272 (dinner ), 131 (midnight\n )\n Microbiology\n Viral DFA\n positive for parainfluenza type 1\n Sputum Gram Stain: 4+ GPCs, 3+ Gram - coccobacilli, 2+ GNRs\n Sputum Cx\n speciation pending; negative for PCP; fungal cx pending\n MRSA screen\n pending\n Blood Cx\n pending\n Urine Cx\n negative\n CMV viral load\n negative\n EKG: NSR; 0.5-1mm ST-segment depressions and T-wave inversions in V2-V5\n (unchanged from yesterday)\n Assessment and Plan\nParainfluenza Infection\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting with hypoxic\n respiratory failure secondary to parainfluenza infection.\n #) Hypoxic Respiratory Failure: Significantly improved. Etiology is\n Parainfluenza Type 1 infection. Treatment is supportive care. Given the\n results of the gram stain, there is the possibility of bacterial\n superinfection, therefore continued broad-spectrum antibiotic coverage\n is warranted until speciation results are available.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue Vancomycin 1g IV Q12H (Day 1 is ) for Gram pos coverage\n -Continue Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram neg\n coverage\n -D/C doxycycline\n -f/u sputum cx speciations and sensitivities\n -f/u sputum fungal cx\n -f/u blood cx\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n #) Abnormal EKG: Unchanged from yesterday. ST-depressions are present\n on EKG from prior admission here in . Pt has been ruled out for MI\n and is asymptomatic.\n #) Thrombocytopenia: Count dropped to 110s from baseline of 200s on\n this admission but is now back up to 139. Explanation is unclear;\n likely medication side effect, given that the patient is on multiple\n drugs (Bactrim, PPI, Vanc) that can affect the plt count.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Fingerstick BS were high during the day\n yesterday, likely secondary to stress-dose steroids in the AM and\n increased PO intake throughout the day. Expect lower FS today with\n return to home steroid dose.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that pt has GVHD involvement in the lung,\n given hypoxia out of proportion to CXR and CT findings, though the\n hypoxia has improve\n -Switch to home dose steroids: Prednisone 10mg PO daily\n -TMP-SMX 1 Tab DS daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) Nausea: Pt currently asymptomatic but has 3-month hx of\n nausea/vomiting attributed to GERD vs esophagitis vs adrenal\n insufficiency vs GVDH involvement in the gut.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID for gut GVHD\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Continue bowel regimen: Colace + Senna\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n #) Hypotension: Resolved\n #) : Resolved.\n #) Headache: Resolved.\n ICU Care\n Nutrition: Diabetic diet\n Glycemic Control: See above\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Pneumoboots, Subcutaneous heparin\n Stress ulcer: PPI, as above\n Communication: Comments: HCP is wife ()\n Code status: Full code\n Disposition: Plan for call out to BMT service today\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402397,
"text": "Presented to oncology clinic today after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Pt required 100% NRB to maintain sats in 90\ns. rr 20\n Congested productive cough.\n r/o for influenza\n+paraflu\n afebrile\n Action:\n Changed pt to 5l nc while sitting on side of bed\n Response:\n Maintaining good sats with nc\n Plan:\n Continue to encourage cough and deep breathe\n OOB as tolerates\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 402482,
"text": "Chief Complaint: Pneumonia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Positive for Parainfluenza on viral screen\n Patient with O2 decreased to 3 lpm\n History obtained from Medical records\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 09:30 PM\n Azithromycin - 12:00 AM\n Aztreonam - 12:00 AM\n Vancomycin - 08:37 AM\n Doxycycline - 10:05 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:37 AM\n Heparin Sodium (Prophylaxis) - 08:37 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: No(t) Cough\n Flowsheet Data as of 11:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (97\n HR: 77 (64 - 86) bpm\n BP: 115/80(89) {106/70(77) - 144/96(107)} mmHg\n RR: 12 (7 - 18) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 4,021 mL\n 1,250 mL\n PO:\n 840 mL\n 600 mL\n TF:\n IVF:\n 3,181 mL\n 650 mL\n Blood products:\n Total out:\n 2,480 mL\n 550 mL\n Urine:\n 2,480 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,541 mL\n 700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 15.1 g/dL\n 139 K/uL\n 113 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 7.9 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n WBC\n 5.4\n 6.5\n 7.9\n Hct\n 42.8\n 42.7\n 43.9\n Plt\n 113\n 117\n 139\n Cr\n 1.1\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n Other labs: PT / PTT / INR:11.3/29.8/0.9, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 55 yo male with h/o AML c/b GVHD to skin, lung, liver and admitted with\n pneumonia. He has a picture suggesting initial viral infection with\n parainfluenza and likely bacterial superinfection now showing good\n trend to clinical improvement with improved respiratory status and\n normal WBC count.\n 1) PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\nHe has had\n substantial improvement in pneumonia with treatement. Influenza A+B\n negative and other cultures negative as well. No new CXR\n -Continue with current antibiotics\n -Acyclovir\n -Aztreonam/Vanco/Doxy\n -Bactrim\n 2)GVHD-\n -Prednisone 10mg dose to continue\n Additional issues to be addressed as defined in the housestaff note of\n this date.\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT: Hep SQ\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor today\n Total time spent: 33\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402466,
"text": "Chief Complaint: Community Acquired Pnemonia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with hypoxic respiratory failure secondary to community acquired\n pneumonia.\n 24 Hour Events:\n No acute events overnight. Patient remained afebrile and\n hemodynamically stable. His O2 requirement was gradually lowered\n througout the day with O2 sats maintained in low-to-mid 90s.\n Microbiology results:\n Parainfluenza Type 1 +\n Influenza A and B negative\n Sputum Culture grew 4+ GPCs, 3+ Gram - coccobacilli, and 2+ GNRs\n Sputum Cx was negative for PCP; fungal cultures are pending\n Urine Cx was negative\n Blood Cx are pending\n Given this viral PNA with possible bacterial superinfection, vanco and\n aztreonam were continued. Doxycycline was discontinued.\n This morning, the patient appears clinically improved. He reports\n feeling better than yesterday, with reduced cough, and no headache,\n SOB, CP, pleurisy, nausea, abd pain, dizziness. He is eating a full\n diet and ambulating to the chair in his room.\n Exam:\n General: Awake, alert, interactive, propped up in bed, oriented x3,\n speaking in full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally. End-inspiratory crackles at R\n lung base. Otherwise clear. No wheezing or ronchi.\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 09:30 PM\n Vancomycin - 08:19 AM\n Doxycycline - 11:00 AM\n Azithromycin - 12:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 PM\n Heparin Sodium (Prophylaxis) - 08:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 68 (64 - 86) bpm\n BP: 137/88(100) {106/70(77) - 144/96(107)} mmHg\n RR: 10 (7 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 4,021 mL\n 590 mL\n PO:\n 840 mL\n 240 mL\n TF:\n IVF:\n 3,181 mL\n 350 mL\n Blood products:\n Total out:\n 2,480 mL\n 250 mL\n Urine:\n 2,480 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,541 mL\n 340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 139 K/uL\n 15.1 g/dL\n 113 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 7.9 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n WBC\n 5.4\n 6.5\n 7.9\n Hct\n 42.8\n 42.7\n 43.9\n Plt\n 113\n 117\n 139\n Cr\n 1.1\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n Other labs: PT / PTT / INR:11.3/29.8/0.9, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:51 PM\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2146-02-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 402469,
"text": "Chief Complaint: Community Acquired Pnemonia\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with hypoxic respiratory failure secondary to community acquired\n pneumonia.\n 24 Hour Events:\n No acute events overnight. Patient remained afebrile and\n hemodynamically stable. His O2 requirement was gradually lowered\n througout the day with O2 sats maintained in low-to-mid 90s.\n Microbiology results:\n Parainfluenza Type 1 +\n Influenza A and B negative\n Sputum Culture grew 4+ GPCs, 3+ Gram - coccobacilli, and 2+ GNRs\n Sputum Cx was negative for PCP; fungal cultures are pending\n Urine Cx was negative\n Blood Cx are pending\n CMV viral load negative\n Given this viral PNA with possible bacterial superinfection, vanco and\n aztreonam were continued.\n This morning, the patient appears clinically improved. He reports\n feeling better than yesterday, with reduced cough, and no headache,\n SOB, CP, pleurisy, nausea, abd pain, dizziness. He is eating a full\n diet and ambulating to the chair in his room.\n Exam:\n General: Awake, alert, interactive, propped up in bed, oriented x3,\n speaking in full sentences without increased respiratory effort\n Lungs: Good air movement bilaterally. End-inspiratory crackles at R\n lung base. Otherwise clear. No wheezing or ronchi.\n Allergies:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Last dose of Antibiotics:\n Acyclovir - 09:30 PM\n Vancomycin - 08:19 AM\n Doxycycline - 11:00 AM\n Azithromycin - 12:00 AM\n Aztreonam - 12:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:40 PM\n Heparin Sodium (Prophylaxis) - 08:40 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.1\nC (96.9\n HR: 68 (64 - 86) bpm\n BP: 137/88(100) {106/70(77) - 144/96(107)} mmHg\n RR: 10 (7 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 4,021 mL\n 590 mL\n PO:\n 840 mL\n 240 mL\n TF:\n IVF:\n 3,181 mL\n 350 mL\n Blood products:\n Total out:\n 2,480 mL\n 250 mL\n Urine:\n 2,480 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,541 mL\n 340 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 139 K/uL\n 15.1 g/dL\n 113 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.4 mEq/L\n 18 mg/dL\n 102 mEq/L\n 138 mEq/L\n 43.9 %\n 7.9 K/uL\n [image002.jpg]\n 05:10 PM\n 08:26 PM\n 09:05 PM\n 04:43 AM\n 05:16 AM\n WBC\n 5.4\n 6.5\n 7.9\n Hct\n 42.8\n 42.7\n 43.9\n Plt\n 113\n 117\n 139\n Cr\n 1.1\n 0.8\n 0.9\n TropT\n <0.01\n <0.01\n TCO2\n 25\n Glucose\n 189\n 175\n 113\n Other labs: PT / PTT / INR:11.3/29.8/0.9, CK / CKMB /\n Troponin-T:55/2/<0.01, ALT / AST:38/31, Alk Phos / T Bili:101/0.2,\n Amylase / Lipase:/41, Differential-Neuts:89.6 %, Lymph:6.9 %, Mono:3.1\n %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, LDH:217 IU/L,\n Ca++:9.2 mg/dL, Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, BACTERIAL, COMMUNITY ACQUIRED (CAP)\n Assessment and Plan\n 55yM with a history of AML, s/p allogenic BMT in complicated by\n severe GVHD to skin and liver, on steroids, presenting from oncology\n clinic with profound hypoxia, fever, and productive cough, likely\n secondary to community-acquired pneumonia.\n #) Community Acquired PNA: Etiology is Parainfluenza Type 1 Infection,\n with bacterial superinfection.\n -Continue to wean O2 with goal of O2Sat>94% on RA (patient\ns baseline)\n -Continue Vancomycin 1g IV Q12H (Day 1 is ) for Gram pos coverage\n -Continue Aztreonam 1000 mg IV Q12H (Day 1 is ) for Gram neg\n coverage, given allergy to cephalosporins and quinolones\n -D/C doxycycline\n -f/u sensitivities\n -f/u sputum fungal cx\n -f/u\n -continue TMP-SMX 1 Tab DS Daily for PCP \n >100.4 --> repeat blood and urine cx\n -PA/Lateral CXR\n #) Hypotension: Resolved\n #) EKG Changes: ST-segment depressions and T-wave inversions initially\n concerning for demand ischemia in the setting of infection, but the\n ST-segment changes are an exaggeration of a baseline abnormality, and\n the patient ruled out for MI.\n -Repeat EKG today\n #) Thrombocytopenia: Plt count dropped from baseline of approx 200 to\n 140s on . Most likely explanation is medication side effect.\n -Continue to trend plt count\n -Continue subcutaneous heparin for DVT ppx unless plt<100\n #) DM2: Steroid-induced. Pt has been maintaining BS in 130s with 12\n units NPH in AM. No PO intake in past three days. Despite this,\n inpatient BS are 170s-180s, most likely stress-dose steroids.\n -Continue 12 units NPH QAM\n -Insulin Sliding Scale PRN\n #) BMT/GVHD: Stable. Possible that GVHD to the lung is contributing to\n the patient\ns hypoxia, as discussed above, though this is not a\n diagnosis we would make in the inpatient setting.\n -Continue steroids, as above\n -TMP-SMX 1 Tab DS Daily for PCP , as above\n -Continue Acyclovir for Herpes ppx\n -Continue Folic Acid 1mg daily\n -Vitamin D 400 units PO daily\n -Repeat PFTs in outpatient setting\n #) : Resolved.\n #) Nausea: Pt currently asymptomatic. Pt has 3-month hx of\n nausea/vomiting. GI work-up was essentially unrevealing. Barium swallow\n indicated mild esophagitis. EGD noted small hiatal hernia; biopsies\n were negative. H pylori studies were negative. Gastric emptying\n studying was normal. Hospital admission in for this CC concluded\n that DDX included GERD vs adrenal insufficiency.\n -Continue Pantoprazole 40mg PO Q12H for GERD\n -Continue Budesonide 3mg PO TID\n -Ondansetron 4 mg IV Q8H PRN for nausea\n -Start bowel regimen: Colace + Senna\n #) Headache: Resolved.\n #) Neuropathic pain: Stable. Continue at-home pain med regimen.\n -Oxycodone SR PO 60mg , 20mg Q2PM\n -Hydromorphone 2-4mg PO Q6H PRN for pain\n #) Electrolyes:\n -Trend Calcium\n -Replete lytes as necessary\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:51 PM\n 22 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 402643,
"text": "Presented to oncology clinic after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n course involved maintenance on NRB mask overnight initially with\n sat range 93-98. Attempt at titrating O2 down after 24 hours with sats\n dropping to 85% on RA. Course involved cool neb mask, back to NRB and\n eventual titration to NC yesterday.\n Pneumonia, bacterial, community acquired (CAP) hypoxia\n Assessment:\n Lungs with some scattered rhonchi and exp wheezing,. Sats 88-95% on 3\n liters. Congested productive cough.\n r/o for influenza\n+paraflu. Afebrile.\n Action:\n 3L NC without event.\n Response:\n Still requiring 02, pt did desat to 89-90. Able to illicit strong\n cough. Tol PO\n Plan:\n -Continue to encourage cough and deep breathe, Albuterol neb prn\n -OOB as tolerates\n ** Medicated ATC for chronic pain and also requested x 1 dilaudid po\n for breakthrough pain.\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 402649,
"text": "Presented to oncology clinic after 2-3 days of fever, malaise,\n n/v, productive cough. Noted b/p low for patient 90/60 and tachycardic\n 120s, room air O2 sat 90-91%, placed on 2L NC w/ O2 sats 93-94%,\n cultured and vanco given and brought to ED. Noted ST depressions\n lateral leads, 1st set CKs -, rec'd total of approx 2L fluid, has\n voided approx 550cc, rec'd 60mg solumedrol and placed on 50% vent mask\n with O2 sats 88-90%, increased to NRB w/ O2 sats 94-95%. CHest CT done,\n no PE noted, appears to have atypical infectious process and emphysemic\n properties. Pt is alert and oriented, in NAD, RR 20s, HR 90s-1teens and\n b/p 125/75. Pt reports left sided chest pain, medicated w/1mg\n dilaudid IV.\n course involved maintenance on NRB mask overnight initially with\n sat range 93-98. Attempt at titrating O2 down after 24 hours with sats\n dropping to 85% on RA. Course involved cool neb mask, back to NRB and\n eventual titration to NC yesterday.\n Pneumonia, bacterial, community acquired (CAP) hypoxia\n Assessment:\n Lungs with some scattered rhonchi and exp wheezing,. Sats 88-95% on 3\n liters. Congested productive cough.\n r/o for influenza\n+paraflu. Afebrile.\n Action:\n 3L NC without event.\n Response:\n Still requiring 02, pt did desat to 89-90. Able to illicit strong\n cough. Tol PO\n Plan:\n -Continue to encourage cough and deep breathe, Albuterol neb prn\n -OOB as tolerates\n ** Medicated ATC for chronic pain and also requested x 1 dilaudid po\n for breakthrough pain.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPOXIA;R/O PNA\n Code status:\n Full code\n Height:\n 71 Inch\n Admission weight:\n 84 kg\n Daily weight:\n Allergies/Reactions:\n Cefepime\n Rash;\n Cipro (Oral) (Ciprofloxacin Hcl)\n Rash;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: AML, s/p BMT w/ hx of GVH of skin and liver\n PE on anticoagulation from \n Type 2 DM\n hyperlipidemia\n h/o AVN bilateral hips\n HTN\n h/o nephrolithiais, lithotripsy and previous nephrostomy tube and\n emergent surgery to repair ureteral damage\n h/o left interpolar renal lesion\n h/o BCC s/p excision\n h/o SCC left cheek, s/o Mohs' \n h/o multiple back surgeries L5-S1 surgery x3 and cervical spine fusion\n (bone graft, no hardware)\n h/o anterior cervical diskectomy and insturment arthrodesis at C5-C6\n and c^-C7 for degenerative cervical spondylitic disease with spinal\n cord compression and foraminal stenosis at C5-C6 and C6-C7 \n -chronic numbness, neuropathic pain in left upper extremity\n multilevel compression fractures T11 T12, L1 and mild compression L3\n and L4\n h/o RSV requiring ICU admit\n h/o OSA, planned BIPAP\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:142\n D:85\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 95% %\n 24h total in:\n 650 mL\n 24h total out:\n 1,525 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:36 AM\n Potassium:\n 4.0 mEq/L\n 05:36 AM\n Chloride:\n 103 mEq/L\n 05:36 AM\n CO2:\n 30 mEq/L\n 05:36 AM\n BUN:\n 16 mg/dL\n 05:36 AM\n Creatinine:\n 0.8 mg/dL\n 05:36 AM\n Glucose:\n 96 mg/dL\n 05:36 AM\n Hematocrit:\n 41.9 %\n 05:36 AM\n Finger Stick Glucose:\n 161\n 01:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2146-02-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 402557,
"text": "55 year old AML patient s/p BMT\n07 presented to oncology clinic\n hypoxic, + para influenza, on contact precaution.\n Pneumonia, bacterial, community acquired (CAP)\n Assessment:\n Received on 3 liters O2 via nasal cannula, denies SOB, lung sounds dim\n at bases; maintained sats 90\n 94% overnight, however does desat to 88%\n on room air.\n Action:\n Rested comfortably overnight, pt was ambulating around unit on w/\n no complaints of SOB.\n Response:\n Denies SOB, afebrile, able to ambulate without assistance\n Plan:\n Continue vancomycin, acyclovir, aztreonam, bactrim and prednisone. Pt\n is called out and awaiting a bed on 7 F\n"
},
{
"category": "Radiology",
"chartdate": "2146-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123623,
"text": " 2:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna? edema?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with hypoxia, hx of stem cell transplatn.\n REASON FOR THIS EXAMINATION:\n pna? edema?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55-year-old male with stem cell transplant, new hypoxia.\n\n COMPARISON: .\n\n FINDINGS: Single AP radiograph of the chest is limited by underpenetration\n and low lung volumes. The lungs are clear without evidence of consolidation\n or edema. There is mild crowding of bronchovascular markings. There are no\n pleural effusions or pneumothorax. The cardiomediastinal silhouette is\n normal. The osseous structures and soft tissues are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-02-14 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1123628,
"text": " 2:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: PE?\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with hx of PE and off coumadin now w/ hypoxia and sob.\n REASON FOR THIS EXAMINATION:\n PE?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa MON 3:55 PM\n No PE. Scattered tree and opacities concerning for atypical infection or\n inflammatory process. No dense consolidation. Mild emphsematous changes.\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST WITH AND WITHOUT CONTRAST\n\n COMPARISON: .\n\n HISTORY: Evaluate for PE, hypoxia, shortness of breath.\n\n TECHNIQUE: MDCT axially acquired images through the chest were obtained. IV\n contrast was administered. Coronal and sagittal reformats were performed.\n\n FINDINGS: There are no filling defects within the main pulmonary artery to\n suggest pulmonary emboli. Scattered mediastinal lymph nodes are identified,\n none of which meet CT criteria for pathological enlargement. There is no\n axillary, hilar, or mediastinal lymphadenopathy. There is no focal\n consolidation, pleural effusion or pneumothorax. Airways are patent to the\n subsegmental level. There are scattered tree-in- opacities seen,\n particularly in the right upper lobe (3, 32-38). There are mild emphysematous\n changes noted. There is bibasilar atelectasis.\n\n Limited views of the upper abdomen are unremarkable.\n\n BONE WINDOWS: Again identified are areas of sclerosis within the right\n posterior seventh rib and callus formation in the anterior right second rib\n and in the left seventh rib, unchanged.\n Multiple compression deformities of the mid-to-lower thoracic spine are\n similar in appearance.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolus.\n 2. Tree-in- opacities particularly in the right upper lobe concerning for\n an infectious or inflammatory process.\n 3. Mild emphysematous changes.\n 4. Compression fractures and focal areas of sclerosis and callus formation in\n the bilateral ribs as described above, unchanged since .\n (Over)\n\n 2:25 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: PE?\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1124547,
"text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrate\n Admitting Diagnosis: HYPOXIA;R/O PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with parainfluenza s/p BMT with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Worsening hypoxia.\n\n FINDINGS:\n\n Comparison is made to the prior study from . Heart and mediastinum\n are within normal limits. Lungs are clear.\n\n IMPRESSION:\n\n No active disease in the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-02-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123712,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: HYPOXIA;R/O PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with AML s/p BMT, new fever, hypoxia\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bone marrow transplant, now with fever.\n\n FINDINGS: In comparison with study of , there are lower lung volumes.\n There is a region of increased opacification at the right base medially.\n Although this could in part reflect atelectasis and crowding of normal\n pulmonary vessels, in view of the clinical history a possibility of pneumonia\n must be seriously considered. If the condition of the patient permits, a\n lateral view would be most helpful.\n\n\n"
}
] |
138 | 188,284 | 50yo M admitted initially to the medicine service for work-up of his newly-dx'd BL renal masses, concerning for malignancy. His platelet count dropped during the time of his transfer, presumably from HIT although the one assay performed here was negative. For this reason his anticoagulation was switched to Argatroban and carefully titrated to effectively anticoagulate for his mechanical valve; his platelet count normalized. He remained as an inpatient during this complicated work-up period. The pathology report from revealed Renal Cell Carcinoma. A metastatic work-up with Head CT, Chest CT, Abd-Pelvic CT, and Bone scan was negative except for an adrenal mass whose density was not consistent with benign adenoma. (MRI could not be performed due to his AICD). Dr. from Urology planned a two-stage resection; first a right-partial and then a left-total. Cardiac clearance was obtained with a combination of studies from and ; an echo here showed EF 20-30% and he was maintained on beta-blocker. He did develop LUE swelling but U/S and CT were negative for DVT. He was maintained on therapeutic argatroban and transitioned successfully to coumadin. EP-Cardiology was contact regarding deactivating his AICD. He underwent a bowel prep on the day prior to surgery. A right partial nephrectomy was performed on while on coumadin. See operative report for details. He was placed in the ICU post-operatively for close hemodynamic monitoring in light of his complicated cardiac history; he remained intubated with a swan-ganz catheter, chest tube, JP drain, NG tube, and Foley catheter. He was extubated without complication on POD 1. On POD 2 the chest tube was removed, CXR showed minimal PTX. The NG tube was removed on POD 3. He was transfused 1 Unit PRBCs for anemia (Hct 27). He remained in the ICU for observation related to mobilizing fluid and concern for volume overload given his compromised cardiac output. It was noted that he developed a contact dermatitis, presumably from the tape during surgical positioning; this resolved after several days with topical cream for comfort. He remained stable and was transferred to the regular floor on POD 4 after the swan-ganz was changed over a wire to a triple-lumen catheter. At this time he was passing regular flatus and given a regular (cardiac) diet. His pain control was transitioned to PO dilaudid. His HCT remained low and he received a 2nd Unit of PRBCs. The JP drain was removed on POD 5. His INR was closely checked throughout his post-operative course with dosage decreased during immediate post-op period (Inr 2.8-3.2); it rose to 3.8 and 3.9 with dosage decreased. After beginning PO intake, the INR dropped significantly to 3.4 then 2.1 over 12 hours and then 1.5. His dose meanwhile had been increased to 7.5 qhs. He was resumed on his usual home medications. The Foley was removed on POD 6 and the triple-lumen catheter on POD 7. At the time of discharge he was urinating independently, tolerating PO diet and pain moderately controlled on PO meds. | Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. There is a tiny residual right apical pneumothorax. IMPRESSION: 1) Interval chest tube removal, with tiny residual right apical pneumothorax. Right-sided chest tube has been removed. Swan-Ganz catheter, and NG tube unchanged in position. The left adrenal gland contains a lesion measuring 2.8 x 1.4 cm, with Hounsfield units that are not consistent with adenoma; metastases cannot be excluded. There is nopericardial effusion.Compared with the findings of the prior report (tape unavailable for review)of , the aortic valve has been replaced. Evaluate small right apical pneumothorax. Left adrenal lesion which does not has CT appearance characteristic for adrenal adenoma worrisome for metastasis. A right-sided chest tube is present with no pneumothorax. There is a single nonpathologically enlarged lymph node in the AP window, measuring 0.6 x 1.4 cm. Increaed AVR gradient.MITRAL VALVE: Normal mitral valve leaflets. There is evidence of a prior median sternotomy, and there is a single lead pacemaker in the left upper chest with its lead in the right ventricle. The questionably diffusely infiltrative area versus infarct in the left kidney is manifested only as an area of decreased perfusion, which was not able to be characterized further. 2) Solid mass in the lower pole of right kidney. Mildly dilated aortic arch. IMPRESSION: 1) Lines and tubes in satisfactory position but note is made of slight over-distention of endotracheal tube cuff. IMPRESSION: Mild, resolving bibasilar atelectasis, without evidence of pneumothorax or pneumonia. CT of the abdomen without and with IV contrast: A large exophitic cystic mass with a solid component is seen arising from the lower pole of left kidney, measuring 5.7 x 6.6 cm in greatest axial diameter. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Swan-Ganz catheter terminates in the proximal right pulmonary artery. 3) Tiny nodular external contour seen on extreme lower pole of right kidney on CT scan not visualized son. INDICATION: S/P right partial nephrectomy. No 2D or Dopplerevidence of distal arch coarctation.AORTIC VALVE: BIleaflet aortic valve prosthesis (AVR). FINDINGS: There has been interval removal of the previously evident Swan-Ganz catheter. There is slight asymmetry of the density of the right lung compared to the left, and a layering right effusion cannot be excluded on this single view. An endotracheal tube is in satisfactory position but the cuff appears over-distended. There is mild symmetric left ventricular hypertrophy. A Swan-Ganz catheter remains in place, terminating at the junction of the main and right pulmonary artery. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PATIENT/TEST INFORMATION:Indication: Aortic valve disease.Height: (in) 68Weight (lb): 233BSA (m2): 2.18 m2BP (mm Hg): 100/70HR (bpm): 70Status: OutpatientDate/Time: at 10:41Test: TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A second lesion in right kidney located laterally, inmediately adjacent and anterior to the described mass is indeterminate based on CT findings. GASTRIC TUBE WITH DRAINAGE COFFEGROUND IN APPEARANCE, PROTONOX CHANGED TO . Trace pedal edema noted. 1+-2+ general edema noted. Recieved lasix today with diuresis. Opens eyes to voice.gi status: ngt to lws w bldy to bilious drng.Endo-bg rx w riss.gu status: vdg to marginal to qs amts of cherry red uop.heme/id: hct stable.wbc coming dwn.Antibx completed.Drsg/drains: rt flank dsg changed for serousy drng , jp drain to bulb suc w sm amts ss drng.A/P: Wean to extubated.? Please see carevue for hemodynamic values. TRANSFUSED WITH 1 U PRBC, TOLERATED WELL, LASIX GIVEN BEFORE TRANSFUSION. Focus: Status updatePt sedated on propofol. Recieved 1 mg coumadin as ordered.Lungs with intermittent wheezes. CXR OK PER SICU TEAM. Blood pressure within normal limits.Lungs clear, diminished at bases. Replete lytes as necessary. It appears to terminate in the superior vena cava. Dr. notified. Using IS and CDB.GI: +BSX4, pt reports flatus. Drain care. Incidental note is made of a dural calcification in the anterior intrahemispheric fissure. PT UNDERSTANDS USE OF PCA AND IS ABLE TO PROPERLY DEMONTRATE.LUNGS CLEAR BILAT. Weaning propofol for wean to extub plans today if tolerates.bbs diminish at bases lt upper lobe w coarse brth snds.Difficult intubation w fiberoptics to intubate in O.R., lip edematous rt side of mouth.Neuro status: weaning propofol to off. CHEST TUBE D/C'D TODAY WITH CXR PRE AND POST. Right chest tube to water suction draining small amounts sanguinous fluid.Abdomen softly distended. Right chest tube with poor fluctuation. Right LQ JP with scant amount of sero/sang drainage. PA NUMBERS WNL, SEE CAREVUE FOR SPECIFICS. INCISIONAL PAIN BETTER CONTROLLED ON DILAUDID PCA WHICH WAS STARTED THIS AM. Bowel sounds hypoactive. Please see carevue for specific hemodynamic data. FOCUS: STATUS UPDATEDATA:PT ALERT AND ORIENTED X3. trnsfer to floor if extubates. Evaluate for metastases. Resp Care Note,Pt weaned down to cpap/ips with good vt's on 10 IPS/5 PEEP. NURSING NOTE VSS, T MAX 99.9. Monitor VS, labs, I/O's, hemodynamics, replete lytes as necessary. Dilaudid PCA 0.05/6/0.5 with good pain control.CARDIO: NSR with occas PVC's. ABG's acceptable per SICU team. ABG's acceptable per SICU team. PROVIDE EMOTIONAL SUPPORT AND MEDICATE WITH ATIVAN IF NEEDED. Medicated for pain with ffentanyl with effect.Normal sinus rhythm an telemetry. Possible extubation in am. Monitor INR. NGT draining small amounts bilious fluid. Chest tube to suction. Numbers acceptable per SICU team. USING INCENTIVE SPIROMETRY FREQUQNTLY. IMPRESSION: Tip of right internal jugular catheter obscured by overlying opacity from ICD, but it likely terminates within the superior vena cava. Dressing changed once due to saturation. Temp max 100.0.Normal sinus rhythm on telemetry. UpdateO: See carevue flowsheet for specifics.CV status: sr no ectopics.hr 60's -70 sbp 120-140 range. RSBI done on 0 PEEP/5 IPS 43.5. Sinus rhythmNonspecific ST-T wave changes -? Still a bit sleepy.Propofol off on neo . Adeq co/ci/svr.Distal pulses palp.Resp status: on cmv overnight,adeq sats. Suctioned for mod amts thick tan secretions.Will cont to monitor resp status for further weaning. | 26 | [
{
"category": "Echo",
"chartdate": "2133-12-29 00:00:00.000",
"description": "Report",
"row_id": 72186,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 68\nWeight (lb): 233\nBSA (m2): 2.18 m2\nBP (mm Hg): 100/70\nHR (bpm): 70\nStatus: Outpatient\nDate/Time: at 10:41\nTest: TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and/or RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Mild symmetric LVH. Moderately dilated LV cavity. Severe global LV\nhypokinesis. No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Mildly dilated aortic arch. No 2D or Doppler\nevidence of distal arch coarctation.\n\nAORTIC VALVE: BIleaflet aortic valve prosthesis (AVR). Increaed AVR gradient.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Normal mitral valve\nsupporting structures. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is moderately dilated. There is severe global left\nventricular hypokinesis (ejection fraction 20-30 percent). No masses or\nthrombi are seen in the left ventricle. There is no ventricular septal defect.\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic arch is mildly dilated. A bileaflet aortic\nvalve prosthesis is present. The transaortic gradient is higher than expected\nfor this type of prosthesis. The mitral valve leaflets are structurally\nnormal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is\nseen. The estimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , the aortic valve has been replaced.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-24 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 847092,
"text": " 2:52 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 100CC NON IONIC CONTRAST\n Reason: NEWLY DIAGNOSED RENAL CELL CA, R/O METS\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with newly diagnosed renal cell CA\n REASON FOR THIS EXAMINATION:\n mets? Please include pelvis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Newly diagnosed renal cell cancer. Staging.\n\n COMPARISON: None.\n\n TECHNIQUE: Oral contrast was administered and a multidetector scanner used to\n obtain contiguous axial images from the lung bases to the superior pelvis. IV\n contrast was then administered, and images obtained in the same field of view.\n Delayed phase images were also obtained from the thoracic inlet to the pubic\n symphysis.\n\n CT of the chest with IV contrast: No pleural or pericardial effusions are\n seen. There is a single nonpathologically enlarged lymph node in the AP\n window, measuring 0.6 x 1.4 cm. No other lymph nodes are seen in the axillary\n or mediastinal regions. No lung lesions are seen.\n\n CT of the abdomen without and with IV contrast: A large exophitic cystic mass\n with a solid component is seen arising from the lower pole of left kidney,\n measuring 5.7 x 6.6 cm in greatest axial diameter. Additionally, there are\n small wedge- shaped areas of hypodensity in the lower pole. A 3.4 x 6.1 cm\n ill-defined heterogeneously hypoenhancing area in the upper pole is also\n noted.\n\n The right kidney has three lesions arising from the lower pole. The largest\n and most posterior lesion measures 2.4 x 2.4 cm in greatest axial diameter,\n and demonstrates contrast enhancement. A 1.1 cm lesion is seen on the lateral\n aspect of the kidney, at the same level within the lower pole, which shows\n equivocal enhancement. A third tiny irregularity is noted in the cortex\n inmediately anterior to the second lesion on the right which is not completely\n characterized. No other renal lesions are seen.\n\n The left adrenal gland contains a lesion measuring 2.8 x 1.4 cm, with\n Hounsfield units that are not consistent with adenoma; metastases cannot be\n excluded. Additionally, close to the hilum of the left kidney, there are some\n small lymph nodes that are not pathologically enlarged. The left kidney is\n supplied by a single renal artery and renal vein.\n\n The right adrenal, liver, gallbladder, spleen, pancreas, stomach, small bowel,\n and loops of large bowel are unremarkable.\n\n (Over)\n\n 2:52 PM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 100CC NON IONIC CONTRAST\n Reason: NEWLY DIAGNOSED RENAL CELL CA, R/O METS\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n CT of the pelvis with IV contrast: The bladder, distal ureters, rectum, and\n small bowel are unremarkable. No lymphadenopathy is seen. There is no free\n fluid within the pelvis.\n\n Osseous structures are remarkable for degenerative changes. No suspicious\n lytic or sclerotic lesions are seen. There are midline sternotomy wires, a\n mechanical valve within the aorta, and wires from a pacer or defibrillator\n within the right ventricle.\n\n IMPRESSION:\n\n 1. Large, cystic/solid left renal mass, concerning for renal cell carcinoma.\n Multiple areas of decreased attenuation in the left kidney may represent renal\n infarcts (based on the clinical history) although based on the imaging\n findings a infiltrative process is not excluded.\n\n 2. Exophitic renal mass in the posterior aspect of the right lower pole\n concerning for renal cell carcinoma.\n\n 3. A second lesion in right kidney located laterally, inmediately adjacent\n and anterior to the described mass is indeterminate based on CT findings. A\n possible third tiny lesion is also noted anterior to this second lesion in the\n right kidney. Intraoperative ultrasound could be performed at the time of\n resection of the mass in the right kidney to further evaluation of these two\n lesions.\n\n 4. Left adrenal lesion which does not has CT appearance characteristic for\n adrenal adenoma worrisome for metastasis.\n\n These findings were communicated to Dr after interpretation on \n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-29 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 847698,
"text": " 5:51 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o thrombus in left subclavian vein, Pt unable to have MRI\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n Contrast: OPTIRAY Amt: 100CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with newly diagnosed renal cell carcinoma, now with acute onset\n edematous left arm arm.\n REASON FOR THIS EXAMINATION:\n r/o thrombus in left subclavian vein, Pt unable to have MRI and U/S unable to\n view under ICD. Must view left subclavian area and base of neck\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Newly diagnosed renal cell cancer with left arm edema, evaluate for\n left vein thrombus.\n\n COMPARISON: CT torso .\n\n TECHNIQUE: Multidetector CT axial images of the chest were obtained following\n the administration of 100 cc of Optiray.\n\n CT CHEST WITH IV CONTRAST: The study is limited by artifact from the patients\n pacer wires. There are no definite filling defects seen in the left\n subclavian vein and intravenous contrast appears to be flowing. There are no\n collateral vessels seen. The great vessels are unremarkable. There is\n evidence of a prior median sternotomy, and there is a single lead pacemaker in\n the left upper chest with its lead in the right ventricle. No significantly\n enlarged mediastinal or axillary lymph nodes are seen. There is an AP window\n lymph node again seen measuring 0.6 x 1.4 cm. There are coronary artery\n calcifications seen. There are no pericardial or pleural effusions. The lungs\n are clear.\n\n Upper images through the abdomen demonstrate the left adrenal gland lesion,\n not significantly changed from five days ago. The kidneys are incompletely\n imaged on this exam.\n\n Bone windows demonstrate no suspicious lytic or blastic lesions.\n\n IMPRESSION:\n Study limited by extensive artifact from pacer wire. No definite evidence of\n left subclavian vein occlusion as intravenous opacification is demonstrated. A\n formal venogram study may be more definitive.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-25 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 847255,
"text": " 5:04 PM\n RENAL U.S. Clip # \n Reason: characterization of renal masses\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with newly diagnosed bilateral renal cell carcinoma\n REASON FOR THIS EXAMINATION:\n characterization of renal masses\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Characterization of renal masses.\n\n RENAL ULTRASOUND: Reference is made to the torso CT scan from one day\n earlier. The masses were somewhat difficult to visualize son. The\n large lesion in the lower pole of the left kidney was well visualized, and\n demonstrates internal vascularity. The questionably diffusely infiltrative\n area versus infarct in the left kidney is manifested only as an area of\n decreased perfusion, which was not able to be characterized further. Located\n within the lower pole of the right kidney is a solid mass which is suspicious\n for renal cell carcinoma which is iso to slightly hyperechoic to renal\n parenchyma. The larger low-attenuation lesion seen on CT scan demonstrates\n characteristics consistent with a cyst. The small nodular contour defect seen\n in the extreme lower pole of the right kidney was not able to be visualized\n son. There is no hydronephrosis. The bladder was grossly normal.\n\n IMPRESSION:\n 1) Large left lower pole renal mass as seen on CT scan. Questionable areas\n of infarct vs diffuse tumoral infiltration in left kidney not well evaluated\n and only seen as an area of decreased perfusion.\n 2) Solid mass in the lower pole of right kidney. Questionable additional\n low-attenuation lesion on CT scan is a cyst.\n 3) Tiny nodular external contour seen on extreme lower pole of right kidney\n on CT scan not visualized son.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848595,
"text": " 11:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess pneumothorax with chest tube on water seal\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p R partial nephrectomy with chest tube placed for\n pneumothorax.\n REASON FOR THIS EXAMINATION:\n please assess pneumothorax with chest tube on water seal\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of right partial nephrectomy and chest tube placement.\n\n Chest tube is present in right upper hemithorax. No pneumothorax. NG tube is\n in stomach. Status post CABG. Swan-Ganz catheter is in right main pulmonary\n artery. Left-sided ICD with distal electrode overlying region of RV apex in\n this single view. Discoid atelectasis is present at the left base, unchanged.\n\n IMPRESSION: No definite pneumothorax. Left basilar atelectasis unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848731,
"text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval size of R pneumothorax\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p R partial nephrectomy, now with R Chest Tube d/c'd.\n\n REASON FOR THIS EXAMINATION:\n please eval size of R pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removed, evaluate for pneumothorax.\n\n AP SUPINE CHEST: Comparison to AP semi-erect chest of . Swan-Ganz\n catheter again identified, with its tip in the main pulmonary artery. NG tube\n has been removed. ICD identified, with its leads unchanged in position. No\n pneumothorax is identified. The lungs are clear without evidence of\n consolidation or effusion. Perhaps mild bibasilar atelectasis.\n\n IMPRESSION: Mild, resolving bibasilar atelectasis, without evidence of\n pneumothorax or pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848658,
"text": " 9:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess placement of swan ganz catheter\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p R partial nephrectomy, now with R Chest Tube d/c'd.\n\n REASON FOR THIS EXAMINATION:\n assess placement of swan ganz catheter\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n INDICATION: Swan-Ganz catheter placement.\n\n A Swan-Ganz catheter remains in place, terminating at the junction of the main\n and right pulmonary artery. An ICD remains in satisfactory position as well as\n an NG tube. Cardiac and mediastinal contours are within normal limits. There\n are resolving atelectatic changes at the left base with minimal residual\n discoid atelectasis remaining.\n\n IMPRESSION: Resolving left basilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-24 00:00:00.000",
"description": "BONE SCAN",
"row_id": 847043,
"text": "BONE SCAN Clip # \n Reason: RENAL CELL CARCINOMA.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fifty year old man with newly diagnosed renal cell carcinoma.\n Evaluate for bony metastases.\n\n INTERPRETATION: Whole body images of the skeleton show no foci of abnormally\n increased tracer activity. Irregular tracer uptake is noted in the upper pole of\n the left kidney, which appears as a filling defect. The lower pole of the left\n kidney, the right kidney, and urinary bladder are visualized, the normal route\n of tracer excretion.\n\n IMPRESSION: No evidence of bony metastases. Filling defect noted within the\n upper pole of the left kidney. Correlate clinically.\n\n /nkg\n\n\n , M.D.\n , M.D. Approved: TUE 9:31 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848622,
"text": " 2:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX.\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p R partial nephrectomy, now with R Chest Tube d/c'd.\n REASON FOR THIS EXAMINATION:\n r/o PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right-sided chest tube removed, assess for pneumothorax.\n\n PORTABLE SUPINE AP CHEST: Comparison to portable semi-upright chest of\n . Right-sided chest tube has been removed. There is a tiny residual\n right apical pneumothorax. Stable cardiomegaly. Unchanged discoid\n atelectasis at the left base. Swan-Ganz catheter, and NG tube unchanged in\n position. Left-sided ICD, with leads unchanged in position. The lungs are\n otherwise clear without evidence of consolidation or effusion.\n\n IMPRESSION:\n 1) Interval chest tube removal, with tiny residual right apical pneumothorax.\n 2) Persistent discoid atelectasis at the left base; no evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-27 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 847389,
"text": " 12:32 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LUE SWELLING, R/O DVT\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Although the subclavian vein was not well imaged due to the\n overlying defibrillator, no secondary signs indicating thrombosis of the\n subclavian vein are seen.\n\n\n 12:32 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LUE SWELLING, R/O DVT\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with presumed HIT on argatroban, p/w LUE swelling, r/o DVT.\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left upper extremity swelling.\n\n COMPARISON: None.\n\n LEFT UPPER EXTREMITY ULTRASOUND: 2-D, color and Doppler waveform imaging was\n obtained of the left internal jugular, axillary, basilic, brachial and\n cephalic veins. Normal compressibility, waveforms and augmentation was\n demonstrated. No intraluminal thrombus was identified. The left subclavian\n vein was not able to be imaged due to an overlying defibrillator.\n\n IMPRESSION:\n No evidence of left upper extremity deep vein thrombosis. The subclavian vein\n was not well visualized due to an overlying defibrillator.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848811,
"text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please follow up on small right apical pneumothorax\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p R partial nephrectomy, now with R Chest Tube d/c'd.\n\n REASON FOR THIS EXAMINATION:\n please follow up on small right apical pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50 y/o male s/p right partial nephrectomy, recent removal of right\n sided chest tube. Evaluate small right apical pneumothorax.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: .\n\n FINDINGS: There has been interval removal of the previously evident Swan-Ganz\n catheter. Right IJ catheter, ICD leads, and sternal wires are again noted, in\n stable position. Heart size is within normal limits. The pulmonary vasculature\n is not engorged. Minor atelectatic changes are evident at the left lung base.\n There is no discernible pneumothorax.\n\n IMPRESSION:\n 1) No evidence of pneumothorax.\n 2) Minor left basilar atelectatic changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848453,
"text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt w/ effusions, compare w/ prior\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p R partial nephrectomy\n\n REASON FOR THIS EXAMINATION:\n pt w/ effusions, compare w/ prior\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to .\n\n INDICATION: S/P right partial nephrectomy. Pleural effusions.\n\n A right sided chest tube remains in place. There is no evidence of\n pneumothorax. There is slight asymmetry of the density of the right lung\n compared to the left, and a layering right effusion cannot be excluded on this\n single view. Swan-Ganz catheter, NG tube and ICD remain in place. NG tube side\n port is in close proximity to GE junction level. There is focal discoid\n atelectasis at the left lung base.\n\n IMPRESSION: 1) No evidence of pneumothorax. It is difficult to exclude a small\n layering right pleural effusion.\n 2) Side port of NG tube in close proximity to GE junction level.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848355,
"text": " 3:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: swan ganz placement\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p R partial nephrectomy\n REASON FOR THIS EXAMINATION:\n swan ganz placement\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest of compared to .\n\n CLINICAL INDICATION: Swan-Ganz catheter placement.\n\n Swan-Ganz catheter terminates in the proximal right pulmonary artery. There\n is no evidence of pneumothorax. An endotracheal tube is in satisfactory\n position but the cuff appears over-distended. A nasogastric tube terminates\n below the diaphragm.\n\n The patient is S/P median sternotomy and valvular surgery. Cardiac and\n mediastinal contours are within normal limits for post-operative status of the\n patient. A right-sided chest tube is present with no pneumothorax. There is\n no evidence of focal consolidation. There is hazy increased opacity adjacent\n to the left costophrenic sulcus, suggestive of a small pleural effusion.\n\n IMPRESSION: 1) Lines and tubes in satisfactory position but note is made of\n slight over-distention of endotracheal tube cuff.\n\n 2) Probable small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-01-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848839,
"text": " 9:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P RT LINE CHANGE/ CHECK POSITION\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p R partial nephrectomy, now with R Chest Tube d/c'd.\n\n REASON FOR THIS EXAMINATION:\n sp line change\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest dated compared to previous study of earlier\n the same date.\n\n INDICATION: Line change.\n\n A right internal jugular vascular catheter is present, but its tip is obscured\n by an overlying ICD. It appears to terminate in the superior vena cava. It\n is not clearly seen below this level. The ICD remains in place with the lead\n terminating in the right ventricle. No pneumothorax is identified.\n\n IMPRESSION: Tip of right internal jugular catheter obscured by overlying\n opacity from ICD, but it likely terminates within the superior vena cava.\n There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-12-24 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 847097,
"text": " 3:27 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: NEWLY DIAGNOSED RENAL CELL CA, R/O METS\n Admitting Diagnosis: HEMATURIA;RENAL MASS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with newly diagnosed renal cell carcinoma\n REASON FOR THIS EXAMINATION:\n metastases?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50 year old man with newly diagnosed renal cell carcinoma.\n Evaluate for metastases.\n\n TECHNIQUE: Axial images of the brain were obtained before and after the\n administration of Optiray contrast.\n\n FINDINGS: There is no evidence of intracranial hemorrhage or mass effect.\n There is no shift of normally midline structures. The ventricles and cisterns\n are normal. The density values of the brain parenchyma are normal. No\n enhancing lesions are detected. The osseous and soft tissue structures are\n unremarkable. Incidental note is made of a dural calcification in the\n anterior intrahemispheric fissure.\n\n IMPRESSION: No evidence of enhancing lesions on the current study. Gadolinium\n enhanced MRI may be more sensitive in the detection of metastases.\n\n"
},
{
"category": "ECG",
"chartdate": "2133-12-24 00:00:00.000",
"description": "Report",
"row_id": 174374,
"text": "Sinus rhythm\nNonspecific ST-T wave changes -? due to left ventricular hypertrophy (upright T\nwave in lead V1)\nSince last ECG, T wave changes in V1 -? due to lead placement or left\nventricular hypertrophy\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-06 00:00:00.000",
"description": "Report",
"row_id": 1261976,
"text": "NURSING NOTE\n VSS, T MAX 99.9. NSR, OCCASIONAL PVC'S, RARE. CVP4-8, URINE OUTPUT QS AMOUNTS, ON LASIX . PA NUMBERS WNL, SEE CAREVUE FOR SPECIFICS. WEDGE 10.\n CHEST TUBE TO SUCTION, NO LEAK, DRAINAGE CHERRY RED IN COLOR. FOLEY STILL WITH CHERRY RED URINE, ALTHOUGH IT WILL CLEAR BRIEFLY AFTER LASIX. GASTRIC TUBE WITH DRAINAGE COFFEGROUND IN APPEARANCE, PROTONOX CHANGED TO .\n MAJOR ISSUE LAST SHIFT FOR HIM WAS PAIN CONTROL. FEN\n CONTINUE TO MONITERTANYL GIVEN 50 MCG Q 1 HOUR WITHOUT GOOD EFFECT. WRITTEN FOR DILAUDID PCA, WHILE WAITING FOR MACHINE, DILAUDID GIVEN IV WITH VERY GOOD EFFECT AND RELIEF OF PAIN.\n CONTINUE TO MONITER HEMODYNAMICS, MEDICATE FOR PAIN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-06 00:00:00.000",
"description": "Report",
"row_id": 1261977,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X3. MOVES ALL EXTREMITIES WITH GOOD STRENGTH. ABLE TO ASSIST IN TURNING. INCISIONAL PAIN BETTER CONTROLLED ON DILAUDID PCA WHICH WAS STARTED THIS AM. PT UNDERSTANDS USE OF PCA AND IS ABLE TO PROPERLY DEMONTRATE.\n\nLUNGS CLEAR BILAT. CONTINUES ON OPEN FACE MASK AT 40% WITH SATS 98-100. STRONG COUGH, USING TONSIL TIP SUCTION ON HIS OWN. USING INCENTIVE SPIROMETRY FREQUQNTLY. CPT WELL TOLERATED LEFT BETTER THAN RIGHT SIDE. CHEST TUBE D/C'D TODAY WITH CXR PRE AND POST. CXR OK PER SICU TEAM. PT. BECOMES A LITTLE ANXIOUS WHEN COUGHING.\n\nRIGHT SIDED INCISION CLEAN AND DRY WITHOUT DRAINAGE. DSD APPLIED.\n\nCONTINUES WITH RED URINE OUTPUT WHICH CLEARS SOME AFTER LASIX DOSE.\n\nNGT WITH BROWN BUBBLY DRAINAGE.\n\nPLAN:\nCONTINUE AGGRESSIVE PULMONARY TOILET. PROVIDE EMOTIONAL SUPPORT AND MEDICATE WITH ATIVAN IF NEEDED. SWAN TO BE CHANGED TO CVP IN AM AND HE TRANFER TO FLOOR IF STABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-07 00:00:00.000",
"description": "Report",
"row_id": 1261978,
"text": "FOCUS: CONDITION UPDATE\nD: PATIENT DOING VERY WELL. PA PULLED BACK TO CVP , KEPT IN ICU ONE EXTRA DAY TO MONITOR CARDIAC STATUS DUE FOR FLUID MOBILIZATION. TRANSFUSED WITH 1 U PRBC, TOLERATED WELL, LASIX GIVEN BEFORE TRANSFUSION. CVP 9-10, LUNGS CLEAR, NO COMPLAINTS OF SOB. JP DRAINING MINIMAL AMOUNTS OF BLOODY. URINE OUTPUT CONTINUES TO BE CHERRY TO PINK, INR 3.1, RECEIVED COUMADIN 2.5 TONIGHT. DILAUDID PCA PUMP INFUSING WITH GOOD RELIEF, SOME DISCOMFORT WHEN COUGHING.\nOOB TO CHAIR, DID VERY WELL. SEEN BY DR. , PLAN TO TRANSFER TO TOMORROW.\nRASH PRESENT OVER R/L BUTTOCK, SEEN BY DR. , ?DUE TO TAPE APPLIED DURING SURGERY.\nP: CONTINUE WITH I/S, GOOD PULMONARY TOILET. CONTINUE TO MONITOR FOR S/S PULMONARY CONGESTION. CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-08 00:00:00.000",
"description": "Report",
"row_id": 1261979,
"text": "NEURO: A+OX3, MAE, PERL, follows commands, speech is clear. Dilaudid PCA 0.05/6/0.5 with good pain control.\nCARDIO: NSR with occas PVC's. slight generalized edema, 20mg IV lasix at 2400 with fair diuresis. CVP 4-7.\nRESPIR: 99-100% on 2LNC, productive cough of thick white sputum. Using IS and CDB.\nGI: +BSX4, pt reports flatus. Denies N/V. Right LQ JP with scant amount of sero/sang drainage. Abd tender to touch.\nGU: Foley with pink to red colored urine.\nSKIN: Right flank incision, CDI DSD covering. Right chest wall with elasto-tape CDI covering.\nPLAN: OOB activity, continue pulmonary toilet, transfer to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-05 00:00:00.000",
"description": "Report",
"row_id": 1261972,
"text": "Update\nO: See carevue flowsheet for specifics.\nCV status: sr no ectopics.hr 60's -70 sbp 120-140 range. Adeq co/ci/svr.Distal pulses palp.\n\nResp status: on cmv overnight,adeq sats. Weaning propofol for wean to extub plans today if tolerates.bbs diminish at bases lt upper lobe w coarse brth snds.Difficult intubation w fiberoptics to intubate in O.R., lip edematous rt side of mouth.\n\nNeuro status: weaning propofol to off. Mae spont, perl 2mm. arousable to voice and mae to command. Opens eyes to voice.\n\ngi status: ngt to lws w bldy to bilious drng.Endo-bg rx w riss.\n\ngu status: vdg to marginal to qs amts of cherry red uop.\n\nheme/id: hct stable.wbc coming dwn.Antibx completed.\nDrsg/drains: rt flank dsg changed for serousy drng , jp drain to bulb suc w sm amts ss drng.\n\nA/P: Wean to extubated.? trnsfer to floor if extubates.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-05 00:00:00.000",
"description": "Report",
"row_id": 1261973,
"text": "Addendum\nO: Neuro/ Pain mngment: med x 2 w 50 mcg fent prior to wean profol off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-05 00:00:00.000",
"description": "Report",
"row_id": 1261974,
"text": "Resp Care Note,Pt weaned down to cpap/ips with good vt's on 10 IPS/5 PEEP. RSBI done on 0 PEEP/5 IPS 43.5. Still a bit sleepy.Propofol off on neo . Suctioned for mod amts thick tan secretions.Will cont to monitor resp status for further weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-05 00:00:00.000",
"description": "Report",
"row_id": 1261975,
"text": "Focus: Status update\nPt alert, oriented, moves all extremities and follows all commands. Pupils 3mm equal and reactive. Medicated for pain with fentanyl and for anxiety with ativan with effect. Temp max 100.0.\n\nNormal sinus rhythm on telemetry. No ectopy noted. SBP < 150. 1+-2+ general edema noted. Recieved lasix today with diuresis. CVP 6-9. Please see carevue for specific hemodynamic data. Numbers acceptable per SICU team. INR 3.2. Recieved 1 mg coumadin as ordered.\n\nLungs with intermittent wheezes. Coarse bilaterally and diminished at bases. Extubated at 1 pm without difficulty. Currently on face tent 15 liters 35% fiO2. ABG's acceptable per SICU team. Right chest tube with poor fluctuation. SICU team aware. Draining small amounts serosang drainage. Dressing changed once due to saturation. Currently dry and intact.\n\nAbdomen softly distended. Bowel sounds present. NGT draining moderate amounts brown/bloody drainage. Dr. notified. Flushed with 50cc NS as ordered. NO improvement. Protonix increased to . Blood glucose treated with sliding scale as ordered.\n\nFoley with large amounts pink/red urine.\n\nPlan: Monitor VS, labs, I/O's and hemodynamics. Keep NPO. Monitor NGT drainage. Drain care. Chest tube to suction. Replete lytes as necessary. MOnitor for pain/anxiety and medicate accordingly. Monitor INR. Possibly DC swan and chest tube tomorrow and transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-04 00:00:00.000",
"description": "Report",
"row_id": 1261970,
"text": "\nPT. MAINTAINED ON A/C VENTILATION AT 50%. VITALS STABLE. B.S. BILAT AND CLEAR. PT IS NEW ADMIT. LAST ABG SHOWED A MILD ALKALOSIS WITH HYPEROXYGENATION. VT DECREASED TO 700 AS INTERVENTION. PT SEDATED AND UNRESPONSIVE. PLAN IS TO CONT WITH SEDATION AND INTUBATION UNTIL \n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-04 00:00:00.000",
"description": "Report",
"row_id": 1261971,
"text": "Focus: Status update\nPt sedated on propofol. Pupils equal and reactive. Follows commands consistently. Moves all extremities. Medicated for pain with ffentanyl with effect.\n\nNormal sinus rhythm an telemetry. Heart rate 70's. CVP 8-11. Please see carevue for hemodynamic values. Recieved 500 cc LR bolus for CVP of 8 with improvement to 10. Trace pedal edema noted. Blood pressure within normal limits.\n\nLungs clear, diminished at bases. On CMV rate 10 tidal volume 700 5 PEEP, .50 FiO2. ABG's acceptable per SICU team. Right chest tube to water suction draining small amounts sanguinous fluid.\n\nAbdomen softly distended. Bowel sounds hypoactive. NGT draining small amounts bilious fluid. JP with moderate amounts serosanguinous fluid.\n\nFoley with adequate amounts pink urine.\n\nPlan: Keep sedated and intubated overnight. Possible extubation in am. Monitor for pain and medicate accordingly. Monitor VS, labs, I/O's, hemodynamics, replete lytes as necessary. Emotional support to pt and family.\n"
}
] |
1,579 | 131,236 | 72 year-old female with past medical history signficant for marginal zone lymphoma and aplastic anemia who was admitted with sepsis and pancytopenia. . 1. Sepsis: On admission, she had coagulase negative staph growing in her urine. She had a torso CT scan that demostrated a dilated esophagus. Subsequently, an upper endoscopy with ultrasound showed severe esophagitis and enlarged mediastinal lymph nodes without abnormal esophageal thickening. She was initially treated with ambisome and voriconazole for severe ; however, the voriconazole was stopped secondary to elevated alkaline phosphatase. Since she was febrile and neutropenic, she was also covered broadly for febrile neutropenia with aztreonam, daptomycin, and flagyl. She was also continued on Acyclovir for zoster prophylaxis. Bactrim was started for nocardia coverage, but stopped due to nausea and vomiting. She initially received stress-dose steroids when she was admitted to the ICU, however, these were tapered during the admission. For further infectious work-up, she had a chest x-ray and CT that showed multifactorial pulmonary nodules. However, a serum galactomannin, urinary legionella, and sputum PCP were negative. Once she was stabalized hemodynamically, she was transfered to the floor. She later developed a VRE bactermia. She was intially treated with daptomycin and gentamicin for the VRE and was later switched to linezolid when she was not clearing the bacteria. Her bacteremia persisted for about 13 days. When she began having mental status changes with somnolence and unresponsiveness, an LP was performed that showed virus on PCR. She was continued on linezolid, aztreonam, flagyl, acyclovir, caspofungin empirically throughout the admission since she remained febrile and neutropenic. . 2. Pancytopenia: She had pancytopenia on admission, which was thought to be secondary to aplastic anemia from her fludarabine treatment. She also had a cold agglutinin syndrome, which was treated with several doses of rituxan. She had several drops in her hematocrit while she wsa hypothermic, and these drops were attributed with cold agglutinin syndrome. Therefore, red cells were warmed prior to transfusion. IVIG treatment was attempted for treatment of hemolytic anemia, but she had a febrile and hypertensive reaction to it. She subsequently was treated with rabbit anti-thymocyte globulin (ATG) for her aplastic anemia; however, she had a hypersensitivity reaction that required emergent intubation for 2 days. Since she had persistent VRE bacteremia and remained neutropenic, it was decided to pursue ATG desensitization to treat her aplastic anemia. She underwent ATG desensitization in the ICU. She received 4 days on ATG per protocol. After treatment with ATG, she continued to have VRE bacteremia and was also found to have virus in her CSF. As a bridge until the ATG took effect, she had 5 granulocyte transfusions. She tolerated these well. Unfortunately, the ATG did not take effect, and she remained neutropenic and pancytopenic. She was maintained on supportive red cell and platelet transfusions. She was maintained on G-CSF for neutropenia. . 3. Marginal zone lymphoma: She had a bone marrow biopsy on that showed that she was in remission. . 4. Mental Status Change: On one occasion, she became somnolent and unresponsive to voice and painful stimuli. An MRI was negative for mass effect or structural brain lesion. EEG was negative for seizure activity. Neurology was consulted and felt that the change in mental status likely secondary to toxic/metabolic causes. Her mental status eventually improved. However, later, she had a second episode of somnolence and unresponsiveness. Again an MRI was negative and an EEG was negative for seizure activity. An LP at that time showed virus in her CSF. Therefore, her unresponsiveness was likely secondary to the virus infection. She did not recover her mental status and remained unresponsive to painful stimuli. She did have some spontaneous movements. . 5. Hypertension: Initially, her antihypertensives were held in the setting of sepsis. These were restarted once she was no longer hypotensive. . 6. Respiratory alkalosis: On several occasions, she had 2 episodes of paradoxical breathing in which an ABG showed a respiratory alkalosis. There was concern for intracranial pathology; however, head CT was negative. Her respiratory status subsequently improved without intervention on several occasions. However, one episode of paradoxical breathing required intubation and mechanical ventilation for 5 days. It was unclear the cause of the respiratory alkalosis. In retrospect, her paradoxical breathing pattern was likely secondary to the virus infection. . 7. Atrial Fibrillation: She was found to have atrial fibrillation during her second period of unresponsiveness. This new atrial fibrillation was though to be related to toxic/metabolic causes. Her cardiac enzymes were negative. She responded well to diltiazam for rate control. She was transitioned to lopressor for both rate control and blood pressure control. . 8. Pulmonary Embolism: Pulmonary embolism: An Echocardigram showed RV dilation. A CTA at that time showed a pulmonary embolism that was thought to be from her catheter thrombus from her right IJ catheter. She was intially started on heparin; however, after further discussions with the family, it was decided that the risks of anticoagulation were not worth the benefits. Therefore, the heparin was stopped. . 9) Rectal bleeding: In the middle of her admission, she had isolated episode of rectal bleeding. She remained hemodynamically stable and did not have a drop in her hematocrit. However, at the end of her hospital stay, she had persistent rectal bleeding. She was transfused as needed to keep platelets and hematocrit up. . 10) FEN: She was initially on neutropenic diet. Once her mental status changed, she was maintained on TPN. . 11) Access: She had several central lines placed and replaced during her period of persistent bacteremia. . 12) Code: She was intially full code. However, once she remained unresponsive and was found to have persistent infections in the setting of neutropenia, she was transitioned to DNR/DNI. A family meeting was held and it was decided to continued supportive measures with antibiotics and TPN to see if her immune system could recover to counter the virus and other infections. She did not improve and there was no indication that her counts would return. Therefore, her family decided to make the goal of care comfort only. She expired on at 2:50 AM. | Normalregional LV systolic function. Normalregional LV systolic function. Normalregional LV systolic function. Normal ascending aorta diameter. Atherosclerotic normal caliber abdominal aorta.Paraaortic and aortocaval lymphadenopathy is unchanged compared to recent CT of . Normal regional LV systolic function. Right retrocrural lymph node measuring up to 1.7 cm, unchanged. Ovoid 1.5 cm hypodensity in the mid splenic parenchyma is unchanged compared to previous CT. Normal RVsystolic function.AORTA: Normal aortic root diameter. Normal RVsystolic function.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Normal RVsystolic function.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Right ventricular systolicfunction is normal.4.The aortic valve leaflets are mildly thickened. Splenomegaly, retroperitoneal and right iliac and right retrocrural lymphadenopathy, stable in the interval. Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:1. Lipomatous hypertrophy of theinteratrial septum.LEFT VENTRICLE: Normal LV wall thickness. Right ventricular systolicfunction is normal.4.The aortic arch is mildly dilated.5.The aortic valve leaflets (3) are mildly thickened. Mild (1+) MR.PERICARDIUM: No pericardial effusion.Conclusions:1. Thereis mild global right ventricular free wall hypokinesis. Scattered mesenteric and retroperitoneal lymphadenopathy is again noted and unchanged. Stable splenomegaly, retroperitoneal, right iliac, and right retrocrural lymphadenopathy. Again seen are multiple enlarged paraaortic and aortocaval lymph nodes, which are unchanged in appearance. Stable nonobstructing midline hernias and left superior lumbar hernia. LIMITED ABDOMINAL ULTRASOUND: Note is made of a right-sided pleural effusion. Position of previously described right subclavian approach central venous line is unchanged. Also was seen to have a non- occlusive right internal jugular vein thrombus on recent CT. TECHNIQUE: Noncontrast head CT. CT OF THE ABDOMEN WITHOUT CONTRAST: Small bilateral pleural effusion are noted at the lung bases. Right sided line was pre-existing FINAL REPORT CHEST, AP PORTABLE, SINGLE VIEW INDICATION: Aplastic anemia, status post left-sided line placement attempt. FINAL REPORT INDICATION: Aplastic anemia, abdominal tenderness, and decreased bowel sounds, rule out obstruction or free air. Sinus tachycardia with marked baseline artifact. REASON FOR THIS EXAMINATION: r/o hepatic inflammaion or clot. Compared to the previous tracing atrial fibrillation is nolonger present. Atrial fibrillation with uncontrolled ventricular response.Anterior T wave changes may be due to myocardial ischemiaSince previous tracing of , tapid atrial fibrillation seen Sinus tachycardia.Modest ST segment junctional depression - is nonspecific and may be withinnormal limitsSince previous tracing of , sinus tachycardia present CHEST CT WITHOUT CONTRAST: There has been interval improvement in the effusions, with residual small right effusion and resolved left effusion. The right subclavian IV catheter terminates in the superior vena cava. Sinus tachycardia with sinus arrhythmia.rSr'(V1) - probable normal variantInferior and lateral ST elevation - possible early repolarizationAnterior T wave changes are nonspecificSince previous tracing of , rate increased FINDINGS: There is a tiny anechoic right-sided pleural effusion. Sinus bradycardia with ventricular premature depolarizations. CHEST AP: Cardiac, mediastinal and hilar contours are within normal limits. IMPRESSION: 1) Patency the of the major hepatic and portal veins. Level pnd.T-max. K-exelate given. Dilt gtt started. Extrem flacid. Cxr done. Temp as above. Norepinephrine d/c @ 0300. Lopressor 5mg IV X2 with slight, transient decrese in HR to 120's-140's. WBC 0.1 on . was found to have a temp on a rise from 97.5 ax at 0130 to 102.1 at 0430. with Hx. Abd US done. Cyclopsporin d/c'd. Receiving TPN. place on 2 L NC during episode of tachycardia. Awaiting C-echo.Follow UO, CVPRestar TPN. CVP: . Pt remains on the dilt drip with HR 100-130 a-fib. BS:CTA, diminished at bases SpO2:>95GI:NPO on aspiration precautions, HOB:30 degrees. Pancytopenic with Hct of 18. Note is made of a right IJ line with the tip in SVC. Maintaining O2sat of 97-99. on multiple abx. NPO on TPN and Lipids. FIANRD 4 ICU 0700-1900Remains intubated & sedated. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. planned for AM. Addendum: Hct now 36. MAE's without deficit.CVS: Currently on levophed which has been titrated down to .05mcg/kg/min to maintain MAP >60. FOLEY CATH WITH ADEQUATE OUT PUT.ID: PT IS ON SEVERAL ABX SECONDARY TO BACTREMIA. Edema +2 to low ext.ID: Pt. H/H 9.8/26.4, Plt 23.Resp: Pt. Continues on Dilt via Dophoff. Ambisome d/c'd.Remains NPO. Intubated for & decreased MS. Pt's post transfusion plt count was sent and will be pnd. Intubated as noted as above. FS Q2H.POC: ATG UNTIL . swelling.ID: Pt. Waiting for fent & versed gtts.WBC 0.1. on neutropenic precautions. Given fent & midaz boluses. BS hypoactive BS. WBC 0.1 and Pt. This AM temp 100.0 and slowley increasing. 23.0 Pt. Abg 7.47/31/443/23/5. ABG at 2100 pH 7.43, PaCO2 26, PaO2 170, HCO3 18. Pt also tachypneic. will start on cyclosporin. continues with high MV, Sats high 90s, LS coarse, suctioned for mod. Last + bld. Plan to wean to extubate this AM. Lactate 2.2. Cxr. Versed drip decreased to 1.0/hr. abx. BS coarse to clear.This AM pt would open eyes when name called & at X's say "what". K 2.9, repleting with 40meq IV and 40 via Dophoff.GI/GU: Cotninues on TPN. Diaphoretic @ times with episodes of . EEG results pnd. Continues on Dilt via dophoff. Extrem flacid. GIVEN DILT. stool for c-diff pending.GI: Pt. WBC 0.1RESP On 4L NP. HYPERTENSIVE AS WELL.RESP: PT. Treat symptomatically?eti of crit drop. Pneumoboots on.BS clear, diminished at bases. cough noted. Continues on multiple antibx. AM K 3.0, team aware, will replete per orders. Also on acyclovir, flagyl, ambisome, linezolid. Both updated by myself on pt condition. Cont on TPNT-max 98.6AX. r/t sepsis. Continues on IV TPN at 63 ml/hr. Repeat aspirgillis antigen sent.GI: Pt is NPO and getting TPN as ordered. TACHPNEIC DURING AF EPISODE. Resolving esophagitis. and being treated with multiple abx. Once c/o cramps when moving bowels.CV: HR 70s-90s, nsr, no ectopy. abx cont for VRE bacteremia.Resp: On RA, sats 98-99, RR 19-25, LSclear, diminished at bases.GI: +BS, abd soft. Cont PS overnight. 10MG IVP WITH GRADUAL CONVERSION TO NSR. PE in LLL subsegmental pulm. C-echo done. K+4.0 today.Resp: Pt is on RA with good sats. | 101 | [
{
"category": "Echo",
"chartdate": "2149-12-17 00:00:00.000",
"description": "Report",
"row_id": 97863,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Left ventricular function. Valvular heart disease.\nHeight: (in) 66\nWeight (lb): 160\nBSA (m2): 1.82 m2\nBP (mm Hg): 172/95\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 10:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Mild to moderate [+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. The right ventricular cavity is mildly dilated. There\nis mild global right ventricular free wall hypokinesis. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nTrivial mitral regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is a trace/small pericardial effusion. There are\nno echocardiographic signs of tamponade.\n\nCompared with the prior study (tape reviewed) of , RV dilation and\nsystolic dysfunction are now detected. Mild to moderate tricuspid\nregurgitation is now present.? Pulmonary embolism?\n\n\n"
},
{
"category": "Echo",
"chartdate": "2149-12-01 00:00:00.000",
"description": "Report",
"row_id": 97864,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 131/75\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 16:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Lipomatous hypertrophy\nof the interatrial septum. Color-flow imaging of the interatrial septum raises\nthe suspicion of an atrial septal defect, but this could not be confirmed on\nthe basis of this study.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Hyperdynamic LVEF.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations\non aortic valve. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild mitral annular calcification. No MR. LV inflow pattern c/w\nimpaired relaxation.\n\nTRICUSPID VALVE: No TR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size. The left atrium is elongated. The right\natrium is moderately dilated. Color-flow imaging of the interatrial septum\nraises the suspicion of an atrial septal defect, but this could not be\nconfirmed on the basis of this study.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets are mildly thickened, specifically between the non\nand left commisures.. No masses or vegetations are seen on the aortic valve.\nNo aortic regurgitation is seen.\n5.The mitral valve leaflets are mildly thickened. No mass or vegetation is\nseen on the mitral valve. No mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation.\n6.The pulmonary artery systolic pressure could not be determined.\n7.There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe left ventricle is more hyperdynamic.\n\nIMPRESSION:\nNo echocardiographic evidence of endocarditis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2149-11-24 00:00:00.000",
"description": "Report",
"row_id": 97865,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 64\nWeight (lb): 162\nBSA (m2): 1.79 m2\nBP (mm Hg): 128/76\nHR (bpm): 90\nStatus: Outpatient\nDate/Time: at 10:15\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Physiologic TR. Normal PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1.The left atrium is normal in size.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic valve leaflets are mildly thickened. Trivial aortic regurgitation\nseen.\n5.The mitral valve leaflets are structurally normal. Trivial mitral\nregurgitation is seen.\n6.The estimated pulmonary artery systolic pressure is normal.\n7.There is no pericardial effusion.\n\nCompared with the findings of the prior report (images unavailable for review)\nof , no change (previously described mitral regurgitation was probably\noverestimated).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2149-11-07 00:00:00.000",
"description": "Report",
"row_id": 97943,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 64\nWeight (lb): 160\nBSA (m2): 1.78 m2\nBP (mm Hg): 105/69\nHR (bpm): 64\nStatus: Inpatient\nDate/Time: at 15:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic arch is mildly dilated.\n5.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations\nare seen on the aortic valve. No aortic regurgitation seen.\n6.The mitral valve leaflets are structurally normal. No mass or vegetation is\nseen on the mitral valve. Mild (1+) mitral regurgitation is seen.\n7.There is no pericardial effusion.\n\nIMPRESSION:\nNo echocardiographic evidence of endocarditis seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890285,
"text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with neutropenia, ? sepsis.\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with neutropenia and sepsis. Evaluate.\n\n COMPARISON: PA and lateral chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: There has been interval placement of a right\n internal jugular central venous catheter terminating in the upper SVC. Slight\n widening of the mediastinum is most likely projectional. The cardiac\n silhouette is stable. The left atrium is more prominent than on prior exam,\n and there is increased bilateral hilar fullness with pulmonary vascular\n redistribution. Mild patchy opacification within the right infrahilar\n region is concerning for a right lower lobe pneumonia. The surrounding soft\n tissue and osseous structures are stable.\n\n IMPRESSION:\n 1. Findings consistent with volume overload.\n 2. Probable right lower lobe pneumonia.\n 3. Right internal jugular central venous catheter with tip in upper SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-05 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 890432,
"text": " 2:11 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate pleural effusions\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with mantle cell lymphoma admitted with concern for sepsis\n and severe anemia.\n REASON FOR THIS EXAMINATION:\n evaluate pleural effusions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mantle cell lymphoma, admitted with severe anemia and sepsis.\n\n TECHNIQUE: Multidetector CT images of the chest were obtained without\n intravenous contrast.\n\n COMPARISON: chest, abdomen, and pelvis CT.\n\n CHEST CT WITHOUT IV CONTRAST: There is a moderate-sized right pleural\n effusion and small left pleural effusion, both of which are new from the prior\n study. Bibasilar atelectasis is present. There are no areas of\n consolidation. Moderate centrilobular emphysema is present.\n\n Multiple small lymph nodes are present within the mediastinum. There is an\n abnormal appearance of the esophagus. The esophagus is air filled and mildly\n dilated. There is soft tissue thickening around the distal esophagus, which\n was not seen on the prior study.\n\n The osseous structures are unremarkable. Appears to be a retrocrural node and\n may be several enlarged porta hepatic lymph nodes. However, this area is\n incompletely imaged. There is an ill-defined low-attenuation lesion within\n the right lobe of the liver. Hepatosplenomegaly is noted.\n\n IMPRESSION:\n\n 1. Moderate-sized right pleural effusion and small left pleural effusion,\n both new from .\n\n 2. Abnormal appearance of the esophagus, with mild dilatation and abnormal\n soft tissue thickening in its distal portion. The soft tissue thickening was\n not seen two weeks prior. This may represent an enlarged lymph nodes or\n inflammatory tissue. Clinical correlation is recommended.\n\n 3. Retrocrural lymph node and low-attenuation liver lesion. Please refer to\n abdomen and pelvis CT performed on the same day for full evaluation of the\n abdominal structures (clip .).\n\n (Over)\n\n 2:11 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: evaluate pleural effusions\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-05 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 890428,
"text": " 1:43 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: r/o abscess, causes for feversplease perform CT abdomen and\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with mantle cell lymphoma adm with concern for sepsis, severe\n anemia\n REASON FOR THIS EXAMINATION:\n r/o abscess, causes for feversplease perform CT abdomen and pelvis with PO\n contrast only.\n ______________________________________________________________________________\n FINAL REPORT\n Intravenous contrast was not given because of renal impairment.\n\n Comparison is made to previous CT of .\n\n CLINICAL DETAILS: Lymphoma, fibrotic evaluate for intraabdominal sepsis.\n\n CT SCAN OF ABDOMEN WITH ORAL CONTRAST:\n\n The absence of intravenous contrast limits the sensitivity of the CT.\n\n Moderate bibasilar pleural effusions, larger on the right side, and associated\n moderate atelectasis of the dependent portion of both lower lobes. This was\n not present on the previous CT and this atelectasis is a potential coarse for\n fever.Heart size is normal, some coronary artery calcification noted.\n\n The liver is within normal size limits. A 2 cm ovoid hypodensity in posterior\n subcapsular segment is unchanged in size compared to the hypodense lesion\n noted on the previous CT of . Moderate enlargement of the\n spleen which measures up to 17 cm AP. Ovoid 1.5 cm hypodensity in the mid\n splenic parenchyma is unchanged compared to previous CT. These areas may\n represent areas of lymphomatous infiltrate. The symmetry is stable in size\n compared to .\n\n Kidneys, both adrenal glands and pancreas is normal on the unenhanced scan\n apart from the 5 mm hypodensity towards the inferior pancreatic head\n anteriorly (unchanged). No hydronephrosis or hydroureter. Atherosclerotic\n normal caliber abdominal aorta.Paraaortic and aortocaval lymphadenopathy is\n unchanged compared to recent CT of . The largest upper left\n periaortic lymph node at the level of the left renal vein measures up to 0.5\n cm AP x 1.7 cm transverse (series 2, image 42).\n\n No abnormal large or small bowel loop dilatation. At least three midline\n anterior abdominal wall incisional hernias are noted. The more cranial in the\n epigastric region contains a short segment of unobstructed colon.Just\n inferiorly there is a type herniation of the anterior wall of a focal\n segment of unobstructed small bowel with any adjacent thickening or\n inflammatory change and inferiorly,a small focal herniation of unobstructed\n small bowel. Small fat containing left superior lumber hernia also noted\n (Over)\n\n 1:43 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: r/o abscess, causes for feversplease perform CT abdomen and\n Admitting Diagnosis: SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n contains a minimal amount of fluid.Some generalized stranding in the\n subcutaneous tissues bilaterally, likely due to third space loss.\n\n Right retrocrural lymph node measuring up to 1.7 cm, unchanged.\n\n CT SCAN OF PELVIS WITH ORAL CONTRAST:\n\n Patient has had a previous hysterectomy. Urinary catheter within a moderately\n distended bladder. Lymphadenopathy along the right iliac chain is stable\n compared to previous CT. The largest node in the right lower external iliac\n chain measures up to 2.9 cm AP x 1.9 cm transverse.\n\n No bone lesions demonstrated on bone window settings.\n\n CONCLUSION:\n\n 1. No acute intra-abdominal or pelvic source for sepsis demonstrated.\n\n 2. Moderate bibasilar pleural effusions and associated atelectasis of the\n posterior lower lobe not present the previous CT. This may be due to\n infection or cardiac failure depending on clinical correlation.\n\n 3. Splenomegaly, retroperitoneal and right iliac and right retrocrural\n lymphadenopathy, stable in the interval. Hypodensities in the liver and\n spleen, unchanged compared to recent imaging.\n\n 4. Several midline incisional hernias containing unobstructed segment of\n bowel and a small fat-containing left superior lumber hernia.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890353,
"text": " 5:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with neutropenia and sepsis.\n\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP CHEST\n\n INDICATION: Neutropenia and sepsis.\n\n COMPARISON: .\n\n Supine AP portable compared to supine AP portable . Mild\n pulmonary edema is improving. There is a new consolidation in the left lower\n lobe that likely represents superimposed pneumonia or atelectasis. The\n previously described opacity in the right lower lobe is improving slightly.\n Right IJ catheter tip unchanged, projects over the SVC. No pneumothorax.\n Cardiac silhouette and mediastinal contour is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-08 00:00:00.000",
"description": "ESOPHAGUS",
"row_id": 890780,
"text": " 2:13 PM\n ESOPHAGUS Clip # \n Reason: please do barrium swallow (pt with discomfort and dilated es\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with marginal cell lymphoma, now with fever, neutropenia,\n epigastric discomfort, and dilated esophagus on CT scan.\n REASON FOR THIS EXAMINATION:\n please do barrium swallow (pt with discomfort and dilated esophagous seen on CT\n scan)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Marginal cell lymphoma, fever, neutropenia, epigastric\n discomfort. Abnormally dilated, thickened esophagus on CT.\n\n BARIUM ESOPHAGRAM: Barium passes freely through the esophagus. There is no\n aspiration into the airway and no significant retention in the vallecula or\n piriform sinuses. There are multiple, small mucosal erosions and ulcerations\n identified within the distal esophagus. No structural abnormalities were\n identified. Tertiary peristaltic waves were identified. There is a small\n hiatal hernia.\n\n IMPRESSION:\n 1. Multiple, tiny superifical erosions involving the distal esophagus.\n These findings are consistent with an erosive esophagitis. In this\n immunocompromised patient, viral or fungal esophagitis should be considered.\n 2. Small hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 893493,
"text": " 7:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: R subclavian line pulled. Please confirm that L IJ was not\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, s/p L IJ placement.\n REASON FOR THIS EXAMINATION:\n R subclavian line pulled. Please confirm that L IJ was not dislodged.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Aplastic anemia, left IJ line placement.\n\n CHEST: A single portable AP upright view at 7:50 p.m. is compared to previous\n examination of . There is a new left IJ central venous\n catheter with the tip in SVC. The right subclavian central venous catheter\n has been removed since the previous examination of . The\n lung volumes are low. The right hemidiaphragm is mildly elevated. The lungs\n are clear. The cardiomediastinal silhouette remains stable. There is no\n pneumothorax. There are bilateral small pleural effusions, right greater.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2149-12-18 00:00:00.000",
"description": "PR UNILAT UP EXT VEINS US PORT RIGHT",
"row_id": 895788,
"text": " 9:50 AM\n UNILAT UP EXT VEINS US PORT RIGHT Clip # \n Reason: interval change in clot\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with right internal jugular clot\n REASON FOR THIS EXAMINATION:\n interval change in clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate interval change in right internal jugular clot.\n\n TECHNIQUE: Unilateral left upper extremity venous ultrasound.\n\n FINDINGS: Grayscale and Doppler son of the right internal jugular,\n subclavian, axillary, brachial, basilic, and cephalic veins were performed. A\n small clot is seen in the right internal jugular vein measuring roughly 12 mm\n x 6 mm. No extension is seen outside of the internal jugular vein. No prior\n studies available for comparison. Normal flow, augmentation, compressibility,\n and waveforms are demonstrated in the more distal venous branches.\n\n IMPRESSION:\n\n Right internal jugular vein thrombus, no extension distally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895428,
"text": " 6:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for progression of infiltrate and position of et\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 y/o female with pulm nodules, aplastic anemia, intubated for tachypnea, s/p\n OG tube placement. With retrocardiac infiltrate on portable.\n REASON FOR THIS EXAMINATION:\n Please eval for progression of infiltrate and position of et, og tubes..\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:03 A.M :\n\n HISTORY: Pulmonary nodules. Aplastic anemia and tachypnea. OG tube\n placement.\n\n IMPRESSION: AP chest compared to and and 2:\n\n Left lower lobe consolidation sumbuming a nodule has increased since . A smaller nodule in the left apex is unchanged since then but new since\n . Findings suggest multifocal infection probably septic emboli.\n Small bilateral pleural effusions are new since . The heart is\n normal size. ET tube and left subclavian line are in standard placements and\n a feeding tube ends in the upper stomach. There is no pneumothorax. Findings\n were discussed by telephone with a house officer answering for Dr. at the\n time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-12 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 895085,
"text": " 1:17 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: Please do with and without gadolinium. Evaluate for acute p\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with marginal cell lymphoma admitted with sepsis, now has\n persistent VRE bacteremia and new altered mental status (unresponsive) compared\n to yesterday.\n REASON FOR THIS EXAMINATION:\n Please do with and without gadolinium. Evaluate for acute pathology, bleed,\n infection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with marginal cell lymphoma admitted with\n sepsis and persistent bacteremia with new altered mental status changes\n (unresponsive) compared to yesterday. Evaluate for acute pathology\n infarction.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was\n performed. Post-gadolinium T1-weighted scans and diffusion-weighted images\n are provided.\n\n Comparison is made to the previous MR examinations of and\n .\n\n FINDINGS:\n\n There is motion artifact limiting evaluation. There is no change in the T1-\n or T2-weighted appearance of the brain since the previous studies. There is\n no abnormal susceptibility artifact identified within the parenchyma. No\n diffusion signal abnormality is seen to suggest the presence of recent\n infarction. No abnormal intracranial enhancement is detected.\n\n IMPRESSION: MR examination shows no change since recent previous studies.\n There is no intracranial mass effect, infarction or sign of abnormal\n enhancement.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895289,
"text": " 4:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess placement of ETT\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 y/o female with pulm nodules, aplastic anemia, intubated for tachypnea\n REASON FOR THIS EXAMINATION:\n assess placement of ETT\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 72-year-old woman with pulmonary nodules and status post intubation\n for tachypnea.\n\n FINDINGS: Compared to the previous study from .\n\n There has been interval placement of an endotracheal tube whose tip is\n appropriately sided at the level of the aortic knob. There is a left-sided\n central venous catheter with the distal tip in the distal SVC. Cardiac\n silhouette and mediastinum is within normal limits. There is again seen at\n least three parenchymal opacities within the left lung, the largest is within\n the left lower lobe. These have not changed significantly since the previous\n study. There is also increasing density in the right lower lobe, which is\n more apparent on today's study.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 894385,
"text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, s/p L IJ placement decompensating,\n tachycardic\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aplastic anemia status post left IJ placement, decompensating,\n tachycardic, rule out pneumonia.\n\n CHEST, SINGLE AP SUPINE VIEW. The technologist notes that the patient had\n uncontrolled rigors during the exam, resulting in mild blurring.\n\n The heart is not enlarged. The aorta is slightly unfolded. There is no CHF,\n frank consolidation, or effusion. Much of the retrocardiac opacity seen on\n has resolved. However, there is a focal rounded 3-cm opacity\n superimposed over the cardiac silhouette. There is suggestion of more central\n lucency in this 3 cm mass, indicating cavitation. An additional smaller 6-mm\n nodular opacity in left lower mid zone is present. There is also suggestion\n of tiny nodular opacities in left upper zone, although these are a less\n certain finding. The right costophrenic angle is excluded from the film. No\n gross effusions are identified.\n\n IMPRESSION:\n\n 1. Multiple nodules in the left lung (some also in the right lung by \n CT scan), suspicious for infectious or inflammatory nodules, with apparent\n cavitation in the largest nodule at the left lung base. In the appropriate\n clinical setting, the differential diagnosis would include metastatic disease,\n but because these nodules developed relatively rapidly between \n and , infection or inflammation was considered more likely at the\n time of the CT scan report.\n\n 2. Left IJ central line tip over proximal SVC. No pneumothorax detected.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-17 00:00:00.000",
"description": "CT HEAD W/ & W/O CONTRAST",
"row_id": 895716,
"text": " 8:59 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: please evaluate for ICH/acute changes, septic emboli\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with mantle cell lymphoma, with mental status changes\n REASON FOR THIS EXAMINATION:\n please evaluate for ICH/acute changes, septic emboli\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mantle cell lymphoma, mental status change.\n\n COMPARISON: CT head dated .\n\n TECHNIQUE: MDCT acquired axial images of the head were obtained before and\n after the administration of IV contrast.\n\n CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence of acute\n intra- or extra-axial hemorrhage. Ventricles are slightly enlarged, but not\n definitely changed since the prior exam. There is stable periventricular white\n matter hypodensity consistent with chronic small vessel ischemia and gliosis.\n There is a stable focus of hypodensity in the right cerebellar hemisphere. No\n definite areas of abnormal enhancement are identified on the post-contrast\n images. Imaged portions of the paranasal sinuses are well aerated.\n\n IMPRESSION: Stable appearance of the head compared to the exam of \n with no definite abnormal enhancement on post-contrast images.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-17 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 895717,
"text": " 9:00 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: TACHY.LYMPHOMA.R/O PE\n Admitting Diagnosis: SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with mantle cell lymphoma, with new RV hypokinesis, dilation,\n and pulm HTN on ECHO (new since ), also tachycardic.\n REASON FOR THIS EXAMINATION:\n please eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Mantle cell lymphoma with new RV hypokinesis, dilatation, and\n pulmonary hypertension on echo, also tachycardic, please evaluate for\n pulmonary embolism.\n\n COMPARISON: CT torso dated .\n\n TECHNIQUE: MDCT acquired axial images of the chest obtained before and after\n the administration of IV contrast. Multiplanar reformatted images were also\n obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: There is a small filling defect present\n in a subsegmental left lower lobe branch consistent with a small pulmonary\n embolus. Previously demonstrated right IJ thrombus cannot be evaluated on\n this study due to differences in contrast administration. No large central\n pulmonary embolism is present. There is interval increase in size in the\n previously demonstrated lingular nodule now measuring 16 mm, previously 7 mm,\n left lower lobe mass now measuring 40 x 33 mm, previously 33 x 23 mm, right\n middle lobe nodule currently measuring 13 x 14 mm, previously 8 x 7 mm, and\n left upper lobe nodule currently measuring 24 x 17 mm, previously 4 x 5 mm.\n There are emphysematous changes of the lungs. There is a persistent moderate\n right- sided effusion and small left-sided pleural effusion. No pericardial\n effusion. The aortic and coronary artery atherosclerotic disease is again\n demonstrated. Small paraesophageal and mediastinal lymph nodes are stable.\n\n Bone windows reveal no suspicious lytic or sclerotic lesions.\n\n MULTIPLANAR REFORMATTED IMAGES: Coronal and sagittal reformatted images were\n obtained and useful in evaluating the above pathology, MPR value 2.\n\n IMPRESSION:\n 1. Subsegmental left lower lobe pulmonary embolism, could be the result\n of previously demonstrated right internal jugular vein thrombus that was not\n imaged on this study, and is better evaluated by ultrasound.\n\n ***NOTE THAT THE PRELIMINARY TRANSCRIPTION OF THE ABOVE READ \"of likely FULL\n clinical significance\" due to transcriptional error***\n\n 2. Interval increase in size in multiple lung nodules, most consistent with\n infectious process in this immunocompromised patient.\n (Over)\n\n 9:00 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: TACHY.LYMPHOMA.R/O PE\n Admitting Diagnosis: SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n 3. Moderate right effusion and small left pleural effusion, not significantly\n changed.\n\n The above was discussed with Dr. at 10:50 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-08 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 894564,
"text": " 10:30 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o RP bleed\n Admitting Diagnosis: SEPSIS\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of marginal zone lymphoma, aplastic anemia, cold\n agglutinin disease, in ICU for ATG desensitization. Now with drop in hct from\n 24 to 15, no evidence of hemolysis. On neutropenic precautions\n REASON FOR THIS EXAMINATION:\n r/o RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of marginal zone lymphoma and aplastic anemia, with\n hematocrit drop. Evaluate for retroperitoneal bleed.\n\n COMPARISON: Study from .\n\n TECHNIQUE: MDCT-acquired contiguous axial images were obtained from the lung\n bases to the pubic symphysis.\n\n CONTRAST: No oral or intravenous contrast was administered.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: Small bilateral pleural effusion are\n noted at the lung bases. There is minimal scattered atelectasis. There is a\n rounded opacity within the left lower lobe, which is seen on the prior study,\n and is not significantly changed.\n\n There is limited evaluation of solid organs without intravenous contrast.\n However, the liver, spleen, pancreas, kidneys, and adrenal glands appear to be\n relatively unchanged from the prior study. There is a tiny amount of free\n fluid noted adjacent to the spleen and liver. Again seen is anterior\n abdominal wall, bowel containing hernia, and protrusion of the omental fat\n between lower left ribs, which are stable in appearance. There is limited\n evaluation of bowel without oral contrast, however, there is no evidence of\n dilatation or free intraperitoneal air. Scattered mesenteric and\n retroperitoneal lymphadenopathy is again noted and unchanged. There is\n extensive vascular calcification of the aorta and its branches. Residual\n contrast can be seen within the distal colon.\n\n No retroperitoneal fluid, hemorrhage, or air is identified.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bladder contains a Foley catheter. The\n rectum is normal in appearance. No free fluid is noted.\n\n BONE WINDOWS: The osseous structures are stable in appearance. No suspicious\n lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n 1. No evidence of retroperitoneal hemorrhage.\n 2. There is a left lower lobe opacity, which is similar in comparison to\n (Over)\n\n 10:30 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o RP bleed\n Admitting Diagnosis: SEPSIS\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n prior study. There is a small right pleural effusion. The remainder of the\n study is unchanged in comparison to prior exam.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891455,
"text": " 12:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, pneumonia.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with neutropenia and fever, now with new O2 requirement.\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable, single view.\n\n INDICATION: Neutropenia and fever, now with new oxygen requirement.\n\n FINDINGS: AP portable view of the chest obtained with the patient in\n semi-upright position is analyzed in direct comparison with a similar\n preceding study of . Position of previously described right\n subclavian approach central venous line is unchanged. No new indwelling\n devices are identified. Chest findings are unchanged, and the more previous\n existing congestive pattern has not reoccurred. Also, comparison of these\n portable examinations suggests that the pleural densities which obscured the\n lateral pleural sinuses slightly have regressed further. There is no evidence\n of new parenchymal infiltrates on this portable examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 892112,
"text": " 4:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, recent pulm nodule by chest CT,\n now with neutropenic fever.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE\n\n INDICATION: 72-year-old woman with aplastic anemia, neutropenic fever.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n with the previous study of .\n\n There is slight increase in opacity in the right lower lobe indicating\n possible pneumonia. If clinically indicated, please repeat PA and lateral\n radiographs of the chest.\n\n The lungs are clear otherwise. The heart and mediastinum are within normal\n limits. The right subclavian IV catheter remains in place. No pneumothorax\n is identified.\n\n IMPRESSION: Possible pneumonia in the right lower lobe. Please repeat PA and\n lateral radiographs of the chest if clinically indicated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 892866,
"text": " 3:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of marginal cell lymphoma and aplastic anemia. Pt\n now pancytopenic, with intractable nausea/vomiting. R/O intracranial bleed.\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT.\n\n INDICATION: Marginal cell lymphoma with intractable nausea and vomiting.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no sign of intracranial hemorrhage, mass effect, shift of\n the normally midline structures, or hydrocephalus. /white matter\n differentiation is preserved. Hypodensities in the periventricular white\n matter area of both cerebral hemispheres are consistent with chronic\n microvascular infarction. There is no sign of fracture or bone destruction.\n The paranasal sinuses and the orbits are unremarkable.\n\n IMPRESSION: No acute intracranial hemorrhage or mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 893025,
"text": " 5:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial bleed\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, now with resp alkalosis and increased\n lethargy.\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aplastic anemia, respiratory alkalosis, increased lethargy.\n\n COMPARISONS: .\n\n TECHNIQUE: Axial non-contrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: There is no evidence of intracranial hemorrhage,\n hydrocephalous, shift of normally midline structures or edema. There are\n areas of periventricular white matter hypoattenuation consistent with chronic\n small vessel ischemia. The paranasal sinuses are well aerated.\n\n IMPRESSION: Stable since the prior day. No evidence of intracranial\n hemorrhage or edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-25 00:00:00.000",
"description": "CT 150CC NONIONIC CONTRAST",
"row_id": 893026,
"text": " 5:53 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n CT CHEST W/CONTRAST\n Reason: evaluate for intraabdominal abcess, perforation.\n Admitting Diagnosis: SEPSIS\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of marginal zone lymphoma, aplastic anemia, now\n with decreased bowel sounds, abd tenderness, resp alkalosis, and lethargy.\n REASON FOR THIS EXAMINATION:\n evaluate for intraabdominal abcess, perforation.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of marginal zone lymphoma, aplastic anemia with decreased\n bowel sounds, abdominal tenderness, respiratory alkalosis, and lethargy.\n\n COMPARISONS: CT abdomen .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung apices to the\n symphysis pubis after the administration of 150 cc of non-ionic Optiray\n contrast.\n\n CT OF THE CHEST WITH IV CONTRAST: A low-attenuation area is seen within the\n right internal jugular vein consistent with thrombus. Contrast is seen\n extending around the thrombus indicating it is non-occlusive. The\n thrombus extends down to the junction with the subclavian and brachiocephalic\n veins. The right subclavian CVL is seen extending into the distal SVC. There\n are small, bilateral pleural effusions, right greater than left with reactive\n atelectasis. A focal opacity is again seen at the left lower lobe. There is\n an 8-mm nodule within the right middle lobe (series 2, image 33) which is new\n when compared to the previous exam from . A smaller, 7-mm\n nodule is seen within the left upper lobe (series 2, image 27), also not\n present on the previous exam. The pleural effusions are new. The esophagus\n is mildly dilated with fluid. No significant mediastinal, hilar, or axillary\n lymphadenopathy is identified.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Tiny, hypoattenuating areas within the\n spleen and liver are stable when compared to the previous exam. There is\n persistent splenomegaly. A midline anterior abdominal wall hernia and\n protrusion of omental fat in between the intercostal spaces of the left\n lateral chest wall are unchanged. There is persistent retrocrural,\n retroperitoneal and iliac adenopathy. The kidneys contain tiny\n hypoattenuating areas bilaterally, not definitively characterized. The\n opacified loops of large and small bowel are unremarkable. There is no\n evidence of free air or free fluid.\n\n CT OF THE PELVIS WITH IV CONTRAST: Retained barium is identified within the\n colon and rectum. There is no free air or free fluid within the pelvis. A\n Foley catheter is seen within the bladder.\n\n (Over)\n\n 5:53 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n CT CHEST W/CONTRAST\n Reason: evaluate for intraabdominal abcess, perforation.\n Admitting Diagnosis: SEPSIS\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. Nonocclusive right internal jugular vein thrombus extending to but not\n involving the right brachiocephalic vein.\n 2. Small- to moderate-sized bilateral pleural effusions, which have increased\n when compared to previous exams.\n 3. Persistent opacity within the left lower lobe with new nodules in the\n right middle lobe and left upper lobe. The rapidity in development of these\n nodules indicates an infectious or inflammatory etiology.\n 4. Persistent splenomegaly, retroperitoneal, iliac, and retrocrural\n lymphadenopathy.\n 5. No evidence of bowel obstruction or abscess formation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-16 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 895524,
"text": " 3:25 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please eval for obstruction/ cause of alk phos elevation\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of marginal cell lymphoma, aplastic anemia, now\n with fevers and acute rise in alk phos and LDH.\n REASON FOR THIS EXAMINATION:\n please eval for obstruction/ cause of alk phos elevation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of marginal cell lymphoma, aplastic anemia, fevers, and\n acute rise in alkaline phosphatase and LDH.\n\n COMPARISONS: CT abdomen . Abdominal ultrasound .\n\n LIMITED ABDOMINAL ULTRASOUND: Note is made of a right-sided pleural effusion.\n There is no evidence of intra- or extrahepatic biliary dilatation and the\n common bile duct measures 4 mm. The patient is status post cholecystectomy.\n No ascites is identified. A tiny, 1 cm calcification is seen within the right\n lobe of the liver. Well-defined, hyperechoic lesions are identified within\n the left lobe of liver and caudate compatible with hemangiomas as previously\n described. The flow within the portal vein is hepatopetal. Multiple small\n lymph nodes are identified within the porta hepatis, adjacent to the pancreas.\n The largest of these lymph nodes measure approximately 2.2 cm.\n\n IMPRESSION:\n 1. Right-sided pleural effusion.\n 2. No evidence of intra- or extrahepatic biliary dilatation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 895183,
"text": " 10:37 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p left subclavian vein CVL placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n check line placement\n REASON FOR THIS EXAMINATION:\n s/p left subclavian vein CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP view of the chest performed on .\n\n HISTORY: Status post left central venous catheter placement. Check line\n placement.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is a left central venous catheter whose distal tip is in the proximal\n SVC. This is unchanged from prior. There is a rounded opacity within the left\n retrocardiac region, which measures 5.4 cm, 3.2 cm previously. There is a NEW\n 2.5-cm nodular opacity within the left upper lobe and a persistent 1.3 cm\n nodular density within the left mid lung zone. The transient nature of these\n lesions over a short time course, is most consistent with an\n infectious/inflammatory process. Nonetheless, these lesions have increased in\n size since . The cardiac silhouette and mediastinum are\n within normal limits.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895381,
"text": " 4:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for og tube position.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 y/o female with pulm nodules, aplastic anemia, intubated for tachypnea,\n now s/p OG tube placement.\n REASON FOR THIS EXAMINATION:\n Please eval for og tube position.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest performed on .\n\n HISTORY: 72-year-old woman with pulmonary nodules and tachypnea. Status post\n orogastric tube placement.\n\n FINDINGS: Compared to prior study from .\n\n The endotracheal tube and left-sided central line has not changed since the\n prior study.\n\n There is a feeding tube identified whose distal tip is in the fundus of the\n stomach. This could be advanced for more optimal placement. There is a new\n left retrocardiac opacity, which was not present previously. There is\n multiple parenchymal nodular densities within the left upper, mid, and lower\n lung fields. These have not changed significantly since the previous study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-29 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 893475,
"text": " 3:22 PM\n CENTRAL LINE PLCT Clip # \n Reason: please place central line, and pull R SC line once access es\n Admitting Diagnosis: SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, now with fevers, R IJ clot, and GPC\n bacteremia.\n REASON FOR THIS EXAMINATION:\n please place central line, and pull R SC line once access established (and send\n tip for cx).\n ______________________________________________________________________________\n FINAL REPORT\n CENTRAL VENOUS LINE PLACEMENT\n\n INDICATION: 72-year-old woman with aplastic anemia, now with bacteremia and\n right IJ venous blood clot.\n\n Details of the procedure and possible complications were explained to the\n patient's husband, as the patient was not alert, and written informed consent\n was obtained.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , staff radiologist, was\n present for the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the left internal\n jugular vein was localized with ultrasound and punctured under direct\n ultrasound guidance using a micropuncture set. wire was then advanced\n through the micropuncture sheath and the sheath exchanged for a 7-French\n dilator. The dilator was then removed and a triple lumen 7-French central\n venous catheter was placed over the wire with its tip positioned in the SVC\n under fluoroscopic guidance. The guidewire was removed. Position of the\n catheter was confirmed by chest x-ray in one view. The catheter was secured to\n the skin with 0-silk sutures.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided triple lumen\n central venous catheter placement via the left internal jugular venous access\n with the tip positioned in SVC.\n\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-28 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 893320,
"text": " 8:17 AM\n MR HEAD W/O CONTRAST; MRA CAROTID/VERTEBRAL W/O CONTRAST Clip # \n MR RECONSTRUCTION IMAGING\n Reason: r/o stroke, intracranial hemorrhage\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, pancytopenia, with profound episodes of\n lethargy and respiratory alkalosis. R/O stroke, intracranial hemorrhage.\n REASON FOR THIS EXAMINATION:\n r/o stroke, intracranial hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old woman with aplastic anemia, pancytopenia, with profound\n episodes of lethargy and respiratory alkalosis. Also was seen to have a non-\n occlusive right internal jugular vein thrombus on recent CT.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging. Diffusion-weighted\n images were also obtained.\n\n FINDINGS: No diffusion abnormalities are identified to suggest acute\n ischemia. T2 hyperintensity in the periventricular cerebral white matter is\n consistent with chronic microvascular ischemia. There is no mass effect,\n hydrocephalus, or shift of normally midline structures. No intracranial\n hemorrhage is identified; however, MRI is less sensitive compared to CT for\n the detection of subarachnoid blood.\n\n 2D time-of-flight imaging of the neck with multiplanar reconstructions.\n\n The exam is significantly limited by patient motion. The transverse and\n sigmoid sinuses are patent. Both internal jugular veins are patent as they\n approach the thorax where the view becomes limited by motion. The area of\n thrombus in the right internal jugular vein seen on recent CT is not well\n visualized on this exam.\n\n IMPRESSION:\n 1. Chronic microvascular ischemia of the periventricular cerebral white\n matter. No evidence of acute vascular territorial infarction.\n\n 2. The non-occlusive right internal jugular vein thrombus seen on recent CT\n is not well visualized on this exam due to patient motion; however, the\n internal jugular vein is patent superior to this area. Patent left internal\n jugular vein.\n\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-29 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 893467,
"text": " 1:24 PM\n MR HEAD W/ CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: evaluate for meningitis, stroke.\n Admitting Diagnosis: SEPSIS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with h/o aplastic anemia, now with R IJ clot, fevers, and\n lethargy. Previous MRI was not done with contrast.\n REASON FOR THIS EXAMINATION:\n evaluate for meningitis, stroke.\n ______________________________________________________________________________\n FINAL REPORT\n MRI BRAIN\n\n CLINICAL INFORMATION: Patient with aplastic anemia with right internal\n jugular vein thrombosis, fever and lethargy, for further evaluation to exclude\n meningeal process.\n\n TECHNIQUE: T1 sagittal, axial and coronal images of the brain were obtained\n following gadolinium administration and comparison was made with the study of\n .\n\n FINDINGS: The post-gadolinium images demonstrate no evidence of abnormal\n parenchymal, vascular, or meningeal enhancement. There is mild prominence of\n ventricles and sulci as noted on the previous study.\n\n IMPRESSION: No evidence of abnormal enhancement seen. Specifically, no\n evidence of meningeal enhancement identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891767,
"text": " 8:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for CHF, infiltrates\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with neutropenia and fever, now with increased\n tachycardia - eval for new infiltates, fluid overload\n REASON FOR THIS EXAMINATION:\n eval for CHF, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 09:18\n\n INDICATION: Neutropenia and fever. Tachycardia.\n\n COMPARISON: .\n\n FINDINGS: Right CVL remains in place with no PTX. There is no evidence for\n interval development of consolidation, effusion or CHF changes.\n\n IMPRESSION:\n\n Stable chest x-ray without evidence for acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-13 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 891494,
"text": " 4:08 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate for progression of lymphoma.\n Admitting Diagnosis: SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with marginal cell lymphoma adm with sepsis, now\n pancytopenic with daily fevers.\n REASON FOR THIS EXAMINATION:\n evaluate for progression of lymphoma.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma, sepsis and fevers.\n\n TECHNIQUE: Axial images through the abdomen and pelvis with IV contrast.\n\n CT OF THE ABDOMEN WITH CONTRAST: There is bibasilar atelectasis. Within the\n left lower lobe is a 2.4 x 1.9 cm peripherally enhancing low attenuation\n center opacity. There is a trace right pleural effusion.\n\n There is a stable low attenuation lesion in segment VI/VII of the liver. There\n is persistent splenomegaly with multiple foci of low attenuation, which are\n unchanged. The kidneys are stable in appearance without hydronephrosis. The\n pancreas is stable in appearance with the suggestion of a low attenuation\n lesion in the pancreatic head. However, due to residual oral contrast, the\n artifact limits detailed visualization. Again seen are multiple enlarged\n paraaortic and aortocaval lymph nodes, which are unchanged in appearance.\n There are no abnormally dilated loops of large or small bowel. Again noted\n are three midline anterior abdominal wall hernias, which contain nonobstructed\n bowel. There is a stable right retrocrural lymph node, measuring\n approximately 1 cm in short axis. There is no free air or free fluid in the\n abdomen. There is atherosclerotic calcification of the descending aorta.\n\n CT OF THE PELVIS WITH CONTRAST: The bladder, distal ureters, and rectum are\n unremarkable. The uterus and ovaries are not visualized. Again seen is\n artifact from the prior oral contrast. There is stable lymphadenopathy along\n the right iliac chain with the largest node measuring approximately 1.6 cm\n along the lower right external iliac vessels. There is no free fluid.\n\n BONE WINDOWS: No suspicious lesions.\n\n IMPRESSION:\n 1. Residual opacity in the left lower lobe, with the appearance consistent\n with residual pneumonia.\n 2. No intraabdominal or pelvic abscess.\n 3. Stable splenomegaly, retroperitoneal, right iliac, and right retrocrural\n lymphadenopathy.\n 4. Stable low attenuation lesions within the liver and spleen.\n 5. Stable nonobstructing midline hernias and left superior lumbar hernia.\n (Over)\n\n 4:08 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: evaluate for progression of lymphoma.\n Admitting Diagnosis: SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-12-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 895741,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for progression.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 y/o female with pulm nodules, aplastic anemia. With retrocardiac\n infiltrate on portable.\n REASON FOR THIS EXAMINATION:\n Please eval for progression.\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 72-year-old woman with aplastic anemia and pulmonary nodules.\n Retrocardiac infiltrate on prior examination. Evaluate for progression.\n\n COMPARISON: .\n\n SUPINE AP PORTABLE CHEST: The endotracheal tube and left subclavian line\n remain in standard position. A feeding tube descends into the stomach.\n Accounting for rotation and differences in position, the heart size is\n probably unchanged. The left retrocardiac opacity is difficult to compare but\n has probably increased. A 2-cm nodular opacity in the right lung base is now\n apparent. The previously reported left upper lobe nodule is unchanged. The\n effusions seen by CTA of the prior day are difficult to quantify in this\n supine study.\n\n IMPRESSION: Probably increased left lower lobe consolidation and new or\n increased small right basilar nodule most compatible with septic emboli. The\n previously noted left apical nodule is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-27 00:00:00.000",
"description": "P CHEST PORT. LINE PLACEMENT PORT",
"row_id": 893258,
"text": "\n CHEST PORT. LINE PLACEMENT PORT; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p LEFT TLC attempted placement. Aborted when wire did not\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia\n REASON FOR THIS EXAMINATION:\n s/p LEFT TLC attempted placement. Aborted when wire did not pass. Needle stick\n was in vein, but no catheter placed. Right sided line was pre-existing\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE, SINGLE VIEW\n\n INDICATION: Aplastic anemia, status post left-sided line placement attempt.\n Right-sided line was preexisting. Evaluate for possible pneumo.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n upright position. There is no evidence of pneumothorax on either side. The\n right-sided subclavian approach central venous line is in unchanged position\n in comparison with a previous study (eight hours earlier). No new parenchymal\n changes have occurred.\n\n IMPRESSION: No evidence of pneumothorax or any other attempt-related\n abnormality in apical chest areas.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 893017,
"text": " 4:33 PM\n PORTABLE ABDOMEN Clip # \n Reason: r/o osbstuction, free air.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, abd tenderness, now with decreased\n bowel sounds, episode of hyperventilation.\n REASON FOR THIS EXAMINATION:\n r/o osbstuction, free air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aplastic anemia, abdominal tenderness, and decreased bowel\n sounds, rule out obstruction or free air.\n\n COMPARISON: CT torso dated .\n\n PORTABLE SUPINE AP VIEW OF THE ABDOMEN: Contrast is seen in the rectosigmoid.\n No dilated loops of small bowel are demonstrated. No evidence of free air on\n this supine view. Scoliotic curvature of the spine convexed to left.\n\n IMPRESSION:\n\n 1. No evidence of obstruction.\n 2. No evidence of free air. Although evaluation is limited on this supine\n view, there is no evidence of free air on the CT torso obtained one hour after\n this examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 892386,
"text": " 6:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax, infiltrate, obstruction.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, recent pulm nodule by chest CT,\n now with acute hypoxic episode following immunoglobulin administration.\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax, infiltrate, obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old woman with aplastic anemia, recent pulmonary nodule by\n chest CT, now with acute hypoxic episode following immunoglobulin\n administration.\n\n COMPARISON: .\n\n CHEST AP: Cardiac, mediastinal and hilar contours are within normal limits.\n There is pulmonary vascular congestion and increased interstitial markings.\n No definite consolidation is identified. The left lower lobe nodule on recent\n chest CT is not well visualized on this exam. Endotracheal tube and right\n subclavian CVL appear in satisfactory position. Osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: Moderate pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-28 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 893344,
"text": " 10:54 AM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: r/o hepatic inflammaion or clot.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of marginal cell lymphoma, aplastic anemia, now\n with fevers and acute rise in alk phos and LDH.\n REASON FOR THIS EXAMINATION:\n r/o hepatic inflammaion or clot.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: History of nodular cell lymphoma, aplastic anemia, now with\n fevers and acute rise in the alk phosphatase and LDH, rule out hepatic\n inflammation or clot.\n\n FINDINGS: No pleural effusion seen on the current study. The hepatic veins\n show appropriate color and spectral Doppler flow. The main portal vein and\n its major tributaries are appropriate for flow and waveforms. The hepatic\n artery shows appropriate flow. The possible hemangioma seen on the prior\n study is not depicted on the images of the current study. The liver is normal\n in echogenicity.\n\n IMPRESSION:\n 1) Patency the of the major hepatic and portal veins. No evidence of clot.\n\n 2) The previously depicted hemangioma on the prior study is not depicted on\n the images of the current study.\n\n 3) No pleural effusion is seen on the current study.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-14 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 891593,
"text": " 12:32 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: MATEL CELL LYMPHOMA,ESOPHAGEAL PATHOLOGY\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with mantle cell lymphoma, now with pancytopenia and \n esophagitis.\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia, esophageal pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mantle cell lymphoma now with pancytopenia and \n esophagitis.\n\n TECHNIQUE: Multidetector CT images of the chest were obtained without\n intravenous contrast.\n\n COMPARISON: Chest CT , torso CT .\n\n CHEST CT WITHOUT CONTRAST: There has been interval improvement in the\n effusions, with residual small right effusion and resolved left effusion. A\n 2.2 x 2.2 cm irregular nodular opacity is present at the left lung base and\n there is a 6- mm irregular nodular opacity at the right lung base, both new\n from earlier torso CT of . Given the atelectasis and effusion\n on the chest CT of of , it is difficult to say whether or not\n these lesions were present at that time. An additional irregular nodular\n opacity is present in the left upper lobe, measuring 7 mm. This was faintly\n visible on torso CT, but is more conspicuous on today's\n examination.\n\n Multiple paraesophageal lymph nodes are present and unchanged. There is\n moderate diffuse thickening of the esophageal wall, which has improved in the\n interval. Aortic and coronary artery calcifications are again noted. There is\n moderate emphysema.\n\n The osseous structures reveal no abnormalities. Limited visualization of the\n upper abdominal organs reveals an enlarged spleen and ill-defined lesions\n within the liver. Please refer to abdomen and pelvis contrast-enhanced CT of\n one day prior, clip for better evaluation of the abdominal structures.\n\n IMPRESSION:\n\n 1. Dominant left lower lobe nodular opacity with smaller right basilar and\n left upper lobe nodular opacities, all new over the prior month and likely\n representing infection. Given the patient's immune status and nodular\n configuration of the lesions, an opportunistic infection is likely, with\n and aspergillus as potential causative organisms.\n\n 2. Improved effusions, with small right residual effusion.\n\n (Over)\n\n 12:32 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: MATEL CELL LYMPHOMA,ESOPHAGEAL PATHOLOGY\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-18 00:00:00.000",
"description": "DUPLEX DOPP ABD/PEL",
"row_id": 892092,
"text": " 2:47 PM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) PORTClip # \n Reason: ACUTE RISE IN ALK PHOS, EVAL HEPATIC BLOOD FLOW\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of marginal cell lymphoma, now with aplastic anemia,\n and acute rise in alk phos.\n REASON FOR THIS EXAMINATION:\n evaluate hepatic blood flow with dopplers.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 72-year-old woman with history of marginal cell lymphoma, now\n with aplastic anemia and an acute rise in alkaline phosphatase.\n\n COMPARISONS: Recent CT scan.\n\n TECHNIQUE: Limited right upper quadrant ultrasound examination with duplex\n Doppler studies of the hepatic vessels.\n\n FINDINGS: There is a tiny anechoic right-sided pleural effusion. The study\n is somewhat limited by breathing artifact, but the right, middle, and left\n hepatic veins show appropriate color and spectral Doppler flow. Likewise, the\n main portal vein and its major tributaries show appropriate Doppler flow and\n waveforms. Examination of the hepatic arteries was not performed. In segment\n VI, there is a small discrete hyperechoic nodule of 1.8 x 1.4 x 2.2 cm, whose\n grayscale appearance is consistent with hemangioma, although flow\n characteristics were not delineated. In correlation with a recent CT from\n , this lesion is consistent with a hemangioma, which in retrospect\n probably corresponds to a subtle area of increased early phase enhancement on\n the prior CT.\n\n IMPRESSION:\n 1. Patency and appropriate flow of the major hepatic and portal veins.\n Examination of the hepatic arteries was not performed.\n 2. Hemangioma in the right lobe of the liver.\n 3. Trace right-sided pleural effusion. The findings were discussed with Dr.\n on the same day.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 892428,
"text": " 5:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for pulm edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, recent pulm nodule by chest CT,\n now with acute hypoxic episode following immunoglobulin administration.\n REASON FOR THIS EXAMINATION:\n Eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Acute hypoxic episodes. Evaluate for pulmonary edema.\n\n Endotracheal tube and central venous catheter are in satisfactory position.\n There has been marked interval improvement in previously described pulmonary\n edema with mild residual interstitial edema remaining. Examination is\n otherwise unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893016,
"text": " 4:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please do cxr and abd xray. r/o infiltrate,edema. r/o free\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, now hyperventilating and lethargic.\n REASON FOR THIS EXAMINATION:\n please do cxr and abd xray. r/o infiltrate,edema. r/o free air under\n diaphragm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 72-year-old woman with aplastic anemia.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared\n with previous study of .\n\n The patient has been extubated. There is new opacity in both lower lobes\n indicating pneumonia versus aspiration in this patient with aplastic anemia.\n\n The lungs are clear otherwise. The heart and mediastinum are within normal\n limits. The right subclavian IV catheter terminates in the superior vena\n cava. No pneumothorax is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 893194,
"text": " 8:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tachypnea, mental status change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with aplastic anemia, now hyperventilating and lethargic.\n\n REASON FOR THIS EXAMINATION:\n tachypnea, mental status change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:40 A.M :\n\n HISTORY: Aplastic anemia. Hyperventilating and lethargic. Suspect pneumonia\n or pulmonary edema.\n\n IMPRESSION: AP chest compared to , 9, and 13:\n\n There has been no appreciable change on plain radiographic appearance over the\n past week. Small pleural effusions were demonstrated on the chest CT and the left lower lobe abscess or septic infarct is not readily visible on\n plain radiographs. Upper lungs are clear. There is no pulmonary edema.\n Heart size is top normal. Tip of the right subclavian line projects over the\n SVC. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 268241,
"text": "Atrial fibrillation with uncontrolled ventricular response.\nAnterior T wave changes may be due to myocardial ischemia\nSince previous tracing of , tapid atrial fibrillation seen\n\n"
},
{
"category": "ECG",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 268242,
"text": "Sinus tachycardia with sinus arrhythmia.\nrSr'(V1) - probable normal variant\nInferior and lateral ST elevation - possible early repolarization\nAnterior T wave changes are nonspecific\nSince previous tracing of , rate increased\n\n"
},
{
"category": "ECG",
"chartdate": "2149-12-09 00:00:00.000",
"description": "Report",
"row_id": 268243,
"text": "Sinus bradycardia with ventricular premature depolarizations. Compared to the\nprevious tracing of no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-12-08 00:00:00.000",
"description": "Report",
"row_id": 268462,
"text": "Sinus rhythm with baseline artifact. Compared to the previous tracing\nof heart rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2149-12-07 00:00:00.000",
"description": "Report",
"row_id": 268463,
"text": "Sinus tachycardia with marked baseline artifact. Non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of heart rate now\nfaster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-21 00:00:00.000",
"description": "Report",
"row_id": 268464,
"text": "Sinus tachycardia. Modest anterior ST-T wave abnormalities which are\nnon-specific. Compared to the previous tracing of ventricular rate is\nslower. Otherwise, no significant diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-16 00:00:00.000",
"description": "Report",
"row_id": 268465,
"text": "Sinus tachycardia.\nModest ST segment junctional depression - is nonspecific and may be within\nnormal limits\nSince previous tracing of , sinus tachycardia present\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-13 00:00:00.000",
"description": "Report",
"row_id": 268466,
"text": "Sinus rhythm with atrial premature beats. Non-specific ST-T wave changes.\nCompared to the previous tracing no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-08 00:00:00.000",
"description": "Report",
"row_id": 268467,
"text": "Sinus tachycardia. Compared to the previous tracing atrial fibrillation is no\nlonger present.\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-04 00:00:00.000",
"description": "Report",
"row_id": 268468,
"text": "Atrial fibrillation with a mean ventricular response, rate 90. Compared to the\nprevious tracing of cardiac rhythm now atrial fibrillation.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-04 00:00:00.000",
"description": "Report",
"row_id": 268469,
"text": "Sinus rhythm with supraventricular premature depolarization. Compared to\ntracing #1, no major change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2149-11-04 00:00:00.000",
"description": "Report",
"row_id": 268470,
"text": "Sinus rhythm. Normal sinus rhythm. Non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of no major change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2149-12-09 00:00:00.000",
"description": "Report",
"row_id": 268461,
"text": "Sinus rhythm with baseline artifact. Compared to the previous tracing\nof no major change.\nTRACING #3\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 890690,
"text": " 3:52 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p c v line ?position????pneumo???? please call wi\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with neutropenia and sepsis.\n\n REASON FOR THIS EXAMINATION:\n s/p c v line ?position????pneumo???? please call with wet read\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE:\n\n INDICATION: 72-year-old woman with neutropenia.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared to prior study of yesterday.\n\n The right subclavian IV catheter terminates in the distal SVC. No\n pneumothorax is identified.\n\n The previously identified congestive heart failure has been improving. There\n is small bilateral pleural effusion and atelectasis in both lower lobes.\n\n The heart is normal in size.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2149-11-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890504,
"text": " 5:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with neutropenia and sepsis.\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Chest.\n\n HISTORY: Neutropenia, sepsis.\n\n CHEST: A single supine portable view is compared to previous examination of\n . Since the previous exam, the pleural effusions, especially\n on the right has increased the heart size is upper normal limits. No focal\n consolidation is seen. There is probable bibasilar atelectasis.\n\n Note is made of a right IJ line with the tip in SVC.\n\n IMPRESSION: Increased bilateral pleural effusions.\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-04 00:00:00.000",
"description": "Report",
"row_id": 1282527,
"text": "MICU EAST Nursing Progress Note (1800)\n\nPt. admitted from heme/onc clinic via EW after syncopal episode. Pancytopenic with Hct of 18. Currently being treated with chemotherapy for recurrence of lymphoma. +cold agglutinin syndrome. Febrile to 105, borderline hypotension treated with IVF/PRBC's/triple antibiotics. Please see nursing admission note for complete assessment.\n\nCNS: Pt. alert, oriented and cooperative. Very pleasant, but frustrated with continual interventions, etc. MAE's without deficit.\n\nCVS: Currently on levophed which has been titrated down to .05mcg/kg/min to maintain MAP >60. Presep catheter present...awaiting lab values in order to calibrate vigilance monitor. Pt. has received 2 PRBC's thus far, along with 5500cc crystalloid and CVP is 16. UOP >30cc/hr.\n\nRESP: Lungs with diminished breath sounds throughout. O2 sat of 98% on 100% NRB. RR in the mid 20's. No cough/no sputum.\n\nSKIN: Intact.\n\nID: Axillary temp of 95. Antibiotics x 3 administered in EW (aztreonam, gent, vanco).\n\nHEME: Repeat Hct, coags pending.\n\n+cold agglutinin syndrome...all blood products to be warmed prior to administration, use of cooling blankets prohibited.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-04 00:00:00.000",
"description": "Report",
"row_id": 1282528,
"text": "Addendum: Hct now 36. SVO2 of 56 and lactate is down to 1.6. Levophed continues to be weaned down. Pt. able to tolerate 6lnc with sats in the mid 90's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-05 00:00:00.000",
"description": "Report",
"row_id": 1282529,
"text": "NPN 1900-0700\nNeuro:Pt slept most of shift, pt awakens when staff enters room. A&O x3. Moves all extremities in bed. PERRL, 3mm/3mm brisk bilaterally. Pt frequently complaining all night of general aches, back pain, and interruption of sleep d/t staff care. Heat packs applied to lower back, pt states some relief of discomfort.\n\nResp: Lung sounds are diminished bilaterally, RR 22-24. Pt has excessive oral secretions and uses yanker as needed. Maintaining O2sat of 97-99. Sputum cultures to be obtained in the AM.\n\nCV: HR 68-84, BP 93-116/55-73, SR-Afib, no ectopy. Norepinephrine d/c @ 0300. CVP: . K and Ca repleted. Pt received 1 unit of blood @ 2200. HCT 26.1 this am, no new orders at this time.Pedal pulses are palpable bilaterally.\n\nEndo: FS 172-132, receiving insulin drip @ 2 units/hr.\n\nGI: NPO, Abdomen soft, obese, +BS, No BM. c/o indegestion and nausea overnight, states \"I haven't been eating lately...my stomach just feels raw from these medicines.\" Given anzimet IV and Maalox po, pt states some relief.\n\nGU: Foley cath intact, draining 27-130cc of clear yellow urine.\n\nID: T max 99.2 Pt receiving vanco, aztreonam, and flagyl. Lactate 1.2.\n\nSkin: Intact with no breakdown. +1 edema in hands bilaterally\n\nPlan: Continue to monitor temp. as pt has cold agglutinin syndrome. Apply bear hugger for temp<97.3. CT of abd. planned for AM. Monitor BS and titrate insulin as needed. Encourage Pt to change position. Continue to follow labs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-05 00:00:00.000",
"description": "Report",
"row_id": 1282530,
"text": "MICU/SICU East Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Please see nursing transfer note...pt. awaiting bed placement on 7Feldberg.\n\nCNS: Alert, oriented and cooperative. Pt voices many complaints over being hospitalized and of all the accompanying interventions.\n\nCVS: Heart rate in the 60's to 70's, NSR without VEA. B/P 100-120/syst. Pt. has been off of levophed since 0300. CVP of 13. SVO2 of 65. Even fluid balance since midnight.\n\nLYTES: K+, Mg and phos have all required replacement today.\n\nID: Temp of 101.7 at 0745. Transfusion dc'ed and transfusion reaction workup sent. Tylenol 650mg given. Hypothermic to 96.5 by 1500 and bair hugger reapplied.\n\nHEME: Hct of 25. No plans for futher transfusions at this point\n\nGI: Taking only sips of water with medications. Results of abd CT pending. Pt. does c/o nausea which was treated with anzemet. Mid \"indigestion\" treated with maalox and protonix.\n\nSKIN: Intact\n\nSOCIAL: Husband in and has been updated by the oncology team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-06 00:00:00.000",
"description": "Report",
"row_id": 1282531,
"text": "NPN 1900-0700\nNeuro: Alert and Oriented x 3, voicing many complaints about general discomfort, comfort provided, meds given for nausea and back pain. Pt to be transferred to floor today when bed available.\n\nResp: Lungs clear to upper lobes bilat, diminished to bases bilat. RR 16-20, O2 sats 95-98% on 4L NC.\n\nCV: HR 70-80's NSR, BP's 112-130/50-60's. Pedal Pulses palp. bilat.\n\nGI: BS (+), x1 BM yesterday day shift guiaiac (-).\n\nGU: FOley intact draining amber urine in adequate amts.\n\nSkin: Intact.\n\nPlan: Up to chair this am, to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-06 00:00:00.000",
"description": "Report",
"row_id": 1282538,
"text": "M/SICU Nursing Transfer Accept Note\nSee FHPA for PMH, PSH, Allergies and recent events preceding transfer to ICU\nSee Carevue Flow sheet for Additional Objective Data\nROS:\nHeme:Hct:29-stable, Plts:44-stable PT/PTT and INR:WNL\nWBC:.1, ANC:30 Fibrino:764 (150-400)\nNo S&sx of bleeding. ?HIT+ per nursing report-No Heparin\n\nID:T:94-96 axillary, bair hugger on. Recent Cx results: BC::GPC, cx speciation:png, :Urine:neg, Cath tip:neg, sputum:negative. + esophogitis, On 7 antibx\n\nCV:Hemodynamically stable. K:3.9, Ca, Mg, PO4:WNL\n\nResp:R/A RR:20-26/min. Denies any SOB, no cough, no sputum production. BS:CTA, diminished at bases SpO2:>95\n\nGI:NPO on aspiration precautions, HOB:30 degrees. Receiving TPN. Abd soft, non-tender w/ + BS. Stooling loose golden colored stools q 1-2 hours OB trace + Alk Phos elevated otherwise LFT's:WNL\n\nEndo:BS:465-492, Insulin gtt started at 5 units/hour. Also receiving 70 units/24 via TPN. BS trending down, repeat at 19:00:png\n\nGU:BUN/Cr: 21/1.9 U/O:130-400cc/hr, I/O since transfer:-425cc\n\nNeuro:A&O x3, somewhat lethargic and withdrawn although she is receiving 50mg IV benadryl q 6 hours. Co-operative with medical regime.\n\nPain/Skin: c/o baseline pain score of 5 secondary to perianal excoriation, mild relief with .\n\nA/P:VRE bacteremia- stable\n Aplastic Anemia- requiring ATG desensitization\n\nCont to monitor S&sx of infection, frequent surveillence cx, stool sent for c diff, cont on multiple antibx, monitor hemodynamic stability, cont with anaphalaxsis prophalaxsis w/ steroids, tylenol and benadryl, anaphalaxsis kit at bedside, start ATG desensitization this evening, ciontinue with aggressive supportive care-TPN, Insulin gtt, skin care, etc\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-07 00:00:00.000",
"description": "Report",
"row_id": 1282539,
"text": "NPN 1900-0700\nNeuro; Pt. lethargic most of shift and confused. Alert to self only. Reaching out for things. ? solumedrol psychosis.\n\nCV: Pt. with Hx. of aplastic anemia was treated with IVIG with no improvement. Pt. had ATG treatment about 3-4 weeks ago with reaction of rigors, temp and tachychardia and med was stoped. Pt. spent 24 hr in ICU at that time. Pt. transfed to MICU for disensetization of ATG and has been on IV steroids and Benadryl for past few days. ATG was started at 2045 and Pt. tolerated desensetization taper well with no change in VS. Cont. infusion was started at 0045 at rate ordered and about 1.5 hr into infusion HR began to increase from 100's to 120's. small rigor was noted and Pt. was found to have a temp on a rise from 97.5 ax at 0130 to 102.1 at 0430. HR also escaleted to 150-160's sinus tach. EKG done with no changes. Cxr done. Pt. recieved Tylenol 650 mg x2 for temp and was placed on cooling blanket. Recieved additional dose of IV Solumedrol and 2.5 mg IV Lopressor to control HR. HR down to 120's Sinus tach with no ectopy BP 120's-130's/50-60's. BP also elevated with episode of temp. ATG stoped at 0300 for ? of a reaction rather than spike of temp. Pt. also recieved 2 250 cc fluid bolus during episode of tachycardia. AM labs pending.\n\nResp: LS clear dim at bases. RA O2 sat 96-99%. Pt. place on 2 L NC during episode of tachycardia. O2 sat 97%. Occ congestion and effort to cough with minimal effect.\n\nGI: Pt. NPO on TPN and Lipids. Pt. on INsulin gtt titreted to BS. BS ranging from 300's to 150's. Insulin gtt at 6 units/hr. Abd soft slightly distended BS+. Pt. noted to have abd hernia especially when coughing. MD aware. Pt. had frequent med. loose stools this shfit.\n\nGU: Foley cath in and draining adequate amount of clear yellow urine.\n\nSkin: peri area red and excoriated. Skin care done after each BM and barrier cream applied to protect skin from breakdown. Multiple bruses to skin all over her body. No open areas noted.\n\nID: Pt. on multiple abx. for +VRE in Blood. WBC 0.1 on . Temp spike ? ATG reaction or sepsis.\n\nSocial: Pt. is a full code. Pt.'s husband called last night and was updated on Pt.'s and treatment status. He will call in AM. Pt. seems withdrawn and angry. Provide emotinal support as needed to Pt. and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-07 00:00:00.000",
"description": "Report",
"row_id": 1282540,
"text": " 4 ICU nursign progress note:\n Aplastic anemia: Counts remain low..afebrile..temp in 95-94 (ax) range..restarted ATG late this afternoon...at lower doses..continuous infusion..will continue to monitor vs closely with infusions.\n ID: Continuing to follow BC (all + for VRE) resent culture today. Temp as above. No change in antibiotics.. Stool for c-diff sent.\n Cardiac: VSS thru day..see care-view for data.\n Volume: ??on dry side..given 1 liter of .45%ns as bolus..has good u/o..40-100cc hr.\n Respiratory: Room air..with sats 98-100%. rr 16-22\n GI: Persistant diarrhea..ob -..fecal bag placed and working well..taking small sips of water..??some aspiration..using swabs instead..On TPN\n Neuro: Alert,orientated this am..late afternoon pt more fidgety..picking at blankets..periods of confusion..dozing intermittently..MAE..easily re-orientated.\n Social: Husband in..updated on plan.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 1282559,
"text": "FIANRD 4 ICU 0700-1900\n\nRemains intubated & sedated. Put on PS 5, PEEP X2 hrs. VT 450-700. RR 25-35 min. MV 12-14L min. Decision to defer extubation. Put on PS 5, PEEP 5 at 1830. BS coarse. This afternoon pt having copiouus, thick, white secretions.\n\nFent & versed gtts d/c'd at 1500. Extrem flacid. Wrist restraints removed. Pupils 2mm NR occas open eyes spont. with increased R at X's.\n\n~1200 HR 150-180 & irregular. Lopressor 5mg IV X2 with slight, transient decrese in HR to 120's-140's. No VEA noted. Dilt gtt started. Titrated to 15mg hr. HR 110-130. CVP 13-15. SBP 116-168\n\nK up to 6.4. K-exelate given. Repeat K 5.7. Cyclopsporin d/c'd. Level pnd.\n\nT-max. 99PO. No antibiotic change\n\nNPO. TPN stopped at 0830 d/t hyperkalemia. Restarted this eve.\nON RISS & NPH fixed dose as well as in TPN. BS 163-135.\n\nGU: Decreased UO for several hrs this afternoon. UO improved on own.\n\nLFT's elevated. Abd US done. Results pnd.\n\nHusband in to visit. Updated on pt's condition by this RN as well as Dr. .\n\nA/P: Tol PS. Increased secretions. ? if pt able to protecy her airway if extubated. Assess overnight.\n\n? eti of RAF. HR improved but well rate controlled. Awaiting C-echo.\n\nFollow UO, CVP\n\nRestar TPN. Follow BS. Insulin in TPN &RISS, NPH\n\nFollow temp. Cont antibiotics.\n\nSupport to family\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 1282560,
"text": "Respiratory Care\nPt on SBT for two hours, Pt positive for airleak, RSBI 65. Plan to extubate this evening or in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 1282561,
"text": "Brief NPN 7PM-11PM coverage:\nPt pre-medicated with tylenol and benadryl as well as her standing dose steroids before granulocyte infusion at . Tolerated infusion without complications. 1 hour Post transfusion granulocyte count to be drawn at 2140. No other bloodwork needed according to team. AM labs will be sufficient. Pt remains on the dilt drip with HR 100-130 a-fib. BP at times dipping down to 90's so drip rate dropped to 10mg/hr for now. Will adjust as needed.\n\nRemains off sedation, remains unresponsive, becomes tachypneic at times with RR into 40's and minute ventillation up to 22L/min. suctioning worked once to decrease resp drive, at other times this increase in rate stops spontaneously. Continues on PSV 5 with 5cm peep. Sats high 90's. Lungs sounds very decreased on the left side. Pt has minimal cough, weak at best and no gag. Ability to maintain patent airway once extubated is in question.\n\nTemp down to 96 axillary so Bear Hugger applied at 8PM. All antibiotics given as scheduled. UO boarderline at 25-30cc/hr. Colace held as pt passing brown liquid stool.\n\nContinue to follow granulocyte count with AM labs ordered at 4AM. Continue antibiotics, follow chemistries with AM labs. Provide vent support as needed and emotional support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-17 00:00:00.000",
"description": "Report",
"row_id": 1282562,
"text": "Respiratory care:\npatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings: PS 5 Peep 5 fio2 @ 40%. Breathsounds are coarse. Suctioned for thick yellow secretions. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-06 00:00:00.000",
"description": "Report",
"row_id": 1282532,
"text": "Respiratory Care:\nPt. seen and was induced for a PCP . also obtained a sputum\nspec. for Cult. and gm Stain.... Samples taken to Micro by RT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-21 00:00:00.000",
"description": "Report",
"row_id": 1282533,
"text": "NPN 1900-0700\nNeuro: Pt. arrived from 7 to MICU at 1900 s/p reaction to ATG with rigors and HR up to 180's sinus tach. Pt. was intubated and sedated on Propofol. Pt. was not responsive even to painful stimuli. Propofol tapered off due to decrease in BP to low 80's. Pt. awoke and responding and following commands appropriatly. Pupils 3mm round equal and reactive to light. Pt. was placed on Fentanyl and versed 12.5 mcg and 0.5 mg/hr for a short time but had to be turned off due to BP down to 70's systolic.\n\nCV: R radial A-line inserted for better BP monitoring. Pt. recieved 1L of NS fluid bolus for low BP with good results. Order for Levophed for MAP<65 currently on hold. BP ranging 86-120's/45-70. HR initilly in 140's dow to 90's and currently 115 Sinus tachy with no ectopy. K 2.9 repleated with 80 Meq of IV KCL. Mg 1.3 and repleated with 4 gr of Mg sulfate. Ionized Ca 1.07 repleated with 3 gr of Ca Gluconate IV. AM labs pending. Pt. has R subclavian TLC intact. CVP 8 increased to 10 after fluid bolus. WBC 0.1 and Pt. on neutropenic precautions. H/H 9.8/26.4, Plt 23.\n\nResp: Pt. on CPAP with 10 pressure support 5 of PEEP and 40% of FiO2. ABG at 2100 pH 7.43, PaCO2 26, PaO2 170, HCO3 18. LS . Respiratory effoer easy unlabored. No secretions.\n\nGI: Abd. soft, non tender BS+. No OGT at this time.\n\nGU: Foley cath inserted at 2100 with initial urine output of 800cc of clear yellow urine plus large incontinent amount. output > 45cc/hr.\n\nSkin: skin intact with small areas of brusing noted all over her body. Edema +2 to low ext.\n\nID: Pt. with Temp 102.2 on arrival to ICU but afebrale for the remainder of night shift. Pt. on multiple ABX.\n\nSocial: Pt.'s husband in at and spoke with MD about events that brought his wife to ICU. Pt. will be in during the day on Friday. Pt. is a full code.\n\nPlan: Pt. will be extubated in AM and possibly transfered back to 7 .\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-21 00:00:00.000",
"description": "Report",
"row_id": 1282534,
"text": "RESPIRATORY CARE NOTE\n\nPt received from floors intubated and placed on AC settings upon arrival in unit. Pt was >22 liters. ABG showed significant metabolic acidosis. Pt also tachypneic. Switched modes of ventilation from AC to PS and pt responded well. Ve, RR decreased. Looks more comfortable on PS. RSBI completed on PS 5=33. Plan to wean to extubate this AM.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-21 00:00:00.000",
"description": "Report",
"row_id": 1282535,
"text": "RESPIRATORY CARE NOTE\nAddendum: Pt placed on PS 5. Vt-765-880, Ve=14-16 liters, RR=17.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-21 00:00:00.000",
"description": "Report",
"row_id": 1282536,
"text": "MICU NPN 7AM-3PM:\nNeuro: Pt awake and alert in AM, anxious for ETT to be removed. Given 1mg IV ativan to get her through until this could be done. Once extubated pt denied discomfort. MAE, follows commands. Speech is clear but soft voice due to thoat irritation after ETT. Spoke to husband by phone.\n\nCV: BP 90-120/60. HR 80-100 NSR no ectopy. K+ repleted. Sociun low at 129. Denies chest pain.\n\nResp: Weaned O2 to 30% face mask with the plan to go to nasal canula soon. RR 18-22. Lungs clear with deminished breath osunds at bases.\n\nGI: abdomen softly distended non-tender. NPO so far today.\n\nGU: UO is good via foley.\n\nEndo: Noon fingerstick did not require sliding scale coverage.\n\nID: Pt remains with non-anion gap acidosis. CO2 down to 14 today. Lactate 2.2. Pt remains on numerous antibiotics and is afebrile.\n\nHeme/onc: Pt will most likely go back to 7Feldberg soon. Heme/onc service has not seen pt yet today. Plt count was down to 15 and our team did not want to transfuse and no bleeding noted. Will ask heme/onc their preference when they round.\n\nSocial: I did speak to her husband this morning for update. he plans to visit this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-11-21 00:00:00.000",
"description": "Report",
"row_id": 1282537,
"text": "Brief Update NPN 3PM-7PM:\nPt remains alert and oriented times three and c/o being hungry. Team has allowed her to have clears since extubation which she has tolerated well. Pt's platelet count was 15 this AM and team ordered for her to get one bag platelets which was done. Pt's post transfusion plt count was sent and will be pnd. Pt denies pain but c/o fatigue. Husband unable to visit due to weather. Pt is called out to 7F but they have not called to say she has a bed available yet. Transfer note written but may need updating when she goes. UO is excellent via foley.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-15 00:00:00.000",
"description": "Report",
"row_id": 1282554,
"text": "Micu Nursing Progress Notes\nEvents: Pt febrile, temp Max 102.0, started on Fentanyl and versed drips, becoming more hypotensive, B/P 90-100/50's.\n\nResp: Pt is vented, A/C 500 x 16, RR has been consistantly 35-40. FiO2 was decreased from 100% to 50%. She was suctioned x2 for minimal secretions. She was lavaged at 2200 so that a sputum specimen could be sent for C&S. Her O2 sats have been 98-99%.\n\nCardiac: B/P was initially 120-130/60's. When she was started on Fentanyl and versed her B/P fell to 88/54 which responded to 250cc bolus of NS. Her B/P increased to 120/70. However over the course of the night her B/P has slowly drifted down to the 90's/50. Her HR has been 126-135 ST.\n\nNeuro: She remains unresponsive. She does not have a gag or a much of a cough when suctioning, she is not moving at all and is very flaccid. Her respitory pattern was very labored and she looked uncomfortable. After the initiation of Fentanyl at 50mcg/hr and versed 3mg/hr her breathing pattern improved.\n\nGI: She remains on TPN at 64.6cc/hr. Her abd remains soft with hypoactive bowel sounds. She has had no stool.\n\nEndo: Blood sugars remain high, midnight sugar was 249. She was given 6u regular insulin.\n\nGU: Foley is draining yellow urine, U/O 70-100cc/hr.\n\nID: Temp 102.0 at just prior to receiving a unit of granulocytes. She was given 50mg benadryl and solumedrol 20mg prior to the transfusion. She tolerated it well with no signs of reaction. She remains on gentamicin, acyclovir, flagly, aztreonam, linezolid and ambisome.\n\nSkin: The rash around her labia and coccyx remains reddened but looks slightly improved, micoazole was applied.\n\nSocial: No contact with the family overnight.\n\nPlan: continue to monitor resp status, there may need to increase her insulin to cover the high sugars, they plan to given granulocytes tonight so given the Solumedrol as a premed when they are ordered, Monitor blood pressure for further hypotention.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-15 00:00:00.000",
"description": "Report",
"row_id": 1282555,
"text": "NPN 0700-1900\nNeuro: Pt. intubated and sedated on Versed 2 mg/hr and Fentanyl 50mch/hr to allow for better ventilation. Pt. remains unresponsive to stimuli. Pupils 2 mm not reactive to light. ICU team aware. Pt. has scleral edema. Pt. flacid and does not move in bed. MRI of brain negative. LP done on negative.\n\nCV: HR remains elevated and ranging from 124-139 ST with no ectopy noted. BP stable ranging from 100-125/52-71. HCt. 23.0 Pt. ordered to transfuse 1 unit of PRBC per BMT rec. Pt. also will recieve granulocyte transfusion daily for 1 week. First day and Pt. tolerated well without s/s of reaction. Pt. will need to be premedicated with Benadryl and solumedrol prior to transfusion of granulocyte. TLC subclavian to L chest wall intact.\n\nResp: Pt. intubated on A/C 500x16 Peep 5 and FiO2 40%. ABG at 1400 see carevue fro values. LS clear and dim bil. Cxr. shows new RLL infiltrate, ? fungal pna. RR has been 30's but unlebored and easy.\n\nGI: Pt. on TPN and lipids @ 64.6 cc/hr. Abd. soft, BS hypoactive. No stools this shift. Eight Fr. OG tube inserted by MD PO per BMT team rec. Tube placement confirmed by X-ray. Pt. on RISS q6 hr. BS 166 at 1200. insulin sliding scale adjusted.\n\nGU: Foley cath in place and draining adequate amounts of dark yellow urine. BUN 57 creat. 0.6. Fluid balance +1.5L for 24 hr. and 13.9L for LOS. Since pt. on vent increased upper and lower ext. swelling.\n\nID: Pt. with Temp elevated since at 1600. This AM temp 100.0 and slowley increasing. T max 102.6 at 1600 after Tylenol supp. at 1200 and 1500. Pt. placed on cooling blanket and will monitor Temp. ? Serum sickness after ATG infusion. Pt. will start on cyclosporin. Pt. on mult. abx. for past 6 weeks. Last + bld. cx from all others are pending. ID team follows Pt. daily.\n\nSocial: Pt. is a full code. Husband in to visit and very emotional about Pt.'s condition. Cont. emotional support for husband and Pt. Cont. to update Husband on Pt.'s care plan and condition.\n\nPlan: Resp. support and daily granulocyte infusions x1 week to increase WBC count.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-15 00:00:00.000",
"description": "Report",
"row_id": 1282556,
"text": "Resp Care\nPt remains intubated on A/C. Dropped FIO2 from 50 to 40. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 1282557,
"text": "71 yr old female transfer pt from 7 . Past HX of mantle cell lymphoma with aplastic anemia admitted with M/S changes and febrile.\n\nRESP Pt remains on vent settings A/C 500x16 with spont RR 0-8 over the vent, Fio40% peep 5, minute vent 14-16liters/min, Pt suctioned several times for thick blood tinged white sputum. Sputum C&S pending. ET tube rotated remains 23 at lip. O2 sats remains 97-98%. CTX shows RLL infiltrate possible fungal PNA. Lungs sounds are diminished with slight crackles at the bases.\n\nCardiac B/P currently @ 119/77 did increase while repositioning etc. and pt given a bolus of fentanyl 25mcg/hr which she tolerated well. Versed drip decreased to 1.0/hr. and fentanly @.25mg /hr for increased sedation. Pt appears to becoming more responsive. Pt HR currently @ 115 and does increase to 130's at times. Has been running sinus tachy throughout shift. Pt pre medicated with tylenol 650 via OG tube and 50 mg Benadryl IV push for transfusion of granulocytes scheduled for 1X daily for 7days. Pt tolerated transfusion well ,no reaction noted.\nLeft subclavian TLC with dressing dry intact.\n\nNEURO pt admitted with M/S changes but according to chart appears not to be new issue. Pt previously admitted to build up tolerance to IVIG. Pt remains sedated from fentanyl and versed, unresposive to painful stimuli,lowered sedation to 25mcg/hr of fentanyl and versed to 1mg/hr. but did have some response to treatment (increase in B/P some grimacing etc) increase in breathing patternwhich responded well to fentayl bolus.\n\nGI Pt on TPN 64.6 cc/hr. Her abdomen is soft and distended with hypoactive bowels sounds. No B/M this shift.. Colace scheduled as PO. Requested from pharmacy to send elixir form of med Since pt has OG tube. Og tube secured and check placement done.\n\nGU foley in place and draining adequate amts of amber clear urine.\n Pt has edema throughout upper and lower extremities.\n\nSKIN Pt has rash labia and coccyx area..improving, Aloe Vista and miconazole applied to both areas.\n\nPt temp WNL this shift. Cont on genta,aztrotrem,linezilod,acyclovir, being treated for VRE bactreremia, Pt wit serum sickness after ATG infusion.\n\nSocial no contact from family overnight. Remains full code\n Plan:follow neuro, lowering sedation as tolerated,monitoring LFT's follow labs and replete electrolytes as needed, monitor temp, ABG today for evaluate resp vent settings. monitor I&O's support family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-16 00:00:00.000",
"description": "Report",
"row_id": 1282558,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 52.9 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-14 00:00:00.000",
"description": "Report",
"row_id": 1282551,
"text": "Micu Nursing Progress Notes\nEvents: received 4 bags platlets prior to LP attempt, Plat ct up to 93. LP was unsuccessful. Pt very restless most of the night.\n\nNeuro: Pt responding to her name by looking at you and saying \"what\". She did answer that she was cold with a yes X 1 but did not respond to any other questions the rest of the night. She has a cycle of restlessness and quiet. When she is restless she moves all extremeties, legs over the rail, hands pulling at everything. She is very tachypnic with RR 40-60 and constantly moaning. At this time her sats drop to 88-90% (could go as low as 84%). She also gets tachycardic, HR 130-140 and hypertensive, 160-170/90's. During the quiet phase her RR drops to 24-28, O2 sats increase to 94-96%, HR decreases to 120's, B/P 130-140/80's. The phases seem to last ~ 1/2 hr. Ativan .5mg IVP tried at 1330 when she was very restlesss, she stayed quiet for ~1hour but then became restless again.\n\nCardiac: B/P and HR as described as above. Her K+ 3.4 so she was repleted with 40 meq Kcl.\n\nResp: She was changed from face mask at 5l to cool neb at 40%. She is mouth breathing and her mouth was getting very dry. She also was collecting alot of secretions in the back of her throat. Her cough and gag are impaired so the back of her throat were suctioned with a yankauer. A very large yellow blood tinged mucous plug was pulled from the back of her throat and there was basicly no gag. At 0400 her sats dropped to 90-91% even during her quiet time so the FiO2 was increased to 50%.\n\nID: Her temp was initially 98.2AX but dropped to 97.1-97.6. The bair hugger was placed on her but with her agitation it is very difficult to keep it on her. It was maintained in an attempt to keep her temp from falling further. LP was attempted but was unsuccessful due to her scoliosis. She remains on multiple antibotics, gent, linazolid, acyclovir, aztreonam, ambisome, and flagyl.\n\nGU: She has a foley is draining clear yellow urine. Her U/O was high when receiving the platlets, 150-170cc/hr. Then her U/O dropped to 90-100cc/hr.\n\nGI: She remains NPO, there is no access to her stomach. She has (+) BS, her abd is soft and non tender. She has not had a stool.\n\nEndo: Her blood sugar at 12mn was 293 and covered with 2u reg insulin. She is to receive her 12u NPH at 6am and a sugar check.\n\nSkin: She has a bad yeast rash around her anus with a small non bleeding ulceration at the right side of her anus. The rash extends up to her labia. Miconazole cream applied.\n\nSocial: No contact with any family during the night.\n\nPlan: Keep pt safe, keep wrist restraints on patient, monitor temp, use bair hugger to keep her warm, and Monitor O2 sats\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-14 00:00:00.000",
"description": "Report",
"row_id": 1282552,
"text": "RESPIRATORY CARE\nPt semi-elective intubation with 7.5 ETT, 23 cm @ lip. Bilateral breath sounds evident as is color change with end tidal C02 detector.\nSpontaneous RR respiratory rate prior to intubation 40-45 bpm, SAT's 99-100% on 100% NRB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-14 00:00:00.000",
"description": "Report",
"row_id": 1282553,
"text": "FNIARD 4 ICU NPN 0700-1900\nBecoming persistently tachypneaic with RR high 40's to 50. Intubated for & decreased MS. Initially on 100% X 500 X 20, 11 spont, PEEP 5. Abg 7.47/31/443/23/5. Fio2 decreased to .6. Syctioned X1 for scant, thick, tan secretions. BS coarse to clear.\n\nThis AM pt would open eyes when name called & at X's say \"what\". Also reslessness alt with dozing. Xyprexia 2.5mg X1 with good effect. ThIs afternoon noted to be very restless, slightly diaphoretic SBP 180, HR 140's RR high 40's with increased work of breathing. Pt also appeared to be shaking over. Skin pale, LE slightly mottled. Pt beginng to settle after approx 30 min. Additional Xyprexia 5mg X1 given with improvement in SX. Desaturated to high 80's when on R side, bed flat for LP. O2 increased to 80% Face tent with improvement. Pt becoming persistently more tachypneaic & unable to arouse. No response to painful stumuli. Intubated as noted as above. Wrist restraints on. Given fent & midaz boluses. Waiting for fent & versed gtts.\n\nWBC 0.1. Decision to give granulocyte transfusion. Awaiting availability. Consent obtained from husband & noted in progres note Needs pre-med with steroids & benedryl.\n\nBair-hugger on most of the day to maintain T>97. Fever spike to 1017.PO. BC X1 from TL, UC sent. Needs second BC, sputum. Tylenol given. Ambisome d/c'd.\n\nRemains NPO. On TPN. Abd soft. BS hypoactive BS. No stool\n\nUO adequate.\n\nHr running 140's at present, SBP 150's.\n\nHusband in X2 today. Updated on pt's condition & plan of care.\n\nA/P: Appears stable on vent.\nInfuse WBC over 1-2 hrs. Premed with steriods & benedryl.\nFollow WBC, plts, crit.\nCont antibiotics.\nFent & versed gtts for sedation.\nSupport to family.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-19 00:00:00.000",
"description": "Report",
"row_id": 1282570,
"text": "Neuro: Pt. opens eyes to voice, shakes head from side to side with mouth care and suctioning, more extremities movement noted, +PERRLA, impaired gag, intact cough. Remains off sedation.\n\nResp: PS 8/5, FiO2 40%, rr 20s-30s, pt. continues with high MV, Sats high 90s, LS coarse, suctioned for mod. yellow thick sputum q 2-3 hrs. No ABG obtained on current settings.\n\nCV: HR 70s-90s, SR, no ectopy noted. BP 112-140s/70s-80s. Continues on Dilt via Dophoff. Palpable pedal pulses, + pedal edema noted. UO 100-300cc/hr. K 2.9, repleting with 40meq IV and 40 via Dophoff.\n\nGI/GU: Cotninues on TPN. Abd. soft, distended, +BS, no BM. Foley patent with amber clear urine.\n\nID: Afebrile. WBC 0.8, Granulocytes transfusions finished 1/4 per team. Continues on multip. abx, antifungal agents. virus isolated from spinal fluid.\n\nEndo: BS 150s-160s, covered with sliding scale and fixed dose, TPN contains insulin as well.\n\nSkin: Coccyx remains excoriated, protective barrier applied, pt. turned and repositioned frequetly.\n\nCoags: Hep gtt off since last night. PTT results pending.\n\nSocial: No contact from family on this shift.\nFULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-19 00:00:00.000",
"description": "Report",
"row_id": 1282571,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. No morning abg results.\n\nSwitched to active humidification due to high MV.\n\nRSBI = 43.6 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-11 00:00:00.000",
"description": "Report",
"row_id": 1282549,
"text": "NPN 7P-7A:\n\nNEURO: PT IS A/OX2. SHE IS CONFUSED TO TIME OF DAY. SHE ASKING WHEN SHE WILL GO HOME. SHE IS HAVEIG HALLUCINATIONS OF CAKES AND OTHER THINGS IN THE ROOM. SHE IS PLEASANT AND COOPERATIVE WITH CARE. FOLLOWS COMMANDS. SHE IS ABLE TO MOVE IN THE BE. FREQ CHECKS WERE DONE FOR SAFETY.\n\nRESP: LS DIMINSHED BILAT LOWER. O2 SAT ON RA 97%. RR 14-20.\n\nCV: NSR TO SB HR 59-68 NO ECTOPY NOTED. TEMP MAX 96.6 SX.\n\nGU/GU: NPO. SHE IS ON TPN. +BS. MUSHROOM CATH IN PLACE. LIQUID BROWN STOOL. FOLEY CATH WITH ADEQUATE OUT PUT.\n\nID: PT IS ON SEVERAL ABX SECONDARY TO BACTREMIA. HER BC ARE STILL COMMING BACK POSITIVE. SHE IS GETTING TX FOR ESOPHAGITIS. WHICH IS WHY SHE IS ON AMBISOME.\n\nHEM: SHE WAS SENT TO ICU FOR ATG DENSINSITAZATION SECONDARY TO APLASTIC ANEMIA. SHE IS ON ATG AT 10CC/HR.\n\nENDO: INSULIN 2U/HR. FS Q2H.\n\nPOC: ATG UNTIL . CBC . TEE ON HOLD. QUESTION NEW LINE. QUESTION CALL OUT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-13 00:00:00.000",
"description": "Report",
"row_id": 1282550,
"text": " 4 ICU NPN 1300-1900\n 72 YO with mantle cell lymphoma in remission with aplastic anemia, VRE bacteremia, neutrapenia, cold agglutinin transferred to 4 ICU with MS changes.\nThree recent admissions for desentization of anti-thymocyte globulin (ATG) for aplastic anemia. During last admission her MS waxed & waned with intermittent delerium without clear etiology. MRI negative. Transferred back to 7F . Initially awake but confused at X. She has become increasingly somnolent. She had received benedryl for premed for plts. Repeat MRI negative. EEG results pnd. This AM unable arouse pt & becoming more tachypneaic. HR 150's Only moaning with to painful stimuli. ABG 7.59/25/54 on 2l NP. Transferred back to ICU.\nMS: Moans when turned or painful stimuli. No spont movement. LP to be done after plts given.\nCV: SBP dow to 74. HR to 164 ST. CVP 6. Given NS bolus 250 cc's X1, 500 cc x2 Currently running 140- 150's ST. No VEA noted.\nID: T-max 100.5 ax. Tylenol given. BC X1 drawn earlier today. Resident aware. New CVL placed earlier today as well. BC positive for VRE which she is being treated with gent & daptomycin. Also on acyclovir, flagyl, ambisome, linezolid. WBC 0.1\nRESP On 4L NP. RR 35-40 min. BS clear. ABG pnd\nGU: foley. Adequate UO\nGI: NPO Abd soft. Positive BS. No stool.\nSocial: Married. Code status discussed with pt's husband again today. He states pt indicated she wanted full treatment.\n\nA/P: MS , fever. Septic looking picture. Fld bolus, Follow CVP, UO, WBC, LP this eve. Cont antibiotics.\nNeutrapenic, Contact precautions\nSupport to family.\n ? r/t sepsis. PE. Abg unchanged at present\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-17 00:00:00.000",
"description": "Report",
"row_id": 1282565,
"text": "Respiratory Care\nPt remains on same setting 40%. Plan to go to cat-scan for head scan this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-18 00:00:00.000",
"description": "Report",
"row_id": 1282566,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. No vent changes made this shift. Remains on cpap/ps to 40%. Patient transported to CT and back without incident. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation until neuro status improves.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-18 00:00:00.000",
"description": "Report",
"row_id": 1282567,
"text": "Neuro: Pt. is off sedation, attempts opening eyes to verbal stimulation, does not follow commands, withdraws extremities to nail bed pressure, minimal bilat. upper and lower extremities movement noted. Impaired gag/cough, +PERRLA. Head CT negative per team.\n\nResp: No changes made overnight, pt. remains on PS 5/5 40% FiO2, rr 20s-30s, Sats high 90s. LS coarse, suctioned for small to moderate thick white secretions Q3-4 hrs. Extubation on hold due to poor gag reflex. Pt. transported to CT at 2100, CTA significant for sm. PE in LLL subsegmental pulm. arterial branch, increase in size of lung nodules and masses consistent with infection, mod. rt. and sm. lt. pleural effusions.\n\nCV: HR 80s-100s, SR, no ectopy noted. BP 130s-150s/70s-90s. Continues on Dilt via dophoff. 1900 K 3.0, repleted with 40meq of KCl, Mg 1.8, repleted with 2g of MgSulfate. AM K 3.0, team aware, will replete per orders. Hep gtt initiated @ 1000u/hr after 1000 u IV bolus. Goal PTT 60-80, am PTT 77.4 Adequate UO 100-300cc/hr.\n\nGI/GU: Abd. soft, slightly distended, having episodes of sm. loose brown stool, colace held. Continues on TPN. Foley patent with amber clear urine.\n\nID: Pt. is normothermic. Bair Hugger currently off. Continues on multip. abx and antifungal agents. Granulocyte transfusion tolerated well. WBC 0.9.\n\nSkin: Coccyx area remains excoriated, protective barrier applied, pt. turned and repositioned frequently.\n\nSocial: No contact from family made overnight.\n\nFULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-18 00:00:00.000",
"description": "Report",
"row_id": 1282568,
"text": "CV: PT BACK IN RAPID AF AT 7:15AM. RATES 140'S-160'S. GIVEN DILT. 10MG IVP WITH GRADUAL CONVERSION TO NSR. DILT PO DOSE INCREASED. PT. NOTED TO HAVE RVD, NEW FROM 2 WEEKS AGO.\n HYPERTENSIVE AS WELL.\nRESP: PT. TACHPNEIC DURING AF EPISODE. RATE'S 40'S. PLACED BACK ON A/C BRIEFLY AND THEN ON PS OF 8 PEEP OF 5. NO FURTHER EPISODES DURING THE DAY. SUCTIONED FOR COPIOUS AMTS OF FROTHY THICK YELLOW SECRETIONS, AND SINCE THEN SMALL=MOD AMTS.\nNERURO: PEARL. TOSSING HEAD. FOLLOWING SIMPLE COMMANDS INCONST. BITING DOWN ON ET WITH MOUTH CARE. YAWNS. R ARM STILL FLACCID. ATTEMPTING TO OPEN EYES WHEN SPOKEN TO. NEURO IN TO SEE PT. AND FEELS SHE IS SLIGHTLY MORE AWAKE THEN 2 DAYS AGO. VIRUS FROM SPINAL FLUID-WAS POSITIVE.\nENDOC: LYTES REDRAWN AT 14:30PM. SSI FOR BS AT 12NOON.\nRENAL: CONT. TO AUTODIURESE.\nGI: CONT. ON TPN. INCONT. SMALL AMT OF STOOL.\nCOAGS: WOULD RECHECK PTT THIS EVENING. ALSO NEEDS GRANULOCYTE LEVEL POST DOSE.\nSOCIAL: HUSBAND INTO VISIT THIS AFTERNOON. DR IS COMING TO SPEAK WITH HIM RE: MENTAL STATUS AND VIRUS RESULT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-18 00:00:00.000",
"description": "Report",
"row_id": 1282569,
"text": "Respiratory Care\nPt had episode of a-fib this am, treated with 10mg diltiazem, Pt had 1 min trial on a/c with poor results of increased RR, weaned to psv 8/5 Pt has remained on these settings for rest of shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-09 00:00:00.000",
"description": "Report",
"row_id": 1282543,
"text": "NPN 1900-0700\nEvents: Hct 15 at 4pm, repeat peripheral stick 17.9 at 8pm with blood running. Pt to CT scan at 2230, CT neg. Stool OB+, but brown color and no visible blood. No other evidence of bleeding. 4th unit of packed cells will be hung shortly.\n\nAplastic anemia: ATG sensitization with ATG running at 10mg/10mls/hr, started yesterday for 4 days. Pt receiving Benadryl and Steroids. No symptoms noted.\n\nNeuro: Mostly lethargic on this shift, oriented x3. Pt slept soundly most of shift c Benadryl 50mg q6hrs given for ATG sensitization. No c/o pain. Once c/o cramps when moving bowels.\n\nCV: HR 70s-90s, nsr, no ectopy. BP 127/61 - 142/76. K repleted with 20meq kcl. am labs pending.\n\nID: Temp wnl range during noc, prior hypothermia, bear hugger off at 9pm for temp 98.1 po. Now taking axillary temps, pt irritated at freq po temps for blood. Repeat blood and fungal cx sent yesterday. abx cont for VRE bacteremia.\n\nResp: On RA, sats 98-99, RR 19-25, LSclear, diminished at bases.\n\nGI: +BS, abd soft. Rectal bag in place for loose stools. As above, OB+. Mod amt. Pt NPO. Coughs with sips of water, even water from sponge. Resolving esophagitis. TPN at 63mls/hr.\n\nGu: U/o mostly >100mls/hr, clear, yellow urine via foley. Miconazole cr applied to peri area, slightly pink.\n\nEndo: Insulin gtt currently at 12 u hr. FS coming down, last 113.\n\nSkin; intact.\n\nSocial: Husband visited . no calls overnoc.\n\nPlan: monitor for S/S ATG tox: HTN, rigors, fever. F/u on am labs. Cont abx, antifungals, steroids. Monitor hct, k. Titrate insulin to FS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-09 00:00:00.000",
"description": "Report",
"row_id": 1282544,
"text": "MICU NPN 7AM-3PM:\nNeuro: Pt somewhat sleepy and at times confused but awake and oriented times two. At times knows name, place and year but seems off at times and follows simple commands but forgets easily. I need to keep reminding her that she has bag on for bowel movements and she keeps asking to get up to bathroom. Pt also takes off her warming blanket with c/o feeling warm but is slightly hypothermic and requires the blanket at this point. Blanket reapplied frequently. MAE slowly. C/o intermittent pain in her legs/thighs which is not new. Given morphine 1mg at 7AM with minimal relief.\n\nCV: BP 120-150/50. HR dropped to 40 with turning briefly and at times is sinus brady 50's but for the most part pt has been in NSR 60-70 no ectopy. K+4.0 today.\n\nResp: Pt is on RA with good sats. Lungs are clear with decreased sounds at bases. O2 sat 96%-97% most of the day.\n\nHeme/ONC: Pt remains on the ATG at 10mg/hr and is at 24hr mark at 1630. Remains on steroids and ATC benadryl. Plan is to continue drip for 4 days. Hct 27.5 today after four units PRBC's overnight. Will recheck hct with 2PM labs and she is ordered for 9PM labs tonight. Plt count was down to 42 this AM so pt transfused with one bag platelets(Goal >50) Repeat count will be drawn at 1600.\n\nID: Pt still hypothermic and remains on bear hugger most of the time but pt c/o feeling warm and takes it off frequently. WBC less than .1 still. Remains on several antibiotics for VRE bacteremia. Plan to get TEE possible tomorrow as recommended by ID service. Repeat aspirgillis antigen sent.\n\nGI: Pt is NPO and getting TPN as ordered. Still NPO as pt has had episodes of aspiration in past. PPI is in TPN Pt passing brown liquid OB+ stool via rectal bag which was replaced by me today.\n\nEndo: Insulin drip adjusted according to Q1hr fingersticks which are elevated while pt on stress steroids. TPN also has a lot of insulin in it as well as PPI.\n\nGU: UO is excellent via foley.\n\nSocial: Pt's daughter and husband in to visit today. Both updated by myself on pt condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-09 00:00:00.000",
"description": "Report",
"row_id": 1282545,
"text": "MICU NPN 3PM-7PM:\nBriefly, pt continues on ATG desentitization protocol with ATG running at 10mg/hr. No signs of tachycardia/hypertension or anaphylaxis noted at this time. Plan is for this rate to continue for the next three days. Pt continues to receive steroids/benadryl around the clock. Visited with family briefly this afternoon who felt pt was slightly clearer in her mental status than previous days. Pt c/o intermittent discomfort and moans at times with c/o needing to get up to go move her bowels. Reminded frequently she needs to remain safe in the bed. HR dropped down to 40's, sinus brady, while sleeping on her left side down and with stable BP at that time. BP 110-140/60. Pt completed the order for bicarb infusion and at this point continues on TPN and numerous antibiotics. Temp came up to 96.7 axillary and bear hugger shut off for now. Pt's insulin drip currently at 8u/hr with glucose 120's. Will hang new TPN at 6PM and continue to follow Q1hr FSBG and titrate drip as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-10 00:00:00.000",
"description": "Report",
"row_id": 1282546,
"text": "MICU Nursing Note 1900-0700\nEvents: Hemodynamically stable overnight. Remains alert but confused. ? of visual hallucinations at times. Continues on IV Insulin gtt at 2 units/hr. Continues to require bear hugger for hypothermia. Remains on continuous infusion of IV Anti-Thymocyte Globulin (ATG) gtt at 10mg/hr for desensitization....No evidence of adverse reaction during the night. Stable HCT at 9pm= 26----am labs still pending.\n\nNeuro: Alert to person and place and disoriented to time however requires freq. reminders on what is happening to her and requires freq. reminders regarding all care and explanations. Mumbles at times. Asking questions about things that aren't present ie: What are all those pants hanging on the windows?\"/ \" why is my room full of all those boxes?\" Freq. reorientation. Pleasant and cooperative with care, follows all commands, Moves all extremities, PEARL. Freq. safety checks.\n\nCardiac: HR= 50-70's SR with occas PVC's. Occasional brief and self-limiting episodes of bradycardia to 40's---EKG obtained and no change from previous and no evidence of block noted. BP= 98-130/40-60. BP and HR slightly decrease when pt is lying on left side. Episode of BP to 80/40 while asleep---BP back to baseline with stimulation and no further hypotension during the night. Diuresed with 20 mg. Lasix during evening.\n\nResp: Lungs clear but diminished at bilat. bases. Room Air Sats= 96-99%. Dry nonprod. cough noted. RR= 18-22\n\nGI: Abd soft with + bowel sounds. C/O abd cramps while moving bowels. NPO maintained. Continues on IV TPN at 63 ml/hr. Incontinent large amts brown liquid stool x 3---pt pulled fecal incontinence bag off and smeared stool with hands x 2---Now with Mushroom catheter in place. Stool brown in color but tested Guiac +.\n\nGU: Foley to CD draining clear dark yellow urine >40ml/hr. Diuresed with 20 mg. IV lasix during evening but remains 8 Liters + for LOS\n\nSkin: Perineum pink with slight rash---miconazole applied. Buttocks reddened--barrier cream applied. Remains on air bed.\n\nID: Continues on neutropenic precautions with WBC < 0.1. Remains hypothermic with temps 95-97 on bear hugger. Continues on multiple antibx. as ordered. Pt's temps drop when she takes off blanket and requiring freq. reapplication of blanket. Temp up to 97 and bear hugger off x2 hours but restarted for temp=95.\n\nEndo: Continues on IV insulin gtt at 2 units/hr with fingersticks 105-143 all night.\n\nSocial: No contact from family or friends during night.\n\nPlan: Possible TEE today. Continue freq reorientation and safety checks, Continue neutropenic and VRE precautions, Monitor closely for reaction to ATG infusion, Transfuse prn, Support pt and family prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-10 00:00:00.000",
"description": "Report",
"row_id": 1282547,
"text": "NPN MICU 7AM-3PM:\nNeuro: Pt alert but somewhat restless and confused. Sometimes found picking at IV's/tapes/lines. Found several times trying to make a phone call using the controls on the side of the bed. Pt requires frequent orientation and observation for safety. Pt follows commands, knows where she is when asked but making poor decisions which may cause safety concerns. need to be loosely restrained for safety this evening. Unrestrained at present.\n\nCV: BP stable. 110-150/60. HR 50-70 NSR. K+ 3.3 and pt repleted with 40meq IV KCL. Skin is warm and slightly diaphoretic at times. Pt c/o being warm and was taking off the bear hugger this AM. Her temp has been stable so blanket left off for now. Cardiology does not want to do TEE on this pt at this point.\n\nResp: Pt stable on Room air with RR 20-24 and sat 96% or greater. Lungs are clear upper lobes deminished with crackles at bases.\n\nGI: Passing brown liquid stool via mushroom catheter. Abdomen soft and pt has good bowel sounds. C/O stomach cramps when she is stooling. Can have small sips PO but otherwise is NPO. Receiving TPN for nutrition.\n\nGU: Foley catheter draining drk yellow urine in adequate amts.\n\nID: Remains on several antibiotics for VRE bacteremia and daily blood cultures being sent. Blood cultures are still coming back positve. need new line change. WBC remains less than .1 Temp has been stable and warming blanket used on/off as needed for hypothermia.\n\nEndo: Pt remains on the insulin drip with Q1-2hr fingersticks. Currently insulin drip is at 3u/hr with last glucose 112.\n\nHeme: Pt remains on the ATG infusion which is to run at 10mg/hr until 1630 on Friday. No signs/symptoms of reaction noted so far. Continues on steroids and benadryl. Hct was 27 this AM and platelet count was 43. Plan to recheck CBC this afternoon at 1600. Team has said she is stable enough to back to BMT service. They are not able to take her today but will try to transfer her back to floor tomorrow. Will plan to stop insulin drip before transfer.\n\nPlan: Continue to administer ATG drip as ordered and follow pt for reaction. Continue antibiotics, daily cultures. Follow lab results. Keep pt and family involved in care and update as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-10 00:00:00.000",
"description": "Report",
"row_id": 1282548,
"text": "MICU NPN Update: 3PM-7PM:\nVital signs remain stable. Pt visited with family for two hours then she fell asleep for a while. HR dropping down to 50 while asleep in sinus brady. BP 124/56. Bear Hugger remains off as pt is warm enough on her own. Last temp 97 PO at 4PM. 4PM hct 28.5 and plt count is 32, team is deciding if they want to give her a bag of plts this evening. Pt still passing brown liquid stool. Stool for c. diff sent as ordered. Rectal area is very red and excoriated. Double guard applied with each pad change. She is aware of planned transfer to floor tomorrow and happy to get back to 7F.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-17 00:00:00.000",
"description": "Report",
"row_id": 1282563,
"text": "Neuro: Pt. attempts opening eyes to verbal stimulation, occasionally moves head, does not follow commands, extremities remain flaccid. Diaphoretic @ times with episodes of . Medicated with Olanzapine 2.5 mg due to above symptomes ? anxiety.\n\nResp: Remains on PS 5/5 FiO2 40%, rr 20s-30s, sats high 90s, LS diminished at bases, suctioned for sm. to mod. thick white secretions.\n\nCV: Pt. received with HR 110s-130s, AF, Dilt gtt @ 10mg/hr. At 0400 pt. washed, HR up to 160s for few minutes, resolved spontaneously, EKG obtained, HR droped to 86, sinus rythm. BP droped from 130s/70s to 90-109/58-62. Dilt gtt decreased to 5mg/hr. Palpable pedal pulses. UO 25-100cc/hr.\n\nGI/GU: COnt. of TPN. Abd. soft, nondistended, +BS, had 2 sm. to medium BMs. FOley patent with clear yellow urine.\n\nID: Afebrile. Bear Hugger off. Continues on triple abx.\n\nSkin: Coccyx with few skin abrasions, protective barrier applied.\n\nEndo: BS checked QID, covered per sliding scale.\n\nSOcial: No contact from family made overnight.\n\nPlan: Will possibly attempt extubation today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-17 00:00:00.000",
"description": "Report",
"row_id": 1282564,
"text": " 4ICU NPN 0700-1900\nDilt gtt d/c'd after starting dilt NG. HR 93-114 NR, ST. NO VEA noted.BP 140-178/71/90. C-echo done. Results pnd. K 4.0\nCyclosporin restarted.\nOccas attempts to open eyes when name called. Will move head slighty from side to side at X's. Does not respond to pain. Extrem flacid. PEARL 3-4mm. Gag & cough very impaired.\nOn PS 5/5/40%. RR 26-44 min. MV 16-20L min. BS coarse. Suctioned Q 3-4 hrs for mod amts thick, white secretions. Sats 96-100%\nNpo except meds. Abd soft, positive BS. Mod amt loose, brown OB positive stool. Colace held. Cont on TPN\nT-max 98.6AX. On ambisome, linezolid, aztreonum, metronidazole, acyclovir, gent.\nCont on RISS, NPH & insulin in TPN for glycemic control. BS 191-161. Cont on steriods\nWBC 0.7. To receive granulocyte infusion this eve.\nHusband in visit. He was updated on pt's condition, plan of care.\n\nA/P:\nRemains in SR on dilt (NG). Cont to assess. Follow K.\nNo sig improvement in MS. ? head Ct scan\n Stable on vent. Cont to have high MV, RR. Doubt if pt can protect airway given MS, impaired gag & cough reflex. Cont PS overnight. Assess in AM.\nWBC transfusion this eve. Day 4 of 7. Premed with tylenol, benedryl & steriods. ** Do not filter granulocytes. Use stem cell Y-tubing. Infuse over one to two hrs.\nCont TPN\nFollow BS.\nSupport to family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-08 00:00:00.000",
"description": "Report",
"row_id": 1282541,
"text": "NPN 1900-0700\nNeuro: Pt. alert confused, restless for most of this shift, only sleeping in short naps. Pt. cooperative with care.\n\nCV: VS stable this shift. BP ranging 109-143/53-70. HR 89-109 NSR with no ectopy. Pt. restarted on ATG infusion on at 1700 and tolerating infusion at this time with no significant increase in HR or temp. L IJ TLC intact and 1 PIV intact. H/H stable.\n\nResp: LSC and dim at bases. O2 sat 98% on RA and no resp. distress.\n\nID: Pt. VRE+ blood cx. and being treated with multiple abx. Pt. on warming blanket initially for temp 94-95. Temp 98.2 at 0400 and warming blanket off. Will monitor temp. stool for c-diff pending.\n\nGI: Pt. NPO on TPN with lipids at 83.3 cc/hr and tolerating well. Pt. also on Insulin gtt at 5 units/hr due to high doses of steorids. BS <200 this shift. Abd. soft non tender, BS +. Pt. oozing loose stool and fecal inc. bag on and working well.\n\nGU: Foley cath in place and draining adequate amounts of clear yellow urine. Mycolog cream to red peri rash as ordered.\n\nSocial: Pt. is a full code. Pt. seems very depressed about her condition. Husband very supportive. No family last night. Emotional support to Pt. as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2149-12-08 00:00:00.000",
"description": "Report",
"row_id": 1282542,
"text": " 4 ICU NPN 0700-1900\nTol ATG at 7mg hr. Started infusion ATG at 10 mg hr at 1630 X4 days. On benedryl & steroids.\nInsulin gtt titrated to BS.\nHr 76-101 SR/ST. No VEA noted SBP 120's-130's. EKG pnd.\nTemp low of 94.6PO. Bair hugger placed on pt. Temperature in room increased. BC X2 obtained with fungal isolater X1. No change in antibiotics or antifungals\nCrit 15.7 this afternoon. First of two units PRBC's hanging. Plts 31. Received bag plts. Post plt count 53. Hemolysis labs pnd.\nNPO. Attempted sips water but immediately began choking. On TPN. Abd soft. Positive BS. Denies abd pain. Liquid brown OB trace positive stool, 380 cc's.\nUO adequate.\nOriented. Slept in naps. OOB to chair X1 hr. Tol fair. C/O bilat LE thigh pain. Resolved on own approx 15 min after getting back to bed. Pneumoboots on.\nBS clear, diminished at bases. sats high 90's on RA. Encouraged to cough\nFamily in to visit. Updated on pt's condition.\n\nA/P: Tol anti-thymocyte globulin. Cont at 10mg hr X4 days. Assess for HTN, tachycardia, rigors, fever. Treat symptomatically\n?eti of crit drop. ? hemolysis. Follow hemolysis labs Transfuse two units PRBC's. Assess for bleeding.\n\n\n\n"
}
] |
2,830 | 193,970 | Neurosurgical Course: admitted to the Neurosurgery service after a fall and was emergently taken to the OR, where under general anesthesia, she underwent external ventricular catheter placement and left craniectomy and evacuation of hemorrhage. Procedure was well tolerated and then she was transferred to ICU, where she was closely monitored. She did spike several fevers and subsequent work up revealed H. flu in sputum and C.Diff and she was treated with antibiotics. She has had negative cultures for MRSA and CSF. Her EVD was slowly raised and clamped over several days and then removed on . Repeat CTs showed resolving blood and persistent hypodensities in the bilateral cerebellar hemispheres. Her sutures and staples were later removed. On she was having guaiac positive stools and episodes of hypotension. GI was consult and stated there was no need to scope on an inpatient basis, and she could be followed as an outpatient. Given her medical history of transplant, the transplant service has been following her hospital course. Her amylase and lipase have been slowly and consistently rising. Transplant service was notified, and they suggested monitoring these labs QOD. She was then transferred to step down and her blood pressure continued to be labile. She also had an episode of tachycardia in the 130s in which her BP was stable, and responded well to lopressor. Her lopressor was adjusted and she had episodes of lower BP while sleeping and it appropriately responds with stimulation. Her exam has consistently waxed and ed. On she did have slight spontaneous movement with the LUE however, no movement with the RUE with noxious stimuli. She did have bilateral spontaneous movements of Lower extremities (L>R). Evaluations with Physical and occupational therapy deemed her to be an appropriate candidate for rehabilitation however on her Lipase continued to rise and Cr bumped although neurologic exam was stable. CT abd/pelvis done showing no significant abnormalities. In collaboration with transplant it was agreed to hydrate aggressively and check Cr in am. Cr on up to 1.8 and it was agreed to transfer patient to the transplant service for medical management. Medical Course: Ms. was transferred to the medical service on because of acute renal failure. She was hydrated and her creatinine returned to (0.8 at discharge). The patient had developed significant diarrhea on the days preceding transfer, thought to be due to the increase in tube feed rate vs. refractory C. difficle infection. Her tube feed rate was decreased and the diarrhea resolved. This is less likely a C.difficle infection given the lack of fever, no leukocytosis and the rapid improvement in decrease in tube feed rate. Should her diarrhea return, would consider checking for C. difficle. She had persistent mild hypercalcemia and was treated with lasix (improved at discharge). She had significant polyuria (2-3 liters UOP per day) thought to be due to hypercalcemia, the normal saline resuscitation and the tube feeds). At rehabilitation, she needs to have approximately 2.5-3 liters per day of intake (tube feeds and free water boluses). Lastly, she had persistent tachycardia with HR 110-120. This continued after volume resuscitation and pain control. She was treated with escalating doses of metoprolol. As it was unlikely (no change in ECG or oxygen requirement), imaging to rule out pulmonary embolism was not obtained. Given her intracranial bleed, she is not a candidate for anticoagulation. Lastly, she was continued on her anti-rejection medications and follow up with her transplant physician was arranged prior to discharge. | Neuro checks Q1hr, Ventriculostomy in place, draining. , absent corneals right,impaired -left Neuro checks Q1hr, Ventriculostomy in place, draining. Mycophenolate Mofetil 11. Mycophenolate Mofetil 11. Sulfameth/Trimethoprim SS 22. Sulfameth/Trimethoprim SS 22. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Plan: Cont q1hr neuro checks. Plan: Cont q1hr neuro checks. Sulfameth/Trimethoprim SS 15. Sulfameth/Trimethoprim SS 15. On Ancef Q12 for prophylaxis. On Ancef Q12 for prophylaxis. Phenylephrine 18. Action: Labetolol drip for bp mgmt, low stimulation level, ventriculostomy open to drainage, transducing icp hourly. Nutrition: Begin TF Renal: Foley, Adequate UO, 30 cc/hr Hematology: HCT stable Endocrine: RISS Infectious Disease: WBC decreased to 14 from 18, continued afebrile, On Ancef Q12 for prophylaxis. Electrolyte & fluid disorder, other Assessment: Phos level 0.9 this am, k+ 3.8 Action: Repleted lytes as per written orders. Electrolyte & fluid disorder, other Assessment: Phos level 0.9 this am, k+ 3.8 Action: Repleted lytes as per written orders. HO made aware of limited access and infiltrated IV-1 IV remaining at this time with labetalol gtt running in and Kphos needing repletion. Electrolyte & fluid disorder, other Assessment: Phos level 0.9 this am, k+ 3.8 Action: Repleted lytes as per written orders. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Response: Pt requiring 3mg/min labetalol gtt to maintain goal BP <160 systolic. Sulfameth/Trimethoprim SS 29. Sulfameth/Trimethoprim SS 24. Plan: Rx sbp > 180 prn as ordered w labetolol if assoc w tachycardia. Sulfameth/Trimethoprim SS 25. F/U sputum and CSF cx. Intubated, EVD placed. Phenylephrine 19. Weaned neo off and htn persisted Action: Labetolol 10mg iv x2 for tachycardia/htn and hydralazine 10mg iv x 1 Response: sbp improved < 180. Mycophenolate Mofetil 17. LS clear-rhonchorus. Tachycardia, Other Assessment: HR 80-120s. Midodrine 19. Phenylephrine 22. Labetalol 10 mg IV Q2H:PRN SBP>180 and HR>120 Order date: @ 2320 26. Labetalol 10 mg IV Q2H:PRN SBP>180 and HR>120 Order date: @ 2320 25. Response: O2 sats maintained >93% Plan: Continue to suction prn, assess lung sounds, assess VS. Response: O2 sats maintained >93% Plan: Continue to suction prn, assess lung sounds, assess VS. Tachycardia, Other Assessment: Tachy to 120-130s, SBP labile 80s-90s. Tachycardia, Other Assessment: Tachy to 120-130s, SBP labile 80s-90s. Labetalol 10 mg IV Q2H:PRN SBP>180 and HR>120 Order date: @ 2320 27. Sulfameth/Trimethoprim SS 30. Action: Neo gtt weaned to off, started on PO mididrine Response: Pt remains labile with SBP dipping to 80s off neo temporarily. Sulfameth/Trimethoprim SS 28. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Mycophenolate Mofetil 23. Tachycardia, Other Assessment: HR 80-120s. Tachycardia, Other Assessment: HR 80-120s. Fluid balance 10L+, Urine osmo wnl Action: Lasix 5mg IVP x1, lasix gtt initiated at 1mg/hr, albumin 25gm ordered q6hr. Action: Neo off, htn persisted, hydralazine 10mg iv w transient improvement in sbp. Resp alkalosis and tachypnea persisted-> placed on cmv mode. Sulfameth/Trimethoprim SS 29. Sulfameth/Trimethoprim SS 29. ------ Protected Section ------ Addendum 06:45: pt + c diff, Dr. . HydrALAzine 10 mg IV Q6H:PRN Order date: @ 0019 23. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Received labetolol 100mg as ordered at 0200 w sbp dwn < 130 req neo Plan: Check w team re: lowering labetolol dosing. Action: Neuro checks q2, assess ICP Response: Neuro status unchanged Plan: Continue to assess neuro status, assess ICP, VS Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Trach & PEG with copious secretions, on CPAP & PS 12, 5 PEEP, 40% FiO2, tidal volumes 300s. Response: O2 sats maintained >93% Plan: Continue to suction prn, assess lung sounds, assess VS. ------ Protected Section ------ Hypertension, benign Assessment: BP 180s/80s Action: 10 mg Labetalol IV q 2 hrs prn Response: BP decreased 120s-140s/50s-60s Plan: Continue to assess BP, VS ------ Protected Section Addendum Entered By: , RN on: 05:54 ------ Chlorhexidine Gluconate 0.12% Oral Rinse 7. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Sulfameth/Trimethoprim SS 28. No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc MON 12:59 AM Interval decrease in size of right cerebellar hemorrhage postoperatively, with expected pneumocephalus. Sulfameth/Trimethoprim SS 23. Endotracheal tube terminates approximately 1.2 cm above the carina. F/U sputum and CSF cx. Action: Neo gtt weaned to off, started on PO mididrine Response: Pt remains labile with SBP dipping to 80s off neo temporarily. In the right frontal region, underlying the site of previous catheter entry, there is interval development of a low-density subdural collection. Nasogastric tube has been removed, although the central catheter remains in place. Previously described left frontal subarachnoid hemorrhage is less conspicuous on today's examination, consistent with evolving blood products. Less conspicuous left frontal subarachnoid hemorrhage, consistent with evolving blood products. Bilateral cerebellar hypodensities, of unclear etiology but possibly consistent with prior infarcts, are unchanged. No contraindications for IV contrast PFI REPORT Interval decrease in size of right cerebellar hemorrhage postoperatively, with expected pneumocephalus. Sinus tachycardiaOtherwise probably normal ECG but baseline artifact in V1 makes assessmentdifficultSince previous tracing of , sinus bradycardia absent, sinus tachycardianow seen and ST-T wave changes decreased FINDINGS: Left subclavian catheter terminates in the superior vena cava. Small bilateral intraventricular hemorrhage is seen. There is a small amount of edema in the right aspect of the pons and bilateral middle cerebellar peduncles. There is a small right frontal subdural hematoma. The pre-existing right basal opacity shows partial resolution. There is only mild inferior tonsillar herniation. Postoperative changes of prior craniectomy are unchanged. | 208 | [
{
"category": "Respiratory ",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339580,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type: Standard, Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Quiet breathing but no response to commands.\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: neurologically impaired occipital fracture.\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Patient remains on PSV with acceptable ABG and good\n RSBI.Neurologically impaired,not following commands.plan to perform\n tracheostomy discussed with family.BS clear,suctioned for small amount\n of tan thick sputum.Full code intracerebral hemorrhage will continue to\n follow.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Passively resting on PSV\n Reason for continuing current ventilatory support: Pending procedure /\n OR; Comments: tracheostomy plan discussed with family\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 338816,
"text": "TITLE: TSICU ADMISSION NOTE\n TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/enlarging\n cerebellar hematoma\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1. 500 mL NS 2. Bisacodyl 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse 5. Docusate Sodium (Liquid) 6. HydrALAzine\n 7. Labetalol 8. Levothyroxine Sodium 9. Magnesium Sulfate 10.\n Mycophenolate Mofetil 11. Phenylephrine 12. Potassium Chloride 13.\n Senna 14. Sulfameth/Trimethoprim SS 15. Tacrolimus\n 24 Hour Events:\n to OR for evacuation\n Post operative day:\n 0\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.8 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:30 PM\n Other medications:\n Flowsheet Data as of 05:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.3\nC (95.6\n T current: 35.3\nC (95.6\n HR: 101 (78 - 104) bpm\n BP: 136/61(89) {102/47(65) - 172/80(119)} mmHg\n RR: 16 (14 - 17) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n ICP: 18 (18 - 24) mmHg\n Total In:\n 92 mL\n PO:\n Tube feeding:\n IV Fluid:\n 92 mL\n Blood products:\n Total out:\n 0 mL\n 418 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n 18 mL\n Balance:\n 0 mL\n -326 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) Pupils fixed and dilated, Right pupil dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/enlarging cerebellar hematoma\n Neurologic: Neuro checks Q: R pupil fixed/dilated; neuron checks Q1 hr,\n Ventriculostomy, to OR today for evacuation\n Cardiovascular: Hemodynamically stable; Keep CPP > 60, SBP < 140\n Pulmonary: Intubated Cont ETT, wean as able when returns from OR\n Gastrointestinal / Abdomen: NPO for now\n Nutrition: NPO\n Renal: s/p renal transplant. Foley, Adequate UO, f/u Creatinine,\n transplant team aware\n Hematology: hematocrit stable\n Endocrine: insulin sliding scale as needed\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, ETT, Ventriculostomy\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:02 PM\n 18 Gauge - 03:02 PM\n Arterial Line - 04:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-08 00:00:00.000",
"description": "Intensivist Note",
"row_id": 338817,
"text": "TITLE: TSICU ADMISSION NOTE\n TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/enlarging\n cerebellar hematoma\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1. 500 mL NS 2. Bisacodyl 3. Calcium Gluconate 4. Chlorhexidine\n Gluconate 0.12% Oral Rinse 5. Docusate Sodium (Liquid) 6. HydrALAzine\n 7. Labetalol 8. Levothyroxine Sodium 9. Magnesium Sulfate 10.\n Mycophenolate Mofetil 11. Phenylephrine 12. Potassium Chloride 13.\n Senna 14. Sulfameth/Trimethoprim SS 15. Tacrolimus\n 24 Hour Events:\n to OR for evacuation\n Post operative day:\n 0\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.8 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:30 PM\n Other medications:\n Flowsheet Data as of 05:00 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.3\nC (95.6\n T current: 35.3\nC (95.6\n HR: 101 (78 - 104) bpm\n BP: 136/61(89) {102/47(65) - 172/80(119)} mmHg\n RR: 16 (14 - 17) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 60 Inch\n ICP: 18 (18 - 24) mmHg\n Total In:\n 92 mL\n PO:\n Tube feeding:\n IV Fluid:\n 92 mL\n Blood products:\n Total out:\n 0 mL\n 418 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n 18 mL\n Balance:\n 0 mL\n -326 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 7.7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) Pupils fixed and dilated, Right pupil dilated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/enlarging cerebellar hematoma\n Neurologic: Neuro checks Q: R pupil fixed/dilated; neuron checks Q1 hr,\n Ventriculostomy, to OR today for evacuation\n Cardiovascular: Hemodynamically stable; Keep CPP > 60, SBP < 140\n Pulmonary: Intubated Cont ETT, wean as able when returns from OR\n Gastrointestinal / Abdomen: NPO for now\n Nutrition: NPO\n Renal: s/p renal transplant. Foley, Adequate UO, f/u Creatinine,\n transplant team aware\n Hematology: hematocrit stable\n Endocrine: insulin sliding scale as needed\n Infectious Disease: no issues\n Lines / Tubes / Drains: Foley, ETT, Ventriculostomy\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:02 PM\n 18 Gauge - 03:02 PM\n Arterial Line - 04:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 338874,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH (Sturdy) where CT showed a cerebellar bleed. Med\n flighted to for further treatment. Upon arrival, pt became\n confused and was intubated for airway protection. Ventric drain placed\n in ED with opening ICP of 25. When transferred to TSICU, pupils\n unequal and right pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV, pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt s/p cerebellar bleed. Absent gag on assessment. High risk\n aspiration.\n Action:\n Pt remains intubated. Vap protocol as ordered. Hob>30 degrees.\n Subglottal suctioning before HOB lowered. Adequate ETT balloon\n pressures.\n Response:\n Plan:\n Headache\n Assessment:\n Pt nodding yes to pain in head. Unable to assess level or type of pain.\n Pt does have lg incision to posterior head, s/p craniotomy.\n Action:\n Fentanyl prn\n Response:\n Pt appears more comfortable after pain medicine, Pt nodding yes when\n asked if pain is improved and tolerable.\n Plan:\n Cont prn pain medicine.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 338879,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH (Sturdy) where CT showed a cerebellar bleed. Med\n flighted to for further treatment. Upon arrival, pt became\n confused and was intubated for airway protection. Ventric drain placed\n in ED with opening ICP of 25. When transferred to TSICU, pupils\n unequal and right pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaver pancreas tx\n , CMV, pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Impaired neuro assessment. Start of shift pt unresponsive. Decreased\n CPP\ns and increase ICP\ns. See flow record for exact data.\n Action:\n Q1 hr neuro checks. Ct head scan. Fentanyl for pain. Ventriculostomy\n cont open to drainage, monitoring ICP\ns .Bp <140 systolically.\n Neosynephrine prn for adequate CPP>60\n Response:\n Improved neuro status. Pt opening eyes to voice and following commands.\n Now c/o HA. Icps now within normal range. Csf bloody in appearance Site\n intact with occlusive dressing. Post head incision with sm amt of sang\n drainage. Head CT improved per nsurg team.\n Plan:\n Cont q1hr neuro checks. Follow up CT scans. Medicate for pain. Neo gtt\n as needed. HOB>30 degrees. Decreased stimulation.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt s/p cerebellar bleed, altered mental status. Absent gag on\n assessment. High risk aspiration.\n Action:\n Pt remains intubated. Vap protocol as ordered. Hob>30 degrees. Sub\n glottal suctioning before HOB lowered.\n Response:\n Remains intubated. Comfortable on cpap.\n Plan:\n Cont to wean on vent as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 338878,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH (Sturdy) where CT showed a cerebellar bleed. Med\n flighted to for further treatment. Upon arrival, pt became\n confused and was intubated for airway protection. Ventric drain placed\n in ED with opening ICP of 25. When transferred to TSICU, pupils\n unequal and right pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaver pancreas tx\n , CMV, pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Started shift pt unresponsive.\n Action:\n Q1 hr neuro checks. Ct head scan. Fentanyl for pain. Ventriculostomy\n cont open to drainage, monitoring ICP\ns . Bp <140 systolically.\n Neosynephrine prn for adequate CPP>60\n Response:\n Improved neuro status. Pt opening eyes to voice and following commands.\n Now c/o HA. Icps now within normal range. Csf bloody in appearance Site\n intact with occlusive dressing. Post head incision with sm amt of sang\n drainage. Head CT improved per nsurg team.\n Plan:\n Cont q1hr neuro checks. Follow up CT scans. Medicate for pain. Neo gtt\n as needed. HOB>30 degrees. Decreased stimulation.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt s/p cerebellar bleed, altered mental status. Absent gag on\n assessment. High risk aspiration.\n Action:\n Pt remains intubated. Vap protocol as ordered. Hob>30 degrees. Sub\n glottal suctioning before HOB lowered.\n Response:\n Remains intubated. Comfortable on cpap.\n Plan:\n Cont to wean on vent as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-09 00:00:00.000",
"description": "ICU Intensivist Note",
"row_id": 338966,
"text": "TITLE:\n TSICU\n HPI:\n HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma\n Chief complaint:\n s/p fall\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SHx: LURT , cadaveric pancreas txp , L tib/fib fixation, s/p\n b/l breast lumpectomies many yrs ago, s/p laser surgery for retinopathy\n :Bactrim daily, Fosamax weekly, Levoxyl\n daily, trazodone as needed, Prograf one milligram b.i.d.,\n CellCept mg b.i.d., Aranesp 40 mcg a week, Protonix 40 mg\n twice a day, Ambien at night, and Valcyte 450 mg b.i.d.\n Current medications:\n Bisacodyl 4. Calcium Gluconate 5. CefazoLIN 6. Chlorhexidine Gluconate\n 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Fentanyl Citrate 9. HydrALAzine 10.\n HydrALAzine 11. Insulin 12. Labetalol\n 13. Levothyroxine Sodium 14. Magnesium Sulfate 15. Mycophenolate\n Mofetil 16. Pantoprazole 17. Phenylephrine\n 18. Potassium Chloride 19. Senna 20. Sodium Chloride 0.9% Flush 21.\n Sulfameth/Trimethoprim SS 22. Tacrolimus\n 23. ValGANCIclovir Suspension\n 24 Hour Events:\n Ventricular drain placed.\n Taken to OR for blown R pupil, hematoma evacuated\n Awakened, following commands, moving all 4s but L < R\n Weaned vent\n Post operative day:\n POD#1 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 05:31 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:30 PM\n Hydralazine - 06:30 PM\n Insulin - Regular - 05:30 AM\n Other medications:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 52 (51 - 104) bpm\n BP: 142/53(81) {102/47(65) - 172/80(119)} mmHg\n RR: 26 (14 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 60 Inch\n ICP: 22 (11 - 27) mmHg\n Total In:\n 2,699 mL\n 537 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,699 mL\n 507 mL\n Blood products:\n Total out:\n 1,276 mL\n 198 mL\n Urine:\n 870 mL\n 159 mL\n NG:\n Stool:\n Drains:\n 56 mL\n 39 mL\n Balance:\n 1,423 mL\n 339 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 350 (350 - 380) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 66\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n SPO2: 100%\n ABG: 7.36/34/194/18/-5\n Ve: 7.3 L/min\n PaO2 / FiO2: 485\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: No(t) Weakness), (LUE: Weakness),\n (RLE: No(t) Weakness), (LLE: Weakness), pain controlled\n Labs / Radiology\n 298 K/uL\n 15.3 g/dL\n 152\n 1.0 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 45.9 %\n 17.8 K/uL\n [image002.jpg]\n 06:52 PM\n 06:57 PM\n 08:00 PM\n 01:13 AM\n 04:00 AM\n 04:46 AM\n WBC\n 12.2\n 17.8\n Hct\n 46.7\n 45.9\n Plt\n 225\n 298\n Creatinine\n 1.0\n TCO2\n 20\n 20\n Glucose\n 191\n 157\n 152\n Other labs: Ca:9.4 mg/dL, Mg:2.0 mg/dL, PO4:1.0 mg/dL\n Assessment and Plan\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma\n POD 1 craniectomy/evacuation hematoma\n ISSUES:\n (1) intracranial bleed\n (2) s/p renal/pancreas transplant\n Neurologic: Awake, following commands, L side weaker than R. ICPs/CPPs\n well controlled. , absent corneals right,impaired -left Neuro checks\n Q1hr, Ventriculostomy in place, draining.\n Cardiovascular: Hemodynamically stable, off drips. Target SBP < 150,\n CPP > 60.\n Pulmonary: Tolerating pressure support . ? wean to extubate.\n Gastrointestinal / Abdomen: Soft, nontender, + BS.\n Nutrition: Start Tubefeeds today\n Renal: Foley, Adequate UO, 30 cc/hr\n Hematology: Hct stable\n Endocrine: s/p pancreas/renal transplant for DM1, off glycemic\n medications at home. RISS.\n Infectious Disease: WBC up to 18, but afebrile. No cultures. On Ancef\n Q12 for prophylaxis.\n Lines / Tubes / Drains: Foley, NGT, ETT, ventriculostomy, Aline\n Wounds: Dry dressings\n Imaging:\n Fluids: NS, 70/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:02 PM\n Arterial Line - 04:35 PM\n 18 Gauge - 06:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 338828,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH where CT showed a cerebellar bleed. Med flighted\n to for further treatment. Upon arrival, pt became confused and\n was intubated for airway protection. Ventric drain placed in ED with\n opening ICP of 25. When transferred to TSICU, pupils unequal and right\n pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt unresponsive, Pupils non-reactive and non-equal, no corneal\n reflexes. Withdrawing BLE to nailbed pressure, no movement noted to\n BUE. No gag, impaired cough.\n Action:\n Neurosurgery , neuro exams continued\n Response:\n Pt taken to OR for emergent craniotomy\n Plan:\n Continue with neuro exams post-op\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 338871,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH (Sturdy) where CT showed a cerebellar bleed. Med\n flighted to for further treatment. Upon arrival, pt became\n confused and was intubated for airway protection. Ventric drain placed\n in ED with opening ICP of 25. When transferred to TSICU, pupils\n unequal and right pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV, pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339072,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Responds to voice inconsistently,\nnodding\n when asked about\n pain level i.e.,\n and\n. See flowsheet for all real time\n documentation and assessments of neurological status. Initial CSF\n output was bloodtinged in AM.\n Gag reflex absent.\n Action:\n HOB >30degrees, Ventriculostomy open to drain, medicated\n with Fentanyl 25mcg IVP for pain when pt nodding yes to pain, turned\n frequently and repositioned, CT of brain done.\n Remains intubated on mech vent., NGT clamped, anti-VAP care\n provided.\n Response:\n Drain Output became clear in afternoon, good response to\n pain meds, when turned onto left side ICP lower than when turned onto\n right side. Neuro checks hourly,\n Gag remains absent, no signs and symptoms of aspiration.\n Plan:\n Continue neuro checks hourly, monitor ICP, notify MD \nICP>25 or if neuro deficits develop, medicate for pain as needed, keep\n HOB >30 degrees. Keep CPP >60.\n Leave intubated until ability to protect airway returns.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339076,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH (Sturdy) where CT showed a cerebellar bleed. Med\n flighted to for further treatment. Upon arrival, pt became\n confused and was intubated for airway protection. Ventric drain placed\n in ED with opening ICP of 25. When transferred to TSICU, pupils\n unequal and right pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaver pancreas tx\n , CMV, pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Responds to voice inconsistently,\nnodding\n when asked about\n pain level i.e.,\n and\n. See flowsheet for all real time\n documentation and assessments of neurological status. Initial CSF\n output was bloodtinged in AM.\n Gag reflex absent.\n Action:\n HOB >30degrees, Ventriculostomy open to drain, medicated\n with Fentanyl 25mcg IVP for pain when pt nodding yes to pain, turned\n frequently and repositioned, CT of brain done.\n Remains intubated on mech vent., NGT clamped, anti-VAP care\n provided.\n Response:\n Drain Output became clear in afternoon, good response to\n pain meds, when turned onto left side ICP lower than when turned onto\n right side. Neuro checks hourly,\n Gag remains absent, no signs and symptoms of aspiration.\n Plan:\n Continue neuro checks hourly, monitor ICP, notify MD \nICP>25 or if neuro deficits develop, medicate for pain as needed, keep\n HOB >30 degrees. Keep CPP >60.\n Leave intubated until ability to protect airway returns.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 338833,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ED\n Reason: Elective\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 338836,
"text": "HPI: 45 YO F s/p fall while walking neighbors dog, fell striking back\n of head. Taken to OSH where CT showed a cerebellar bleed. Med flighted\n to for further treatment. Upon arrival, pt became confused and\n was intubated for airway protection. Ventric drain placed in ED with\n opening ICP of 25. When transferred to TSICU, pupils unequal and right\n pupil unreactive. Emergently taken to OR for crani.\n Chief complaint:\n Intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Intracerebral hemorrhage (ICH)\n Assessment:\n Impaired neurological assessment with low CPP\ns. Pt remains\n unresponsive. See flow record for neuro assessment.\n Action:\n HOB elevated, Ventric open to drain, neo gtt initiated\n Response:\n CPPS >60, Pt taken to OR for emergent craniotomy\n Plan:\n Continue with neuro exams post-op, titrate neo to maintain CPP\ns >60,\n Ventric open to drain, HOB elevated, head midline. Monitor ICP\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-09 00:00:00.000",
"description": "ICU Intensivist Note",
"row_id": 338916,
"text": "TITLE:\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-09 00:00:00.000",
"description": "ICU Intensivist Note",
"row_id": 338917,
"text": "TITLE:\n TSICU\n HPI:\n HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma\n Chief complaint:\n s/p fall\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SHx: LURT , cadaveric pancreas txp , L tib/fib fixation, s/p\n b/l breast lumpectomies many yrs ago, s/p laser surgery for retinopathy\n :Bactrim daily, Fosamax weekly, Levoxyl\n daily, trazodone as needed, Prograf one milligram b.i.d.,\n CellCept mg b.i.d., Aranesp 40 mcg a week, Protonix 40 mg\n twice a day, Ambien at night, and Valcyte 450 mg b.i.d.\n Current medications:\n Bisacodyl 4. Calcium Gluconate 5. CefazoLIN 6. Chlorhexidine Gluconate\n 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Fentanyl Citrate 9. HydrALAzine 10.\n HydrALAzine 11. Insulin 12. Labetalol\n 13. Levothyroxine Sodium 14. Magnesium Sulfate 15. Mycophenolate\n Mofetil 16. Pantoprazole 17. Phenylephrine\n 18. Potassium Chloride 19. Senna 20. Sodium Chloride 0.9% Flush 21.\n Sulfameth/Trimethoprim SS 22. Tacrolimus\n 23. ValGANCIclovir Suspension\n 24 Hour Events:\n Ventricular drain placed.\n Taken to OR for blown R pupil, hematoma evacuated\n Awakened, following commands, moving all 4s but L < R\n Weaned vent\n Post operative day:\n POD#1 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 05:31 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:30 PM\n Hydralazine - 06:30 PM\n Insulin - Regular - 05:30 AM\n Other medications:\n Flowsheet Data as of 05:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.5\nC (99.5\n HR: 52 (51 - 104) bpm\n BP: 142/53(81) {102/47(65) - 172/80(119)} mmHg\n RR: 26 (14 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 60 Inch\n ICP: 22 (11 - 27) mmHg\n Total In:\n 2,699 mL\n 537 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,699 mL\n 507 mL\n Blood products:\n Total out:\n 1,276 mL\n 198 mL\n Urine:\n 870 mL\n 159 mL\n NG:\n Stool:\n Drains:\n 56 mL\n 39 mL\n Balance:\n 1,423 mL\n 339 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 350 (350 - 380) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 66\n PIP: 25 cmH2O\n Plateau: 23 cmH2O\n SPO2: 100%\n ABG: 7.36/34/194/18/-5\n Ve: 7.3 L/min\n PaO2 / FiO2: 485\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: No(t) Weakness), (LUE: Weakness),\n (RLE: No(t) Weakness), (LLE: Weakness), pain controlled\n Labs / Radiology\n 298 K/uL\n 15.3 g/dL\n 152\n 1.0 mg/dL\n 18 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 45.9 %\n 17.8 K/uL\n [image002.jpg]\n 06:52 PM\n 06:57 PM\n 08:00 PM\n 01:13 AM\n 04:00 AM\n 04:46 AM\n WBC\n 12.2\n 17.8\n Hct\n 46.7\n 45.9\n Plt\n 225\n 298\n Creatinine\n 1.0\n TCO2\n 20\n 20\n Glucose\n 191\n 157\n 152\n Other labs: Ca:9.4 mg/dL, Mg:2.0 mg/dL, PO4:1.0 mg/dL\n Assessment and Plan\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma\n POD 1 craniectomy/evacuation hematoma\n ISSUES:\n (1) intracranial bleed\n (2) s/p renal/pancreas transplant\n Neurologic: Awake, following commands, L side weaker than R. ICPs/CPPs\n well controlled. Neuro checks Q1hr, Ventriculostomy in place,\n draining.\n Cardiovascular: Hemodynamically stable, off drips. Target SBP < 150,\n CPP > 60.\n Pulmonary: Tolerating pressure support . ? wean to extubate.\n Gastrointestinal / Abdomen: Soft, nontender, + BS.\n Nutrition: Start Tubefeeds today\n Renal: Foley, Adequate UO, 30 cc/hr\n Hematology: Hct stable\n Endocrine: s/p pancreas/renal transplant for DM1, off glycemic\n medications at home. RISS.\n Infectious Disease: WBC up to 18, but afebrile. No cultures. On Ancef\n Q12 for prophylaxis.\n Lines / Tubes / Drains: Foley, NGT, ETT, ventriculostomy, Aline\n Wounds: Dry dressings\n Imaging:\n Fluids: NS, 70/hr\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 03:02 PM\n Arterial Line - 04:35 PM\n 18 Gauge - 06:16 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339070,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 10:00\n no complications\n"
},
{
"category": "General",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Generic Note",
"row_id": 339155,
"text": "TITLE: Respiratory Care:\n Patient intubated on mechanical support. Vent settings initially PSV\n 10, Peep 5, Fio2 40%. Spont vols decreasing to low 300\ns with ^ RR mid\n 30\ns. PSV ^ to 15 with spont vols ^ back to 380-400\ns. RR decreasing\n back to high 20\ns. BS clear bilaterally. Suctioned for small amount of\n thick tan secretions x1 otherwise secretions thick white. Increasing\n ICP\ns. No RSBI at this time. ABG reveals compensated metabolic\n acidosis. No further changes made at this time.\n Plan: Continue with PSV as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339064,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n No gag reflex present, positive cough, clear RUL and LUL sounds,\n diminished RLL and LLL sounds. Scant amt of thin secretions in ETT,\n Sats 100% on CPAP 40FIO2, 5 PEEP and 10 of pressure support.\n Action:\n Suctioned occasionally, neuros checked hourly, anti-VAP care provided,\n NGT checked for placement manually.\n Response:\n No gag reflex present, mechanical ventilation continued.\n Plan:\n Continue mechanical ventilation, Neuro checks hourly.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Intubated, responds to voice inconsistently, localizes to pain and\n withdraws from painful stimulus, no gag reflex, positive cough reflex,\n absent right corneal reflex, impaired left corneal reflex, pupils equal\n and reactive to light,\nnodding\n when asked about pain level i.e.,\n and\n. Drain at 10cm above the tragus.\n Action:\n Ventriculostomy drain output ml hourly emptied, no sedation used,\n medicated with Fentanyl 25mcg IVP for pain when pt nodding yes to pain,\n turned frequently and repositioned,\n Response:\n Drain Output became clear in afternoon, good response to pain meds,\n when turned onto left side lower than when turned onto right side.\n Neuro checks hourly, CT of brain done.\n Plan:\n Continue neuro checks hourly, monitor , notify MD >25 or if\n neuro deficits develop, medicate for pain as needed, keep HOB >30\n degrees.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339069,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Responds to voice inconsistently,\nnodding\n when asked about pain level\n i.e.,\n and\n. See flowsheet for all real time documentation and\n assessments of neurological status. Initial CSF output was bloodtinged\n in AM.\n Action:\n HOB >30degrees, Ventriculostomy open to drain, medicated with Fentanyl\n 25mcg IVP for pain when pt nodding yes to pain, turned frequently and\n repositioned, CT of brain done.\n Response:\n Drain Output became clear in afternoon, good response to pain meds,\n when turned onto left side lower than when turned onto right side.\n Neuro checks hourly,.\n Plan:\n Continue neuro checks hourly, monitor , notify MD >25 or if\n neuro deficits develop, medicate for pain as needed, keep HOB >30\n degrees. Keep CPP >60.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339052,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n No gag reflex present, positive cough, clear RUL and LUL sounds,\n diminished RLL and LLL sounds. Scant amt of thin secretions in ETT,\n Sats 100% on CPAP 40FIO2, 5 PEEP and 10 of pressure support.\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 339240,
"text": "Subjective\n pt intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 167.6 cm\n 81.5 kg\n 84 kg ( 06:00 AM)\n 29\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 138%\n 65\n Diagnosis: ICH\n PMH : ESRD d/t type 1 DM, s/p renal and pancreas transplants, CMV\n pancytopenia, hypothyroidism, retinopathy, RLS, flow related heart\n mumur\n Food allergies and intolerances: NKFA\n Pertinent medications: fentanyl gtt, bowel regimen, SS lytes,\n levothyroxine Na, RISS, transplant meds\n Labs:\n Value\n Date\n Glucose\n 130 mg/dL\n 01:54 AM\n Glucose Finger Stick\n 108\n 08:00 AM\n BUN\n 14 mg/dL\n 01:54 AM\n Creatinine\n 1.0 mg/dL\n 01:54 AM\n Sodium\n 138 mEq/L\n 01:54 AM\n Potassium\n 3.9 mEq/L\n 01:54 AM\n Chloride\n 111 mEq/L\n 01:54 AM\n TCO2\n 18 mEq/L\n 01:54 AM\n Calcium non-ionized\n 9.1 mg/dL\n 01:54 AM\n Phosphorus\n 1.2 mg/dL\n 01:54 AM\n Ionized Calcium\n 1.22 mmol/L\n 02:12 AM\n Magnesium\n 1.9 mg/dL\n 01:54 AM\n Current diet order / nutrition support: Replete c/ Fiber @70mL/ (1680\n kcals/104 gr aa)\n GI: Abd soft/+bs\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs based on adjusted weight\n Calories: 1629 (BEE x 25 or / cal/kg)\n Protein: 78-98 (1.2-1.5 g/kg)\n Specifics:\n 43 y/o female c/ ICH p/ hitting head while walking dog. Pt s/p\n craniotomy c/ evac of hematoma . Ordered to begin TF\ns-current\n goal will meet 100% estimated nutrition needs. Low PO4-repletion\n noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n TF's as ordered\n BG and lyte management as you are\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339344,
"text": "44 yo female s/p fall while walking a friend\ns dog, striking head\n directly. Sustained IVH, cerebellar hemorrhage., s/p craniotomy,\n evacuation. Patient remains intubated, off of all sedation for >12\n hours at this time. Past medical hx includes type 1 diabetes\n (childhood onset), kidney and pancreas txp, both renal and transplant\n teams following.\n Intracerebral hemorrhage (ICH)\n Assessment:\n s/p craniotomy to occipital site, neuro exam remains poor, off of all\n sedation. Continues to exhibit posturing movements w/ any stimulation\n and at rest. Autoregulatory system affected, note signif.\n tachycardia and hypertension w/ any stimulus, w/ inability to resolve\n normal hemodynamics at rest.\n Action:\n Labetolol drip for bp mgmt, low stimulation level, ventriculostomy open\n to drainage, transducing icp hourly.\n Response:\n BP much better controlled w/ beta blockade, icp\ns improved w/ better\n bp\ns, minimal output from ventriculostomy.\n Plan:\n Serial neuro exams, low environmental stimulation, optimize\n hemodynamics w/ beta blockade (maintain sbp<160, cpp>60), optimize\n lytes, glucose levels, temps.\n Alkalosis, respiratory\n Assessment:\n Pt w/ central neuro breathing pattern, tachypneic to mid 20s-30s.\n hypocarbic as result, pco2 high 20s.\n Action:\n Attempted to adjust w/ higher psv.\n Response:\n Little improvement noted in abg, pt autocompensating regardless of vent\n settings.\n Plan:\n Abg acceptable, ph wnl. Continue ventilation as per current settings,\n follow abg/clinical exam ongoing.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Neuro exam remains poor, pt unable to maintain airway. Cough, gag very\n poor.\n Action:\n Pt remains intubated on cpap+ps, 40%, .\n Response:\n Abg acceptable, resp. alkalosis evidence of central neuro breathing\n pattern.\n Plan:\n Continue present ventilation settings, patient will remain intubated\n until neuro exam much improved.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339428,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339190,
"text": "Acidosis, Metabolic\n Assessment:\n Bicarbonate and total C02 16-18, tachypnea with shallow volumes, low\n PaC02 levels, over compensated respiratory alkalosis with pH 7.43.\n Action:\n Increased pressure support on ventilator from 10 to 15 cmH20, NGT to\n cont wall suction, repleated electrolytes, measured anion gap,\n considered switching IV fluids with Neuro surgery and TSICU resident.\n Response:\n Decreased tachypnea from 30\ns to 20\ns, increased PaCo2 levels to\n correct over compensation.\n Plan:\n Continue to follow labs and blood gas values and make corrections as\n needed.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339424,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339429,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Continued Q1hr neuro checks throughout shift, exam remains unchanged.\n Pt did not open eyes or respond to voice/pain/stimulation, continues to\n posture in all extremities. See chart for full assessment.\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Morning labs: Potassium phosphate 0.9, potassium 3.8. No ectopy noted.\n Action:\n 30mmol Phosphate and 44mEq Potassium repleted IV.\n Response:\n Unknown response d/t Potassium Phosphate running in at time of note.\n IV electrolytes will continue to infuse until 11:30.\n Plan:\n Repeat labs to be drawn in AM to evaluate efficacy of electrolyte\n repletion.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 339217,
"text": "TITLE:\n TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate\n 0.12% Oral Rinse 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\n HydrALAzine 11. HydrALAzine 12. Insulin 13. Labetalol 14. Levothyroxine\n Sodium 15. Magnesium Sulfate 16. Mycophenolate Mofetil 17. Pantoprazole\n 18. Phenylephrine 19. Potassium Chloride 20. Senna 21. Sodium Chloride\n 0.9% Flush 22. Sulfameth/Trimethoprim SS 23. Tacrolimus\n 24. ValGANCIclovir Suspension\n 24 Hour Events:\n () IV drain lowered to 0 cm height to improve CSF drainage\n Post operative day:\n POD#2 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:59 PM\n Pantoprazole (Protonix) - 06:00 PM\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.4\nC (99.4\n HR: 74 (55 - 101) bpm\n BP: 162/50(86) {122/42(66) - 162/65(99)} mmHg\n RR: 28 (19 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n ICP: 20 (9 - 25) mmHg\n Total In:\n 2,421 mL\n 100 mL\n PO:\n 30 mL\n Tube feeding:\n IV Fluid:\n 2,201 mL\n 100 mL\n Blood products:\n Total out:\n 1,198 mL\n 252 mL\n Urine:\n 966 mL\n 215 mL\n NG:\n Stool:\n Drains:\n 232 mL\n 37 mL\n Balance:\n 1,223 mL\n -152 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 345 (338 - 423) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Elevated ICP\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.43/28/129/18/-3\n Ve: 6.1 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: Overweight / Obese, not responsive, intubated\n HEENT: 4mm brisk response\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 215 K/uL\n 14.5 g/dL\n 130 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 111 mEq/L\n 138 mEq/L\n 44.1 %\n 14.3 K/uL\n [image002.jpg]\n 06:57 PM\n 08:00 PM\n 01:13 AM\n 04:00 AM\n 04:46 AM\n 08:00 AM\n 02:00 PM\n 09:04 PM\n 01:54 AM\n 02:12 AM\n WBC\n 17.8\n 14.3\n Hct\n 45.9\n 44.1\n Plt\n 298\n 215\n Creatinine\n 1.0\n 1.0\n TCO2\n 20\n 20\n 16\n 19\n Glucose\n 157\n 152\n 147\n 120\n 110\n 130\n Other labs: Lactic Acid:1.1 mmol/L, Ca:9.1 mg/dL, Mg:1.9 mg/dL, PO4:1.2\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma s/p drainage\n Neurologic: Poorly responsive in comparison to yeaterday, L side weaker\n than R. ICPs elevated to 20s, CPPs maintained by elevated SBP Neuro\n checks Q1hr, Ventriculostomy in place, draining lowered to 0 cmm from\n vetricular height to improve drainage with elevated ICP, will follow\n with neurosurgery . Keep ICP <25. BP <160. No CT today.\n Cardiovascular: Hemodynamically stable, off drips. Target SBP <\n 150,however to maintain CPP > 60 SBP is between 150 and 160\n Pulmonary: Cont ETT, Tolerating pressure support .\n Gastrointestinal / Abdomen: Soft, nontender, + BS.\n Nutrition: Begin TF\n Renal: Foley, Adequate UO, 30 cc/hr\n Hematology: HCT stable\n Endocrine: RISS\n Infectious Disease: WBC decreased to 14 from 18, continued afebrile, On\n Ancef Q12 for prophylaxis.\n Lines / Tubes / Drains: Foley, NGT, ETT, ventriculostomy, Aline\n Wounds: Dry dressings\n Imaging:\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:02 PM\n 20 Gauge - 03:02 PM\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339325,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Evacuation of hematoma post fall.Patient weaning on PSV with\n good spt VT. Metabolic acidosis corrected by dropping her Paco2 to 29\n mmhg.ESRD secondary to DM1,Bs clear,but suctioned for small amount of\n bloody thck sputum;will continue to follow.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 339491,
"text": "TSICU\n HPI:\n HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n .\n POD 3 crani/evacuation hematoma\n .\n ISSUES:\n (1) intracranial bleed\n (2) s/p renal/pancreas transplant\n Chief complaint:\n CHIEF COMPLAINT: intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n Bactrim daily, Fosamax weekly, Levoxyl daily, trazodone as needed,\n Prograf one milligram b.i.d., CellCept mg b.i.d., Aranesp 40 mcg a\n week, Protonix 40 mg twice a day, Ambien at night, and Valcyte 450 mg\n b.i.d.\n 24 Hour Events:\n () placed on labetolol gtt - SBP 170s, uncontrolled w/lopressor\n bolusing but now well-controlled on gtt; TF begun\n Post operative day:\n POD#3 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Infusions:\n Labetalol - 3 mg/min\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 06:24 PM\n Other medications:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.7\nC (99.8\n HR: 85 (75 - 103) bpm\n BP: 167/80(113) {119/49(71) - 179/6,261(113)} mmHg\n RR: 24 (22 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 10 (7 - 25) mmHg\n Total In:\n 3,056 mL\n 667 mL\n PO:\n Tube feeding:\n 481 mL\n 408 mL\n IV Fluid:\n 2,085 mL\n 259 mL\n Blood products:\n Total out:\n 1,909 mL\n 388 mL\n Urine:\n 1,695 mL\n 330 mL\n NG:\n Stool:\n Drains:\n 214 mL\n 58 mL\n Balance:\n 1,147 mL\n 279 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 519 (334 - 519) mL\n PS : 15 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 60\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.42/31/147/20/-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 199 K/uL\n 13.7 g/dL\n 151 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 111 mEq/L\n 136 mEq/L\n 40.4 %\n 10.2 K/uL\n [image002.jpg]\n 04:46 AM\n 08:00 AM\n 02:00 PM\n 09:04 PM\n 01:54 AM\n 02:12 AM\n 01:12 PM\n 02:00 AM\n 02:21 AM\n 02:38 AM\n WBC\n 17.8\n 14.3\n 10.2\n Hct\n 45.9\n 44.1\n 40.4\n Plt\n 298\n 215\n 199\n Creatinine\n 1.0\n 1.0\n 0.8\n TCO2\n 16\n 19\n 19\n 21\n Glucose\n 147\n 120\n 110\n 130\n 135\n 151\n Other labs: Lactic Acid:1.2 mmol/L, Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:0.9\n Imaging: CT head: No new regions of intracranial hemorrhage\n identified with stable appearance to right cerebellar hemorrhage and\n intraventricular hemorrhage. Decreased conspicuity to left frontal\n subarachnoid hemorrhage consistent with evolving blood products.\n CT head:Interval decrease in size of right cerebellar hemorrhage\n postoperatively, with expected pneumocephalus. Right frontal approach\n drain terminates with the tip in the third ventricle, with no evidence\n of ventriculomegaly. Unchanged size and appearance of small left\n frontal subarachnoid hemorrhage.\n CT Cspine: no acute fx; 3mm calcific density subjacent to the\n anterior arch of C1 (stable from ), which may be dystrophic\n ligamentous calcification as there is no identifiable \"donor\" fracture\n site (FINAL)\n echo: EF >65%, 1+ TR, 1+ AR\n Microbiology: None\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma s/p drainage.\n Neurologic: Neuro checks Q: 1 hr, less responsive than yeaterday, L\n side weaker than R. Keep ICP <25, Neuro checks Q1hr, Ventriculostomy\n in place, draining.\n Cardiovascular: Hemodynamically stable, on labetolol gtt\n Target SBP < 160, CPP > 60.\n Pulmonary: Tolerating pressure support \n Gastrointestinal / Abdomen: Soft, nontender, + BS.\n Nutrition: Started TF (replete w/fiber FS - goal 70cc/hr)\n Renal: Foley, Adequate UO, 30+ cc/hr\n Hematology: stable\n Endocrine: s/p pancreas/renal transplant for DM1, off glycemic\n medications at home. RISS. Follow tacrolimus values this AM.\n Infectious Disease: WBC decreased to 10 from 14, continued afebrile.\n On Ancef Q12 for prophylaxis\n Lines / Tubes / Drains: Foley, NGT, ETT, ventriculostomy, Aline needs\n CVL today\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Failure), Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:25 AM 70 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 03:02 PM\n 20 Gauge - 03:02 PM\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339609,
"text": "Patient is a 44 yo female s/p fall from standing, striking head\n directly. Sustained cerebellar and intraventricular hemorrhages. s/p\n craniotomy and evacuation . Neurological status remains poor at\n this time. Past medical hx includes kidney and pancreas txp >5yrs\n ago.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam remains poor, some minimal improvement noted w/ mild\n withdrawl from nailbed pressure to all but L arm. L arm continues to\n posture w/ any stimulation, posturing x4 extrem at rest noted as\n well. Gag and cough remain very poor, continues w/ hemodynamic\n autoregulatory deficit and central breathing pattern. Ventriculostomy\n w/ mod amts blood tinged drainage, icp\ns stable.\n Action:\n Hourly neuro exams continue, no sedation >24h as of current hour.\n Ventric drain open, 10cm above tragus. Low stimulation environment\n maintained, clustering of care helpful.\n Response:\n BP well controlled w/ labetolol infusion, titrated to goal sbp<160.\n Plan:\n Follow neuro exam ongoing, follow icp\ns, hemodynamics.\n Alkalosis, respiratory\n Assessment:\n d/t neurological damage, pt w/ central breathing pattern, hypocarbic.\n Ph wnl on abg\n Action:\n Remains intubated, on cpap+ps mode, 15 psv.\n Response:\n Despite changes to mech vent settings, breathing pattern unchanged,\n overcompensatory. Pco2 remains high 20s.\n Plan:\n Continue ventilation as per present, follow blood gases ongoing. Low\n stimulation ensured.\n Electrolyte & fluid disorder, other\n Assessment:\n Phos level 0.9 this am, k+ 3.8\n Action:\n Repleted lytes as per written orders.\n Response:\n K+ improved, wnl, phos remains low at 1.4\n Plan:\n Further po repletion given this pm, will follow.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339608,
"text": "Patient is a 44 yo female s/p fall from standing, striking head\n directly. Sustained cerebellar and intraventricular hemorrhages. s/p\n craniotomy and evacuation . Neurological status remains poor at\n this time. Past medical hx includes kidney and pancreas txp >5yrs\n ago.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam remains poor, some minimal improvement noted w/ mild\n withdrawl from nailbed pressure to all but L arm. L arm continues to\n posture w/ any stimulation, posturing x4 extrem at rest noted as well.\n Gag and cough remain very poor, continues w/ hemodynamic\n autoregulatory deficit and central breathing pattern. Ventriculostomy\n w/ mod amts blood tinged drainage, icp\ns stable.\n Action:\n Hourly neuro exams continue, no sedation >24h as of current hour.\n Ventric drain open, 10cm above tragus. Low stimulation environment\n maintained, clustering of care helpful.\n Response:\n BP well controlled w/ labetolol infusion, titrated to goal sbp<160.\n Plan:\n Follow neuro exam ongoing, follow icp\ns, hemodynamics.\n Alkalosis, respiratory\n Assessment:\n d/t neurological damage, pt w/ central breathing pattern, hypocarbic.\n Ph wnl on abg\n Action:\n Remains intubated, on cpap+ps mode, 15 psv.\n Response:\n Despite changes to mech vent settings, breathing pattern unchanged,\n overcompensatory. Pco2 remains high 20s.\n Plan:\n Continue ventilation as per present, follow blood gases ongoing. Low\n stimulation ensured.\n Electrolyte & fluid disorder, other\n Assessment:\n Phos level 0.9 this am, k+ 3.8\n Action:\n Repleted lytes as per written orders.\n Response:\n K+ improved, wnl, phos remains low at 1.4\n Plan:\n Further po repletion given this pm, will follow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339468,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments: pt on cpap 15/5 and not able to tolerate psv 10/5 as of yet.\n pt B.S ronchorous and clear with suctioning.. will continue with\n weaning attemps\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340103,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Pt was received on PSV 8/5. D/T decreased spo2 and tachypneic episodes\n pt was placed on PSV 15/5 which was weaned back down to 8/5 at end of\n shift.Pt bs reveals Rhonchi throughout and was suctioned for small tan\n secretions. Please refer to carevue respiratory flowsheet for more\n detail.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 338901,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n :\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n c-scan\n 930pm\n none\n Pt. weaned to IPS overnoc. Fio2 weaned to 40%. RSBI 66 this am.\n Continue vent support until pt. can protect airway.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339886,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340825,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Marked tachypnea with increased WOB and increase in vital\n signs when changed over to PSV\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\n Comments: frequent alarms when on PSV\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n RSBI 103\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340008,
"text": "Patient is a 44 yo female s/p fall while walking, striking head\n directly. Patient found down, unknown length of time. Sustained IVH,\n cerebellar hemorrhage. Patient to OR night of admission, for\n craniotomy and hematoma evacuation. Neuro exam remains poor, patient\n remains intubated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt is s/p craniotomy, with a ventriculostomy in place at 15 cm from\n tragus. Neuro exam remains poor; unresponsive, only response is to\n painful stimulus by withdrawal/posturing, not opening her eyes, moves\n extremities non-purposefully with every neuron check, PERLA. SBP\n increased to 170s, HO informed, given hydralazine 10 mg IVP stat and\n the labetelol dose increased to 300 mg Q 8 hrs.\n Action:\n Serial neurologic exam being done Q 2 hrs, low environmental stimulus,\n ventriculostomy drain continued to drain 7-13cc/h.\n Response:\n Neuro exam remains poor, still unresponsive but to painful stimuli, ICP\n has been stable below 20, gag and cough slowly improving. Withdrawing\n to nailbed pressure stimuli, withdrawal with occasional posturing of\n extremities, after hydralazine and the increased dose of labetelol\n drip, BP improved.\n Plan:\n Cont serial neuro exams, follow icp\ns and drainage from EVD ongoing.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Remains intubated via ETT attached to mechanical ventilatilator on CPAP\n and PS 8, FiO2 60%.\n Action:\n Suctioned frequently for excessive thick yellowish to tan secretions\n from ETT and mouth. Tube feed stopped at 0400 for trach and PEG.\n Response:\n Saturation above 95%, no tachypnea, LS CTA with occasional exp wheezes,\n diminished at bases,\n Plan:\n Continue to wean PS and O2 as tolerated, for tracheostomy and PEG\n placement today.\n"
},
{
"category": "Nutrition",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 340211,
"text": "Subjective\n Pt remains intubated\n Objective\n Pertinent medications:\n Noted\n Labs:\n Value\n Date\n Glucose\n 157 mg/dL\n 02:07 AM\n Glucose Finger Stick\n 78\n 08:00 AM\n BUN\n 19 mg/dL\n 02:07 AM\n Creatinine\n 0.7 mg/dL\n 02:07 AM\n Sodium\n 136 mEq/L\n 02:07 AM\n Potassium\n 4.3 mEq/L\n 02:07 AM\n Chloride\n 107 mEq/L\n 02:07 AM\n TCO2\n 20 mEq/L\n 02:07 AM\n PO2 (arterial)\n 199 mm Hg\n 06:19 AM\n PCO2 (arterial)\n 35 mm Hg\n 06:19 AM\n pH (arterial)\n 7.45 units\n 06:19 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 06:19 AM\n Calcium non-ionized\n 9.2 mg/dL\n 02:07 AM\n Phosphorus\n 2.0 mg/dL\n 02:07 AM\n Ionized Calcium\n 1.26 mmol/L\n 02:37 PM\n Magnesium\n 1.9 mg/dL\n 02:07 AM\n WBC\n 8.9 K/uL\n 02:07 AM\n Hgb\n 13.9 g/dL\n 02:07 AM\n Hematocrit\n 41.5 %\n 02:07 AM\n Current diet order / nutrition support: NPO, FS Replete w/ Fiber\n @70cc/hr\n GI: Abd soft, +BS\n Assessment of Nutritional Status\n Pt adm w/ ICH, S/P craniotomy and evac of hematoma. Pt S/P PAK.\n Transplant team following.\n Pt S/P trach/PEG. Was receiving TF @goal, held now. Pt w/\n hyperglycemia.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Restart TF via PEG in 24hrs, initiate w/ 20cc/hr of FS Replete\n w/ Fiber and adv to goal of 70cc/hr to provide 1680kcals and 104g\n prot/day.\n 2. Check residuals q 4-6 hrs, hold TF if >150cc\n 3. BG mngt, insulin gtt vs. SS\n 4. Continue to monitor and replete lytes prn- low Phos, pls\n replete prior to restarting TF\n 16:11\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339709,
"text": "Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n bleed\n Action:\n Labetalol drip continues\n Response:\n SBP < 160 (goal), CPP > 60\n Plan:\n Titrate labetalol to maintain SBP < 160 and CPP > 60.\n Alkalosis, respiratory secondary to central neurological breathing\n pattern.\n Assessment:\n Patient continues to be hypocarbic.\n Action:\n Wean pressure support\n Response:\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated\n Altered mental status (not Delirium) s/p cerebellar parenchymal\n hemorrhage, frontal SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy\n Response:\n Patient unresponsive. ICPs remain <20.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for prophylaxis.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 339796,
"text": "TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1. 2. 3. 500 mL NS 4. Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Heparin 11. Insulin\n 12. Labetalol 13. Levothyroxine Sodium 14. Magnesium Sulfate 15.\n Mycophenolate Mofetil 16. Neutra-Phos 17. Pantoprazole 18.\n Phenylephrine 19. Potassium Chloride 20. Potassium Phosphate 21. Senna\n 22. Sodium Chloride 0.9% Flush 23. Sodium Chloride 0.9% Flush\n 24. Sulfameth/Trimethoprim SS 25. Tacrolimus\n 24 Hour Events:\n MULTI LUMEN - START 11:50 AM\n triple lumen catheter placed\n CSF CULTURE - At 02:24 PM\n specimen taken by , PA-C\n SPUTUM CULTURE - At 08:40 PM\n () valgancyclovir d/c'd, IV drain at 10 cm,, R subclavian placed,\n SQH started, Tacro incr to 2mg q12h (level=2.2), sent sputum cx -\n purulent secretions, family agreed to trach / PEG - need consent,\n drainage from ventriculostomy redder in color\n Post operative day:\n POD 3 crani/evacuation hematoma\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Infusions:\n Labetalol - 1 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:26 PM\n Pantoprazole (Protonix) - 06:39 PM\n Other medications:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 36.8\nC (98.2\n HR: 85 (74 - 98) bpm\n BP: 147/62(91) {124/55(79) - 161/67(102)} mmHg\n RR: 19 (19 - 28) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 15 (8 - 19) mmHg\n Total In:\n 2,801 mL\n 637 mL\n PO:\n Tube feeding:\n 1,660 mL\n 367 mL\n IV Fluid:\n 691 mL\n 269 mL\n Blood products:\n Total out:\n 2,113 mL\n 774 mL\n Urine:\n 1,898 mL\n 720 mL\n NG:\n Stool:\n Drains:\n 215 mL\n 54 mL\n Balance:\n 688 mL\n -137 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (398 - 494) mL\n PS : 8 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.44/33/140/20/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 350\n Physical Examination\n General Appearance: intubated\n postures to painful stimuli UE, on LE - withdraws to painful stimuli\n HEENT: pupils briskly reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases, bilateral)\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli)\n Labs / Radiology\n 187 K/uL\n 13.4 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 18 mg/dL\n 109 mEq/L\n 136 mEq/L\n 41.4 %\n 9.2 K/uL\n [image002.jpg]\n 09:04 PM\n 01:54 AM\n 02:12 AM\n 01:12 PM\n 02:00 AM\n 02:21 AM\n 02:38 AM\n 07:43 AM\n 01:54 AM\n 01:59 AM\n WBC\n 14.3\n 10.2\n 9.2\n Hct\n 44.1\n 40.4\n 41.4\n Plt\n \n Creatinine\n 1.0\n 0.8\n 0.8\n TCO2\n 16\n 19\n 19\n 21\n 20\n 23\n Glucose\n 130\n 135\n 151\n 145\n 141\n Other labs: Lactic Acid:1.2 mmol/L, Ca:8.8 mg/dL, Mg:2.0 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w/occipital\n fx/cerebellar hematoma s/p drainage ()\n Neurologic: Neuro checks Q: 1 hr, ICP monitor, Ventriculostomy, Keep\n ICP <25, Neuro checks Q1hr, Ventriculostomy in place @10cm, draining.\n No improvement in exam.\n Cardiovascular: Hemodynamically stable, on labatelol gtt: target SBP <\n 160, CPP > 60. will add po labetolol to get off drip.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Tolerating pressure\n support . will trach tomorrow\n Gastrointestinal / Abdomen: *Need consent for trach/PEG from family -\n (brother) - coming * npo 4am\n Nutrition: Tube feeding, TF (replete w/fiber FS - goal 70cc/hr)\n Renal: Foley, Adequate UO, Foley, Adequate UO. Tacrolimus 2mg q12h with\n qd levels in AM\n Hematology:\n Endocrine: RISS, s/p pancreas/renal transplant for DM1, off glycemic\n medications at home. RISS\n Infectious Disease: monitor WBC, afebrile. F/U sputum and CSF cx. On\n Ancef Q12 for prophylaxis\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:34 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 32\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340084,
"text": "Patient is a 44 yo female s/p fall while walking, striking head\n directly. Patient found down, unknown length of time. She sustained\n IVH, cerebellar hemorrhage. Patient was sent to OR the night of\n admission, for craniotomy and hematoma evacuation. Neuro exam\n remains poor, patient remains intubated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt is s/p craniotomy, with a ventriculostomy in place at 15 cm from\n tragus. Neuro exam remains poor; unresponsive, only response is to\n painful stimulus by withdrawal/posturing, not opening her eyes, moves\n extremities non-purposefully with every neuron check, PERLA. SBP\n increased to 170s, HO informed, given hydralazine 10 mg IVP stat and\n the labetelol dose increased to 300 mg Q 8 hrs.\n Action:\n Serial neurologic exam being done Q 2 hrs, low environmental stimulus,\n ventriculostomy drain continued to drain 7-13cc/h. Potassium and\n phosphate repleted this AM. Pt was pan cultured yesterday.\n Response:\n Neuro exam remains poor, still unresponsive but to painful stimuli, ICP\n has been stable to a maximum of 20 or below 20 most of the time, gag\n and cough slowly improving. Withdrawing to nailbed pressure stimuli,\n withdrawal with occasional posturing of extremities, after hydralazine\n and the increased dose of labetelol drip, BP improved.\n Plan:\n Cont serial neuro exams follow icp\ns and drainage from EVD ongoing.\n Follow up on lytes and replete as needed, FS checking QiD and cover\n with insulin as needed, continue antibiotics and f/u on cxs results.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Remains intubated via ETT attached to mechanical ventilatilator on CPAP\n and PS 10, PEEP 5, FiO2 40%.\n Action:\n Suctioned frequently for excessive thick yellowish to tan secretions\n from ETT and mouth. Tube feed stopped at 0400 for trach and PEG.\n Response:\n Saturation above 95%, no tachypnea, LS CTA with occasional exp wheezes,\n diminished at bases, ABGs this am revealed 7.45, 35, 199, accordingly,\n FiO2 decreased to 40%.\n Plan:\n Continue to wean PS and O2 as tolerated; pt is for tracheostomy and PEG\n placement today, probably by noon time.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340383,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt occasionally opens eyes to voice, otherwise unresponsive. Pupils\n equal and reactive. Corneal reflex absent in right, impaired in left.\n Gag absent, cough impaired. Occasionally withdraws to nail bed pressure\n with UE, consistently withdraws LE. Ventric drain open 15cm above the\n tragus.\n Action:\n Q 2 hour neuro checks.\n Response:\n Unchanging neuro exam.\n Plan:\n MRA today.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339171,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Cerebellar hemorrhage and intraventricular hemorrhage per radiology\n elevated ICP 20-25 mmHg (sustained), CSF and bloody drainage from\n ventriculostomy, GCS of 7.\n Action:\n Neurosurgery team notified, frequent neurological examinations, HOB at\n 30 degrees, straight head to facilitate venous drainage,\n ventriculostomy dropped to level of tragus and clamp is open for\n continuous drainage, quiet and calm atmosphere, space out nursing care\n such as changes in position and suctioning, lifter systolic blood\n pressure parameters to maintain an adequate CPP.\n Response:\n CPP > 60 mmHg, ICP continues to slowly increase.\n Plan:\n Monitor neurological function closely, implement all ICP reducing\n strategies applicable, consider obtaining another CT scan of head,\n consider suppressing neuronal activity if applicable, and continue to\n inform TSICU resident and neurosurgery team about changes in\n physical/mental status.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-10 00:00:00.000",
"description": "Intensivist Note",
"row_id": 339172,
"text": "TITLE:\n TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate\n 0.12% Oral Rinse 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\n HydrALAzine 11. HydrALAzine 12. Insulin 13. Labetalol 14. Levothyroxine\n Sodium 15. Magnesium Sulfate 16. Mycophenolate Mofetil 17. Pantoprazole\n 18. Phenylephrine 19. Potassium Chloride 20. Senna 21. Sodium Chloride\n 0.9% Flush 22. Sulfameth/Trimethoprim SS 23. Tacrolimus\n 24. ValGANCIclovir Suspension\n 24 Hour Events:\n () IV drain lowered to 0 cm height to improve CSF drainage\n Post operative day:\n POD#2 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 05:59 PM\n Pantoprazole (Protonix) - 06:00 PM\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.4\nC (99.4\n HR: 74 (55 - 101) bpm\n BP: 162/50(86) {122/42(66) - 162/65(99)} mmHg\n RR: 28 (19 - 34) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n ICP: 20 (9 - 25) mmHg\n Total In:\n 2,421 mL\n 100 mL\n PO:\n 30 mL\n Tube feeding:\n IV Fluid:\n 2,201 mL\n 100 mL\n Blood products:\n Total out:\n 1,198 mL\n 252 mL\n Urine:\n 966 mL\n 215 mL\n NG:\n Stool:\n Drains:\n 232 mL\n 37 mL\n Balance:\n 1,223 mL\n -152 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 345 (338 - 423) mL\n PS : 15 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Elevated ICP\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.43/28/129/18/-3\n Ve: 6.1 L/min\n PaO2 / FiO2: 322\n Physical Examination\n General Appearance: Overweight / Obese, not responsive, intubated\n HEENT: 4mm brisk response\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present, Obese\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 215 K/uL\n 14.5 g/dL\n 130 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 111 mEq/L\n 138 mEq/L\n 44.1 %\n 14.3 K/uL\n [image002.jpg]\n 06:57 PM\n 08:00 PM\n 01:13 AM\n 04:00 AM\n 04:46 AM\n 08:00 AM\n 02:00 PM\n 09:04 PM\n 01:54 AM\n 02:12 AM\n WBC\n 17.8\n 14.3\n Hct\n 45.9\n 44.1\n Plt\n 298\n 215\n Creatinine\n 1.0\n 1.0\n TCO2\n 20\n 20\n 16\n 19\n Glucose\n 157\n 152\n 147\n 120\n 110\n 130\n Other labs: Lactic Acid:1.1 mmol/L, Ca:9.1 mg/dL, Mg:1.9 mg/dL, PO4:1.2\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma s/p drainage\n Neurologic: Poorly responsive in comparison to yeaterday, L side weaker\n than R. ICPs elevated to 20s, CPPs maintained by elevated SBP Neuro\n checks Q1hr, Ventriculostomy in place, draining lowered to 0 cmm from\n vetricular height to improve drainage with elevated ICP, will follow\n with neurosurgery\n Cardiovascular: Hemodynamically stable, off drips. Target SBP <\n 150,however to maintain CPP > 60 SBP is between 150 and 160\n Pulmonary: Cont ETT, Tolerating pressure support .\n Gastrointestinal / Abdomen: Soft, nontender, + BS.\n Nutrition: NPO\n Renal: Foley, Adequate UO, 30 cc/hr\n Hematology: HCT stable\n Endocrine: RISS\n Infectious Disease: WBC decreased to 14 from 18, continued afebrile, On\n Ancef Q12 for prophylaxis.\n Lines / Tubes / Drains: Foley, NGT, ETT, ventriculostomy, Aline\n Wounds: Dry dressings\n Imaging:\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:02 PM\n 20 Gauge - 03:02 PM\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 37 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340850,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Marked tachypnea with increased WOB and increase in vital\n signs when changed over to PSV\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\n Comments: frequent alarms when on PSV\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot manage secretions\n RSBI 103\n ------ Protected Section ------\n MD to PSV 10PS and 5 peep, RR in 30\n PaO2 as low as 70\ns and HR as high as 120 acceptable.\n ------ Protected Section Addendum Entered By: , RTT\n on: 06:04 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340209,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Hemodynimic instability\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Bedside tracheostomy (1215)\n Comments:\n Patient had bedside tracheostomy, trach tube Portex size 8 inserted,\n suctioned for small thick blood-tinged secretions, breath sounds\n bilaterally wheezing and rhoncherous, becomes bradypneic upon\n suctioning, SPO2 98% remains on PSV, will continues to be followed.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339700,
"text": "Altered mental status (not Delirium) s/p cerebellar parenchymal\n hemorrhage, frontal SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy\n Response:\n Patient unresponsive. ICPs remain <20.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for prophylaxis.\n Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n bleed\n Action:\n Labetalol drip continues\n Response:\n SBP < 160 (goal), CPP > 60\n Plan:\n Titrate labetalol to maintain SBP < 160 and CPP > 60.\n Alkalosis, respiratory\n Assessment:\n Patient continues to be hypocarbic.\n Action:\n Wean pressure support\n Response:\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339707,
"text": "Altered mental status (not Delirium) s/p cerebellar parenchymal\n hemorrhage, frontal SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy\n Response:\n Patient unresponsive. ICPs remain <20.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for prophylaxis.\n Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n bleed\n Action:\n Labetalol drip continues\n Response:\n SBP < 160 (goal), CPP > 60\n Plan:\n Titrate labetalol to maintain SBP < 160 and CPP > 60.\n Alkalosis, respiratory secondary to central neurological breathing\n pattern.\n Assessment:\n Patient continues to be hypocarbic.\n Action:\n Wean pressure support\n Response:\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340000,
"text": "Patient is a 44 yo female s/p fall while walking, striking head\n directly. Patient found down, unknown length of time. Sustained IVH,\n cerebellar hemorrhage. Patient to OR night of admission, for\n craniotomy and hematoma evacuation. Neuro exam remains poor, patient\n remains intubated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt is s/p craniotomy, with a ventriculostomy in place at 15 cm from\n tragus. Neuro exam remains poor; unresponsive, only response is to\n painful stimulus by withdrawal/posturing, not opening her eyes, moves\n extremities non-purposefully with every neuron check, PERLA.\n Action:\n Serial neuro exams being done Q 2 hrs, low environmental stimulus, icp\n drain raised to 15cm above tragus, continuing to drain 5-10cc/h.\n icp\ns stable.\n Response:\n As above, exam poor, gag and cough slowly improving. Withdrawing to\n nailbed pressure, at times w/ spont posturing of all limbs.\n Plan:\n Cont serial neuro exams, follow icp\ns and drainage from EVD ongoing.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient remains intubated via ett at this time, mech ventilated on\n cpap+ps mode.\n Action:\n Weaned psv to 5 from 8, tol well for short while, becoming tachypneic,\n returned to prev. settings.\n Response:\n As above, able to only tolerate lower psv for short time. Patient\n hypocarbic at times despite changes in settings d/t central breathing\n pattern.\n Plan:\n Cont to attempt weaning of psv as tolerated, full vent support as\n needed. For trach procedure tomorrow.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340327,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments: Pt had bilateral rhonchi at beginning of shift. RN suctioned,\n Lung sounds became clear\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt has spontanous Tidal volumes of 280-330ml\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Maintain PEEP at current level and\n reduce FiO2 as tolerated; Comments: Pt has good spontanous drive, but\n needs higher tidal volumes to be weaned off vent.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved; Comments: Pt not very responsive- con't current support\n Bedside RSBI- 95\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 339436,
"text": "TSICU\n HPI:\n HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n .\n POD 3 crani/evacuation hematoma\n .\n ISSUES:\n (1) intracranial bleed\n (2) s/p renal/pancreas transplant\n Chief complaint:\n CHIEF COMPLAINT: intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n Bactrim daily, Fosamax weekly, Levoxyl daily, trazodone as needed,\n Prograf one milligram b.i.d., CellCept mg b.i.d., Aranesp 40 mcg a\n week, Protonix 40 mg twice a day, Ambien at night, and Valcyte 450 mg\n b.i.d.\n 24 Hour Events:\n () placed on labetolol gtt - SBP 170s, uncontrolled w/lopressor\n bolusing but now well-controlled on gtt; TF begun\n Post operative day:\n POD#3 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Infusions:\n Labetalol - 3 mg/min\n Other ICU medications:\n Fentanyl - 09:30 AM\n Pantoprazole (Protonix) - 06:24 PM\n Other medications:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.7\nC (99.8\n HR: 85 (75 - 103) bpm\n BP: 167/80(113) {119/49(71) - 179/6,261(113)} mmHg\n RR: 24 (22 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 10 (7 - 25) mmHg\n Total In:\n 3,056 mL\n 667 mL\n PO:\n Tube feeding:\n 481 mL\n 408 mL\n IV Fluid:\n 2,085 mL\n 259 mL\n Blood products:\n Total out:\n 1,909 mL\n 388 mL\n Urine:\n 1,695 mL\n 330 mL\n NG:\n Stool:\n Drains:\n 214 mL\n 58 mL\n Balance:\n 1,147 mL\n 279 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 519 (334 - 519) mL\n PS : 15 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 60\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.42/31/147/20/-2\n Ve: 8.6 L/min\n PaO2 / FiO2: 367\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 199 K/uL\n 13.7 g/dL\n 151 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 3.8 mEq/L\n 18 mg/dL\n 111 mEq/L\n 136 mEq/L\n 40.4 %\n 10.2 K/uL\n [image002.jpg]\n 04:46 AM\n 08:00 AM\n 02:00 PM\n 09:04 PM\n 01:54 AM\n 02:12 AM\n 01:12 PM\n 02:00 AM\n 02:21 AM\n 02:38 AM\n WBC\n 17.8\n 14.3\n 10.2\n Hct\n 45.9\n 44.1\n 40.4\n Plt\n 298\n 215\n 199\n Creatinine\n 1.0\n 1.0\n 0.8\n TCO2\n 16\n 19\n 19\n 21\n Glucose\n 147\n 120\n 110\n 130\n 135\n 151\n Other labs: Lactic Acid:1.2 mmol/L, Ca:8.9 mg/dL, Mg:2.2 mg/dL, PO4:0.9\n Imaging: CT head: No new regions of intracranial hemorrhage\n identified with stable appearance to right cerebellar hemorrhage and\n intraventricular hemorrhage. Decreased conspicuity to left frontal\n subarachnoid hemorrhage consistent with evolving blood products.\n CT head:Interval decrease in size of right cerebellar hemorrhage\n postoperatively, with expected pneumocephalus. Right frontal approach\n drain terminates with the tip in the third ventricle, with no evidence\n of ventriculomegaly. Unchanged size and appearance of small left\n frontal subarachnoid hemorrhage.\n CT Cspine: no acute fx; 3mm calcific density subjacent to the\n anterior arch of C1 (stable from ), which may be dystrophic\n ligamentous calcification as there is no identifiable \"donor\" fracture\n site (FINAL)\n echo: EF >65%, 1+ TR, 1+ AR\n Microbiology: None\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma s/p drainage.\n Neurologic: Neuro checks Q: 1 hr, less responsive than yeaterday, L\n side weaker than R. Keep ICP <25, Neuro checks Q1hr, Ventriculostomy\n in place, draining.\n Cardiovascular: Hemodynamically stable, on lopressor gtt\n Target SBP < 160, CPP > 60.\n Pulmonary: Tolerating pressure support \n Gastrointestinal / Abdomen: Soft, nontender, + BS.\n Nutrition: Started TF (replete w/fiber FS - goal 70cc/hr)\n Renal: Foley, Adequate UO, 30+ cc/hr\n Hematology: stable\n Endocrine: s/p pancreas/renal transplant for DM1, off glycemic\n medications at home. RISS. Follow tacrolimus values this AM.\n Infectious Disease: WBC decreased to 10 from 14, continued afebrile.\n On Ancef Q12 for prophylaxis\n Lines / Tubes / Drains: Foley, NGT, ETT, ventriculostomy, Aline\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Failure), Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:25 AM 70 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 03:02 PM\n 20 Gauge - 03:02 PM\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker, PPI, Sucralafate, Not indicated\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339455,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Continued Q1hr neuro checks throughout shift, exam remains unchanged.\n Pt did not open eyes or respond to voice/pain/stimulation, continues to\n posture in all extremities. ICP 9-15, IVD draining clear to blood\n tinged drainage 7-15cc/hr. See chart for full assessment.\n Action:\n Pain/stimulation with every neuro check to attempt to wake pt. IVD\n open to drain and transduce throughout shift.\n Response:\n Pt\ns neuro status remains poor, unchanged.\n Plan:\n Continue Q1 hr neuro checks, monitor for changes. BP goal <160\n systolic, CPP goal >60. Continue to support pt and family with pt\n current status.\n Electrolyte & fluid disorder, other\n Assessment:\n Morning labs: Potassium phosphate 0.9, potassium 3.8. No ectopy noted.\n Action:\n 30mmol Phosphate and 44mEq Potassium repleted IV.\n Response:\n Unknown response d/t Potassium Phosphate running in at time of note.\n IV electrolytes will continue to infuse until 11:30.\n Plan:\n Repeat labs to be drawn in AM to evaluate efficacy of electrolyte\n repletion. HO to order neutraPhos PO.\n Hypertension, benign\n Assessment:\n Pt\ns BP/HR WNL for most of shift with stimulation. Labetalol weaned\n off d/t BP 120-130\ns systolic and CPP 58-62 for ~4hrs. BP/HR WNL with\n neuro exams while off labetalol until bath/repositioning at 05:15. Pt\n hyperdynamic with HR to 110, and sBP to 170\ns. VS decreased slightly\n but did not recover to goal.\n Action:\n Labetolol restarted at 05:30 at 2mg/min and increased to 3mg/min to\n decrease HR/BP. Calm, quiet environment with minimal stimulation\n promoted.\n Response:\n Pt requiring 2mg/min labetalol gtt to maintain goal BP <160 systolic.\n Pt occasionally still tachycardic to 105 at rest without stimulation.\n Plan:\n Attempt to decrease labetalol gtt as tolerated. Maintain sBP <160 and\n CPP >60.\n Problem\n IV access\n Assessment:\n Pt with 2PIVs, both requiring routine changes today . Left ac\n peripheral flushes/draws but positional, right hand IV only flushes.\n Right hand IV infiltrated at 06:30.\n Action:\n Multiple RNs viewed veins, few attempts made without success. IV RN\n called, unable to place new IVs, recommended central line. HO made\n aware of limited access and infiltrated IV-1 IV remaining at this time\n with labetalol gtt running in and Kphos needing repletion. Right hand\n IV discontinued d/t infiltration and elevate on pillow.\n Response:\n HO noted limited IV access, plans to place central line in AM.\n Labetalol gtt continues to run into left ac, no issues at this time\n with site. Right hand slightly less puffy with elevation.\n Plan:\n Place central line as soon as possible. Monitor left ac for adequate\n infusion. Continue electrolyte repletion as able.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340325,
"text": "TITLE:\n TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1Bisacodyl 4. Calcium Gluconate 5. CefazoLIN 6. Chlorhexidine Gluconate\n 0.12% Oral Rinse 7. Docusate Sodium (Liquid) 8. Fentanyl Citrate 9.\n Heparin 10. HydrALAzine 11. Insulin 12. Labetalol 3. Levothyroxine\n Sodium 14. Magnesium Sulfate 15. Mycophenolate Mofetil 16. Pantoprazole\n 17. Potassium Chloride\n 18. Potassium Phosphate 19. Senna 20. Sodium Chloride 0.9% Flush 21.\n Sodium Chloride 0.9% Flush 22. Sulfameth/Trimethoprim SS 23. Tacrolimus\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 PM\n URINE CULTURE - At 12:24 PM\n BLOOD CULTURED - At 01:00 PM\n FEVER - 101.6\nF - 12:00 PM\n Bradycardia to 30s during positioning for Trach placement\n Post operative day:\n POD#6 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.8\nC (98.2\n HR: 65 (64 - 113) bpm\n BP: 126/51(76) {105/49(69) - 166/70(103)} mmHg\n RR: 14 (14 - 33) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 25 (13 - 28) mmHg\n Total In:\n 1,502 mL\n 40 mL\n PO:\n Tube feeding:\n 280 mL\n IV Fluid:\n 1,112 mL\n 40 mL\n Blood products:\n Total out:\n 2,244 mL\n 209 mL\n Urine:\n 2,080 mL\n 175 mL\n NG:\n Stool:\n Drains:\n 164 mL\n 34 mL\n Balance:\n -742 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 315 (185 - 385) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 87\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.47/32/111/22/0\n Ve: 8.5 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present, Obese\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Unresponsive)\n Labs / Radiology\n 252 K/uL\n 13.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 5.5 mEq/L\n 23 mg/dL\n 103 mEq/L\n 133 mEq/L\n 40.4 %\n 8.7 K/uL\n [image002.jpg]\n 02:21 AM\n 02:38 AM\n 07:43 AM\n 01:54 AM\n 01:59 AM\n 02:37 PM\n 02:07 AM\n 06:19 AM\n 01:53 AM\n 02:13 AM\n WBC\n 10.2\n 9.2\n 8.9\n 8.7\n Hct\n 40.4\n 41.4\n 41.5\n 40.4\n Plt\n 199\n 187\n 211\n 252\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.9\n TCO2\n 21\n 20\n 23\n 22\n 25\n 24\n Glucose\n 151\n 145\n 141\n 157\n 126\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Ca:9.4\n mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: CT head:Hypodensities are now apparent at the superior\n aspect of the cerebellum could be due to acute infarcts. MRI can help\n for further assessment. No new hemorrhages seen. There has been\n decrease in mass effect with better appreciated basal cisterns on the\n current study\n CT head: No new regions of intracranial hemorrhage identified w/\n stable appearance to R cerebellar hemorrhage and intraventricular\n hemorrhage. Decreased conspicuity to L frontal subarachnoid hemorrhage\n c/w evolving blood products.\n CT head:Interval decrease in size of R cerebellar hemorrhage\n postoperatively, w/expected pneumocephalus. R frontal approach drain\n terminates w/tip in 3rd ventricle, w/no evidence of ventriculomegaly.\n Unchanged size/appearance of small L frontal subarachnoid hemorrhage.\n CT Cspine: no acute fx; 3mm calcific density subjacent to\n anterior arch of C1 (stable from ), which may be dystrophic\n ligamentous calcification as there is no identifiable \"donor\" fracture\n site (FINAL)\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w/occipital\n fx/cerebellar hematoma s/p drainage\n Neurologic: Keep ICP <25, Neuro checks Q2hr, Ventriculostomy in\n place @15cm, draining.\n Cardiovascular: Hemodynamically stable, on labatelol PO, off gtt:\n target SBP < 160, CPP > 60.\n Pulmonary: Trach, S/P trach \n Gastrointestinal / Abdomen: Soft, nontender, + BS. PEG placed NPO\n except for meds for 24 hours, holding tube feeds, will restart in AM at\n goal of 70\n Nutrition: NPO, TF held after PEG, will restart at 20 with goal of 70\n Renal: Foley, Foley, Adequate UO. Tacrolimus 4mg q12h with qd levels in\n AM\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: monitor WBC, afebrile. F/U sputum and CSF cx.\n On Bactrim for prophylaxis. negative thus far, BLD PND\n Lines / Tubes / Drains: Foley, Trach, Foley, ventriculostomy, Aline\n Wounds:\n Imaging: Brain MRI today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339434,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Continued Q1hr neuro checks throughout shift, exam remains unchanged.\n Pt did not open eyes or respond to voice/pain/stimulation, continues to\n posture in all extremities. ICP 9-15, IVD draining clear to blood\n tinged drainage 7-15cc/hr. See chart for full assessment.\n Action:\n Pain/stimulation with every neuro check to attempt to wake pt. IVD\n open to drain and transduce throughout shift.\n Response:\n Pt\ns neuro status remains poor, unchanged.\n Plan:\n Continue Q1 hr neuro checks, monitor for changes. BP goal <160\n systolic, CPP goal >60. Continue to support pt and family with pt\n current status.\n Electrolyte & fluid disorder, other\n Assessment:\n Morning labs: Potassium phosphate 0.9, potassium 3.8. No ectopy noted.\n Action:\n 30mmol Phosphate and 44mEq Potassium repleted IV.\n Response:\n Unknown response d/t Potassium Phosphate running in at time of note.\n IV electrolytes will continue to infuse until 11:30.\n Plan:\n Repeat labs to be drawn in AM to evaluate efficacy of electrolyte\n repletion. HO to order neutraPhos PO.\n Hypertension, benign\n Assessment:\n Pt\ns BP/HR WNL for most of shift with stimulation. Labetalol weaned\n off d/t BP 120-130\ns systolic and CPP 58-62 for ~4hrs. BP/HR WNL with\n neuro exams while off labetalol until bath/repositioning at 05:15. Pt\n hyperdynamic with HR to 110, and sBP to 170\ns. VS decreased slightly\n but did not recover to goal.\n Action:\n Labetolol restarted at 05:30 at 2mg/min and increased to 3mg/min to\n decrease HR/BP. Calm, quiet environment with minimal stimulation\n promoted.\n Response:\n Pt requiring 3mg/min labetalol gtt to maintain goal BP <160 systolic.\n Pt occasionally still tachycardic to 105 at rest without stimulation.\n Plan:\n Attempt to decrease labetalol gtt as tolerated. Maintain sBP <160 and\n CPP >60.\n IV access!\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339616,
"text": "Patient is a 44 yo female s/p fall from standing, striking head\n directly. Sustained cerebellar and intraventricular hemorrhages. s/p\n craniotomy and evacuation . Neurological status remains poor at\n this time. Past medical hx includes kidney and pancreas txp >5yrs\n ago.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam remains poor, some minimal improvement noted w/ mild\n withdrawl from nailbed pressure to all but L arm. L arm continues to\n posture w/ any stimulation, posturing x4 extrem at rest noted as\n well. Gag and cough remain very poor, continues w/ hemodynamic\n autoregulatory deficit and central breathing pattern. Ventriculostomy\n w/ mod amts blood tinged drainage, icp\ns stable.\n Action:\n Hourly neuro exams continue, no sedation >24h as of current hour.\n Ventric drain open, 10cm above tragus. Low stimulation environment\n maintained, clustering of care helpful.\n Response:\n BP well controlled w/ labetolol infusion, titrated to goal sbp<160.\n Plan:\n Follow neuro exam ongoing, follow icp\ns, hemodynamics.\n Alkalosis, respiratory\n Assessment:\n d/t neurological damage, pt w/ central breathing pattern, hypocarbic.\n Ph wnl on abg\n Action:\n Remains intubated, on cpap+ps mode, 15 psv.\n Response:\n Despite changes to mech vent settings, breathing pattern unchanged,\n overcompensatory. Pco2 remains high 20s.\n Plan:\n Continue ventilation as per present, follow blood gases ongoing. Low\n stimulation ensured.\n Electrolyte & fluid disorder, other\n Assessment:\n Phos level 0.9 this am, k+ 3.8\n Action:\n Repleted lytes as per written orders.\n Response:\n K+ improved, wnl, phos remains low at 1.4\n Plan:\n Further po repletion given this pm, will follow.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Neurological exam poor, unable to maintain airway d/t TBI\n Action:\n Pt intubated, currently on cpap+ps mode, tol well.\n Response:\n Breathing evident of central pattern, tachypneic at times, consistently\n hypocarbic as result.\n Plan:\n Patient likely to take signif amt of time to recover from brain injury,\n likely will need tracheostomy for interim. Potentially scheduled for\n procedure Friday of this week.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340123,
"text": "TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1. 2. 3. 500 mL NS 4. Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Heparin 11. Insulin\n 12. Labetalol IV/PO 13. Levothyroxine Sodium 14. Magnesium Sulfate 15.\n Mycophenolate Mofetil 16. Neutra-Phos 17. Pantoprazole 18.\n Phenylephrine 19. Potassium Chloride 20. Potassium Phosphate 21. Senna\n 22. Sodium Chloride 0.9% Flush 23. Sodium Chloride 0.9% Flush 24.\n Sulfameth/Trimethoprim SS 25. Tacrolimus 26. Hydralazine prn\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 PM\n URINE CULTURE - At 12:24 PM\n BLOOD CULTURED - At 01:00 PM\n FEVER - 101.6\nF - 12:00 PM\n () Temp 101, blood/urine cx sent. Consented for Trach/PEG.\n Neurosurg raised drain to 15cm.\n Post operative day:\n POD#5 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 03:55 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:25 PM\n Pantoprazole (Protonix) - 06:00 PM\n Other medications:\n Flowsheet Data as of 04:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 37.3\nC (99.1\n HR: 83 (75 - 105) bpm\n BP: 105/49(72) {85/46(63) - 166/77(110)} mmHg\n RR: 23 (17 - 35) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 17 (10 - 18) mmHg\n Total In:\n 2,934 mL\n 384 mL\n PO:\n Tube feeding:\n 1,680 mL\n 280 mL\n IV Fluid:\n 804 mL\n 44 mL\n Blood products:\n Total out:\n 3,526 mL\n 675 mL\n Urine:\n 3,330 mL\n 630 mL\n NG:\n Stool:\n Drains:\n 196 mL\n 45 mL\n Balance:\n -592 mL\n -291 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 389 (331 - 400) mL\n PS : 15 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 48\n PIP: 21 cmH2O\n SPO2: 99%\n ABG: 7.43/32/185/20/-1\n Ve: 11.9 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), postures to painful stimuli\n UE, on LE- withdraws to painful stimuli\n Labs / Radiology\n 211 K/uL\n 13.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.3 mEq/L\n 19 mg/dL\n 107 mEq/L\n 136 mEq/L\n 41.5 %\n 8.9 K/uL\n [image002.jpg]\n 02:12 AM\n 01:12 PM\n 02:00 AM\n 02:21 AM\n 02:38 AM\n 07:43 AM\n 01:54 AM\n 01:59 AM\n 02:37 PM\n 02:07 AM\n WBC\n 10.2\n 9.2\n 8.9\n Hct\n 40.4\n 41.4\n 41.5\n Plt\n 199\n 187\n 211\n Creatinine\n 0.8\n 0.8\n 0.7\n TCO2\n 19\n 19\n 21\n 20\n 23\n 22\n Glucose\n 135\n 151\n 145\n 141\n 157\n Other labs: Amylase / Lipase:86/57, Lactic Acid:1.2 mmol/L, Ca:9.2\n mg/dL, Mg:1.9 mg/dL, PO4:2.0 mg/dL\n Imaging: CT head: No new regions of intracranial hemorrhage\n identified w/ stable appearance to R cerebellar hemorrhage and\n intraventricular hemorrhage. Decreased conspicuity to L frontal\n subarachnoid hemorrhage c/w evolving blood products.\n CT head:Interval decrease in size of R cerebellar hemorrhage\n postoperatively, w/expected pneumocephalus. R frontal approach drain\n terminates w/tip in 3rd ventricle, w/no evidence of ventriculomegaly.\n Unchanged size/appearance of small L frontal subarachnoid hemorrhage.\n CT Cspine: no acute fx; 3mm calcific density subjacent to\n anterior arch of C1 (stable from ), which may be dystrophic\n ligamentous calcification as there is no identifiable \"donor\" fracture\n site (FINAL)\n echo: EF >65%, 1+ TR, 1+ AR\n Microbiology: Blood cx, urine cx: P\n CSF cx: 2+PMNs, no orgs\n sputum cx: P\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w/occipital\n fx/cerebellar hematoma s/p drainage ()\n Neurologic: Neuro checks Q: 2 hr, ICP monitor, Ventriculostomy, Keep\n ICP <25, Neuro checks Q2hr, Ventriculostomy in\n place @15cm, draining.\n Cardiovascular: Beta-blocker, BP controlled with PO labetalol, prn\n hydralazine\n Pulmonary: (Ventilator mode: CPAP + PS), Trach today\n Gastrointestinal / Abdomen: PEG today\n Nutrition: NPO, TF held for Trach/PEG today\n Renal: Foley, Adequate UO, Tacrolimus 4mg q12h with qd levels in AM\n Hematology: hct stable\n Endocrine: RISS, s/p pancreas/renal transplant for DM1, off glycemic\n medications at home.\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n ------ Protected Section ------\n Pt seen and examined . Agree with the above. Plan for trach and PEG\n today. Time spent 31 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:26 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340580,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt was on Aerosol Cool Mist via Trach Mask for first half of\n shift. Pt then became tachypneic (RR=37) and desaturated. Pt was then\n placed on vent with CPAP/PSV settings. Due to persistent tachypnea,\n pt's pressure support was raised.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Comments: Pt had Pressure support raised to alleviate high RR\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Underlying illness not resolved; Comments: Pt to\n con't current support\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340682,
"text": "SICU\n HPI:\n HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR \nief complaint:\n IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n 1. 2. 3. 1000 mL NS 4. Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Heparin 11.\n HydrALAzine 12. Insulin 13. Labetalol\n 14. Levothyroxine Sodium 15. Magnesium Sulfate 16. Mycophenolate\n Mofetil 17. Pantoprazole 18. Potassium Chloride\n 19. Potassium Phosphate 20. Senna 21. Sodium Chloride 0.9% Flush 22.\n Sodium Chloride 0.9% Flush\n 23. Sulfameth/Trimethoprim SS 24. Tacrolimus 25. Tacrolimus\n 24 Hour Events:\n transferred to SICU from TICU\n Post operative day:\n POD#7 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Cefazolin - 03:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:37 PM\n Other medications:\n Flowsheet Data as of 10:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 37.3\nC (99.1\n HR: 81 (61 - 92) bpm\n BP: 145/56(83) {105/43(64) - 172/66(103)} mmHg\n RR: 28 (18 - 31) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 8 (8 - 16) mmHg\n Total In:\n 2,684 mL\n 861 mL\n PO:\n Tube feeding:\n 1,014 mL\n 754 mL\n IV Fluid:\n 1,450 mL\n 108 mL\n Blood products:\n Total out:\n 1,240 mL\n 806 mL\n Urine:\n 1,089 mL\n 770 mL\n NG:\n Stool:\n Drains:\n 151 mL\n 36 mL\n Balance:\n 1,444 mL\n 55 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 350 (282 - 350) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Agitated\n PIP: 16 cmH2O\n SPO2: 96%\n ABG: ///23/\n Ve: 11.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present), (Pulse -\n Posterior tibial: Present)\n Neurologic: Minimally responsive this AM, GCS 5\n Labs / Radiology\n 312 K/uL\n 13.9 g/dL\n 122\n 0.9 mg/dL\n 23 mEq/L\n 5.4 mEq/L\n 28 mg/dL\n 102 mEq/L\n 132 mEq/L\n 41.5 %\n 9.2 K/uL\n [image002.jpg]\n 01:54 AM\n 01:59 AM\n 02:37 PM\n 02:07 AM\n 06:19 AM\n 01:53 AM\n 02:13 AM\n 02:13 AM\n 09:00 AM\n 10:00 AM\n WBC\n 9.2\n 8.9\n 8.7\n 9.2\n Hct\n 41.4\n 41.5\n 40.4\n 41.5\n Plt\n 187\n 211\n 252\n 312\n Creatinine\n 0.8\n 0.7\n 0.9\n 0.9\n TCO2\n 23\n 22\n 25\n 24\n Glucose\n 145\n 141\n 157\n 126\n 157\n 130\n 122\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Ca:9.4\n mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45 year with IPH\n Neurologic: Neuro checks Q: 1 hr, ICP monitor, Ventriculostomy, ICP\n stable, currently around 12. Neurologic exam unchanged. F/u MRI done\n \n Cardiovascular: Labetalol for BP control\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean to TC as\n tolerated.\n Gastrointestinal / Abdomen: PEG-\n Nutrition: Tube feeding, @ goal\n Renal: Foley, Adequate UO, h/o renal and pancreas transplant\n Hematology: Stable\n Endocrine: RISS, h/o pancreas transplant\n Infectious Disease: on immunosuppresive drugs, and prophylaxis for h/o\n renal and kidney transplant\n Lines / Tubes / Drains: G-tube, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:31 AM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n"
},
{
"category": "General",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Generic Note",
"row_id": 340760,
"text": "TITLE:\n RESPIRATORY CARE: PT REMAINS W/ 8.0 PORTEX TRACH IN PLACE. PT APPEARED\n TO RESPOND THIS AM .\n PS 10/5 PEEP FIO2 .50 AND APPEARS COMFORTABLE. ICP ELEVATED TO 24 SO\n TRACH COLLAR ON HOLD.\n WILL C/W PS 10 AS TOLERATED UNTIL ICP RETURNS TO BASELINE OF 10. D/W\n RN.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 339720,
"text": "TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1. 2. 3. 500 mL NS 4. Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Heparin 11. Insulin\n 12. Labetalol 13. Levothyroxine Sodium 14. Magnesium Sulfate 15.\n Mycophenolate Mofetil 16. Neutra-Phos 17. Pantoprazole 18.\n Phenylephrine 19. Potassium Chloride 20. Potassium Phosphate 21. Senna\n 22. Sodium Chloride 0.9% Flush 23. Sodium Chloride 0.9% Flush\n 24. Sulfameth/Trimethoprim SS 25. Tacrolimus\n 24 Hour Events:\n MULTI LUMEN - START 11:50 AM\n triple lumen catheter placed\n CSF CULTURE - At 02:24 PM\n specimen taken by , PA-C\n SPUTUM CULTURE - At 08:40 PM\n () valgancyclovir d/c'd, IV drain at 10 cm,, R subclavian placed,\n SQH started, Tacro incr to 2mg q12h (level=2.2), sent sputum cx -\n purulent secretions, family agreed to trach / PEG - need consent,\n drainage from ventriculostomy redder in color\n Post operative day:\n POD 3 crani/evacuation hematoma\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Infusions:\n Labetalol - 1 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:26 PM\n Pantoprazole (Protonix) - 06:39 PM\n Other medications:\n Flowsheet Data as of 05:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 36.8\nC (98.2\n HR: 85 (74 - 98) bpm\n BP: 147/62(91) {124/55(79) - 161/67(102)} mmHg\n RR: 19 (19 - 28) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 15 (8 - 19) mmHg\n Total In:\n 2,801 mL\n 637 mL\n PO:\n Tube feeding:\n 1,660 mL\n 367 mL\n IV Fluid:\n 691 mL\n 269 mL\n Blood products:\n Total out:\n 2,113 mL\n 774 mL\n Urine:\n 1,898 mL\n 720 mL\n NG:\n Stool:\n Drains:\n 215 mL\n 54 mL\n Balance:\n 688 mL\n -137 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 400 (398 - 494) mL\n PS : 8 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 48\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.44/33/140/20/0\n Ve: 9.4 L/min\n PaO2 / FiO2: 350\n Physical Examination\n General Appearance: intubated\n postures to painful stimuli UE, on LE - withdraws to painful stimuli\n HEENT: pupils briskly reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases, bilateral)\n Abdominal: Soft, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli)\n Labs / Radiology\n 187 K/uL\n 13.4 g/dL\n 141 mg/dL\n 0.8 mg/dL\n 20 mEq/L\n 4.2 mEq/L\n 18 mg/dL\n 109 mEq/L\n 136 mEq/L\n 41.4 %\n 9.2 K/uL\n [image002.jpg]\n 09:04 PM\n 01:54 AM\n 02:12 AM\n 01:12 PM\n 02:00 AM\n 02:21 AM\n 02:38 AM\n 07:43 AM\n 01:54 AM\n 01:59 AM\n WBC\n 14.3\n 10.2\n 9.2\n Hct\n 44.1\n 40.4\n 41.4\n Plt\n \n Creatinine\n 1.0\n 0.8\n 0.8\n TCO2\n 16\n 19\n 19\n 21\n 20\n 23\n Glucose\n 130\n 135\n 151\n 145\n 141\n Other labs: Lactic Acid:1.2 mmol/L, Ca:8.8 mg/dL, Mg:2.0 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w/occipital\n fx/cerebellar hematoma s/p drainage ()\n Neurologic: Neuro checks Q: 1 hr, ICP monitor, Ventriculostomy, Keep\n ICP <25, Neuro checks Q1hr, Ventriculostomy in place @10cm, draining.\n Cardiovascular: Hemodynamically stable, on labatelol gtt: target SBP <\n 160, CPP > 60.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Tolerating pressure\n support .\n Gastrointestinal / Abdomen: *Need consent for trach/PEG from family -\n (brother) - coming *\n Nutrition: Tube feeding, TF (replete w/fiber FS - goal 70cc/hr)\n Renal: Foley, Adequate UO, Foley, Adequate UO. Tacrolimus 2mg q12h with\n qd levels in AM\n Hematology:\n Endocrine: RISS, s/p pancreas/renal transplant for DM1, off glycemic\n medications at home. RISS\n Infectious Disease: monitor WBC, afebrile. F/U sputum and CSF cx. On\n Ancef Q12 for prophylaxis\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:34 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340245,
"text": "47 yo s/p ICH and occipital skull fx. after fall backwards.\n Ventriculostomy drain placed, 15cm above ear, neuro exam poor.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n No cough or gag, pt. sx. For thick white secretions.\n Action:\n Trach @ bedside today, pt. sx. For thick bloody secretions.\n Response:\n Ls clear bilat\n Plan:\n Continue ventilation, wean vent settings.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Ventriculostomy drain in place 15cm above ear, draining blood-tinged\n CSF. 2 episodes of bradycardia to 30\ns with movement and suctioning.\n Pt. recovers quickly without interventions. Pt. unresponsive, PERRL @\n 3mm bilat, no cough or gag, withdraw to pain with upper extremities at\n times, withdraws to pain in lower extremities consistently. ICP\n occasionally over 290 with stimulation.\n Action:\n Head CT this afternoon results pending.\n Response:\n Neuro exam remains poor, CSF remains blood-tinged\n Plan:\n Continue neuro checks q2, ICP\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339716,
"text": "45F.y.f. s/p fall backward from standing, w occipital fx & cerebellar\n hematoma, s/p crani/evacuation (), now POD 4.\n Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n bleed\n Action:\n Labetalol drip continues\n Response:\n SBP < 160 (goal), CPP > 60\n Plan:\n Titrate labetalol to maintain SBP < 160 and CPP > 60.\n Alkalosis, respiratory secondary to central neurological breathing\n pattern.\n Assessment:\n Patient continues to be hypocarbic.\n Action:\n Wean pressure support\n Response:\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated\n Altered mental status (not Delirium) s/p cerebellar parenchymal\n hemorrhage, frontal SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy\n Response:\n Patient unresponsive. ICPs remain <20.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for prophylaxis.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340572,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n S/P trach , tolerating trach mask well for most of shift. This am pt\n becoming increasingly tachpnic and Sat decreased to 91%. LS remain\n clear.\n Action:\n Pt suctioned for scant amount blood tinged secretions. Pt placed back\n on vent, CPAP 5/10/50%.\n Response:\n RR down to 24 and sat up to 100%. Pt seems to be tolerating better.\n Plan:\n Wean to TM in am as tolerated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam unchanged. Occasionally pt will open eyes to voice and\n spontaneously. Withdrawing to all four extremities. Pupils equal and\n reactive. Ventricular drain 15cm/tragus. Open to drain. ICP 13-20.\n Action:\n Q 2 hour neuro exam.\n Response:\n Unchanged exam\n Plan:\n Cont to monitor for neuro changes.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340631,
"text": "NPN (NOC): Pt transferred to SICU from T-SICU ~ 4am. Briefly, Pt is a\n 45 y/o woman s/p kidney/pancreas transplant in for IDDM who was\n doing well until when she fell backwards while walking a dog,\n sustaining a skull fx w/ ICH, edema and shift. She has undergone a\n craniotomy and ventriculostomy drain as well as trach/PEG. Latest CT\n shows new infarcts in vertebral artery distribution but less edema and\n mass effect. Nuero exam is quite limited (see flowsheet). Vent drain\n put out 20 cc\ns since adm to Sicu and ICP\ns 13-14 (goal under 20). Tol\n TM trial well yesterday and rested overnoc. Is hemodynamically stable.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342291,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342303,
"text": "Tachycardia, Other\n Assessment:\n HR 80-120s. tachycardic episodes transiently through out night both\n when pt anxious and at complete rest.\n Action:\n No betablockers given, SICU resident made aware.\n Response:\n Pt resolved episodes on her own.\n Plan:\n Cont to monitor hemodynamics. Betablocker available if pt tachycardic\n for extended periods of time.\n Altered mental status (not Delirium)\n Assessment:\n Pt more lethargic tonight. Not following any commands through out\n shift. Opened eyes occasionally spontaneously, mostly to pain/noxious\n stimuli. MAE on bed except for LUE. Some purposeful movement noted. Pt\n appears more restless/agitated than moving purposefully.\n Action:\n Neuro checks q 2.\n Response:\n Pt continued to have unimpressive neuro exams. SICU resident\n Dr. made aware.\n Plan:\n Monitor neuro status closely\nq 2 exams. If pt cont decrease in MS,\n ?repeat CT.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade fevers 99-100.9.\n Action:\n 650mg PO acetaminophen given x1. Cold bath given.\n Response:\n Minimal effects from bathing/ antipyretics. Pt broke to temp of 99\n later in shift.\n Plan:\n Cont to monitor for fever, s/s worsening infection.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342385,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro status waxes & wanes; pt more alert this afternoon with period of\n following commands, but reverts to being unarousable. Withdrawls all\n extremities to nailbed pressure. Pupils 3-4 mm equal and reactive, R\n pupil sluggish at times. Absent gag, impaired cough.\n Action:\n Assess neuro status q2\n Response:\n No change in neuro status\n Plan:\n Continue to assess neuro status q2\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Trach & PEG, copious secretions noted in mouth, thick green sputum\n suctioned from trach. TF infusing as ordered. Pt weaned from vent,\n currently on trach collar, ABG WNL. Lungs coarse upper lobes, decreased\n at bases.\n Action:\n Suction prn, administer TF as ordered.\n Response:\n O2 sats > 96%, RR 20-30, ABG WNL.\n Plan:\n Monitor respiratory status, draw ABGs as indicated, suction prn.\n Tachycardia, Other\n Assessment:\n HR 120s, no signs/symptoms of pain\n Action:\n 25 mcgs fentanyl IV given as ordered without effect on HR, 5 mg\n lopressor IV given as ordered\n Response:\n HR low 100s\n Plan:\n Continue to monitor HR, VS\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Black tarry stool\n Action:\n Assess HCT, assess stool output, assess GI status, assess for other\n sites of bleeding\n Response:\n No change in melena\n Plan:\n Continue to assess GI status, assess HCT, assess stool output.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341096,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.3 continues w copious thick tan secretions. Sputum cult + for\n gm neg rods. +wbc in csf sample .\n Action:\n Tylenol pr as ordered given x 1 overnight. Aggressive pulm toilet w\n freq suct and vap protocol maintained.Vanco, flagyl, cipro started on\n . Cefazolin & bactrum continue.\n Response:\n Continues to have intermittent fever spikes over 101. w temps sbp\n dipped w cpp < 60 requiring resuming neo early am.\n Plan:\n Tylenol prn as ordered for temp over 101, Check w team re: reculture.\n Cont aggressive pulm toilet. Check for finalized culture results and\n sensitivities.\n Altered mental status (not Delirium)\n Assessment:\n Neuro exam essent unchanged, no gag, no corneals, impaired gag. Opens\n eyes spontaneously, not to stimuli or command. Minimal flexion and\n withdraw to pain of lower extrems, no movement upper extremeties.\n Action:\n Neuro vs q2h. CT scan done \n Response:\n No change in neuro vs. CT results pending, prelim report in careweb.\n Plan:\n Continue to monitor for any changes in neuro vs and report any changes\n to team.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt. unable to clear copious oral and tracheal secretions d/t alt cough\n and no gag reflex.\n Action:\n Suctioned q1h and prn for desats to 91%. Fio2 incr to 60% after suct\n failed to consistently maintain sats>92%\n Response:\n O2 sats 98% on fio2 60% cpap ps15 peep 5. stv 380-400. Suct for copious\n thick tan secretions\n Plan:\n Cont. w aggressive pulm toilet and vap bundle. Reattempt wean ps and\n fio2 once sao2 stabilizes and secretions decreased.\n Hypertension, benign\n Assessment:\n Labile bp hypo-> hypertension. Initially on low dose neo. Weaned neo\n off and htn persisted\n Action:\n Labetolol 10mg iv x2 for tachycardia/htn and hydralazine 10mg iv x 1\n Response:\n sbp improved < 180.\n Plan:\n Rx sbp > 180 prn as ordered w labetolol if assoc w tachycardia. Rx sbp\n >180 w hydralazine if hr wnl.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Evd at 20cm at tragus for cerebral edema. Neuro exam unchanged\n Action:\n Draining clear drainage 0-15cc/hr . titrating neo to goal cpp > 60 sbp\n <180\n Response:\n No improvement in neuro exam. Cefazolin continues while vent drain in\n place.\n Plan:\n Check w neuro team re: readjust level icp drain in view of continued\n cerebral edema and unchanged neuro status.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342280,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Flexiseal draining black liquid stool\n Action:\n Assess HCT lab results, assess amount of stool draining, assess VS\n Response:\n No change\n Plan:\n Continue to assess HCT results, VS, stool output\n Hypotension (not Shock)\n Assessment:\n Pt MAP <80\n Action:\n Phenylneprine gtt infusing at 0.5 mcg/kg/min\n Response:\n MAP >80\n Plan:\n Continue to assess BP, VS\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG, copious clear secretions in mouth; thick, white\n secretions from trach, pt desat to 80s, suctioned for thick white\n secretions; lung coarse, RR 20-30.\n Action:\n Pt remained on CPAP & PS 12\n Response:\n O2 sat > 94%\n Plan:\n Wean vent as tolerated, assess lung sounds, suction prn.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342278,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342279,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Flexiseal draining black liquid stool\n Action:\n Assess HCT lab results, assess amount of stool draining, assess VS\n Response:\n No change\n Plan:\n Continue to assess HCT results, VS, stool output\n Hypotension (not Shock)\n Assessment:\n Pt MAP <80\n Action:\n Phenylneprine gtt infusing at 0.5 mcg\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342426,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt had semiformed, brown stool forcing out her flexiseal ~2400 this AM.\n Several medium sized semi-formed, soft brown stools through out shift.\n Does not appear melanotic. Abd soft distended.\n Action:\n TF cont at 50cc/h. Colace held this evening. Unable to contain stool\n using pouch/device d/t consistency of stool.\n Response:\n Pt continuing to stool ~q2.\n Plan:\n Monitor for s/s GIB. Contain stool. Skincare/ breakdown prevention.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats 96-100. LS clear-rhonchorus. RR 16-20s. Pt on trach collar all\n night, 50% Fi02.\n Action:\n Suctioned for thick green secretion through out shift. ABG drawn with\n AM labs.\n Response:\n LS cleared with suctioning. ABGs WNL. Pt appeared comfortable with no\n s/s distress.\n Plan:\n Cont trach collar\nmaintain pt status off vent. Monitor ABGs. Cont\n suctioning PRN. Trach care.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342143,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Green / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: shallow, occas tachypnea\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: trach mask trials\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342583,
"text": "Hypotension (not Shock)\n Assessment:\n Pt BP drifted from 160s systolically to 80s at start of shift, u/o\n dropped off to 19-25cc/hr\n Action:\n Given 500 NS bolus\n Response:\n SBP back into 100-140s, u/o improved\n Plan:\n Monitor BPs, pt has been labile\n Altered mental status (not Delirium)\n Assessment:\n Pt less responsive whwn BP low into 80s/40s. Required deep sternal rub\n to elicit response. No spontaneous movement noted in extremities during\n this episode\n Action:\n Pt bloused for low BP, frequent neuro checks, NSURG up to assess\n patient\n Response:\n Pt with increased responsiveness when BP elevated\n Plan:\n Continue to follow neuro exams\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 342650,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR done\n -Pt with fever, Pan cultured. Labetalol decreased back to 100 tid as\n pt hypotensive\n -Labile BP overnight, resp distress. placed on AC by RT\n - allowed to autoregulate, consulted orthopedics for arm fracture,\n following urine/serum osmoles\n -started lasix/albumin and Neo to maintain SBP>100. Neuro status:\n responding to verbal commands. Labetalol prn for HTN/tachy responds\n well.\n - Continues to have fevers. Ventriculostomy clamped, call NS if ICP\n >30.\n - afebrile until midnight, PO Vanc started for suspected CDiff,\n CDiff sent, tacro adjusted, four hours of trach collar, CVL placed\n without incidient in LSC, reduced to a pressure support of five\n : stopped vanco\n .\n Chief complaint:\n IPH, Respiratory Failure\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n 1. 2. 3. 500 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Heparin 11. 12.\n Insulin 13. Levothyroxine Sodium\n 14. LeVETiracetam 15. Magnesium Sulfate 16. MetRONIDAZOLE (FLagyl) 17.\n Metoprolol Tartrate 18. Midodrine\n 19. Mycophenolate Mofetil 20. Pantoprazole 21. Phenylephrine 22.\n Potassium Chloride 23. Potassium Phosphate\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Sodium Chloride 0.9% Flush\n 28. Sulfameth/Trimethoprim SS 29. Tacrolimus Suspension\n 24 Hour Events:\n PICC LINE - START 06:25 PM\n stopped vanco as cultures not speciating at this time, adjusted tacro\n dosing, no acute events overnight\n Post operative day:\n POD#18 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 06:28 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 08:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.6\nC (99.7\n HR: 113 (74 - 126) bpm\n BP: 156/67(84) {84/30(49) - 171/97(127)} mmHg\n RR: 28 (18 - 36) insp/min\n SPO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 82.7 kg (admission): 81.5 kg\n Height: 60 Inch\n CVP: 13 (3 - 18) mmHg\n Total In:\n 2,832 mL\n 890 mL\n PO:\n Tube feeding:\n 1,442 mL\n 607 mL\n IV Fluid:\n 1,090 mL\n 253 mL\n Blood products:\n Total out:\n 2,359 mL\n 1,155 mL\n Urine:\n 2,159 mL\n 1,155 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 473 mL\n -264 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SPO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), No(t)\n Moves all extremities, (RUE: Weakness), (LUE: Weakness), (RLE:\n Weakness), (LLE: Weakness)\n Labs / Radiology\n 362 K/uL\n 9.1 g/dL\n 136 mg/dL\n 0.7 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 21 mg/dL\n 105 mEq/L\n 137 mEq/L\n 27.9 %\n 7.4 K/uL\n [image002.jpg]\n 02:09 PM\n 04:17 AM\n 04:32 AM\n 06:50 PM\n 02:53 AM\n 02:48 PM\n 06:41 PM\n 02:10 AM\n 02:21 AM\n 02:38 AM\n WBC\n 14.3\n 12.1\n 6.7\n 7.4\n Hct\n 29.8\n 28.1\n 27.3\n 27.9\n Plt\n 556\n 461\n 358\n 362\n Creatinine\n 0.9\n 0.8\n 0.8\n 0.7\n TCO2\n 21\n 25\n 22\n 23\n 23\n 25\n Glucose\n 118\n 129\n 119\n 136\n Other labs: PT / PTT / INR:13.9/24.8/1.2, Amylase / Lipase:123/116,\n Differential-Neuts:71.2 %, Lymph:24.5 %, Mono:2.9 %, Eos:1.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.3 g/dL, Ca:9.8 mg/dL, Mg:1.9 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma, s/p crani/evacuation (), PEG and trach.\n Currently stable BP and ICPs.\n Neurologic: Neuro checks Q: 1 hr, fentanyl for pain intermittently; CT\n head to be ordered for interval exam today\n Cardiovascular: Beta-blocker, has been stable hemodynamically\n Pulmonary: Trach, continue on trach collar today\n Gastrointestinal / Abdomen: g-tube in place\n Nutrition: Tube feeding, Tolerating replete @ 70cc/hr (goal) - will\n continue\n Renal: Foley, Adequate UO, patient has continued with adequate urine\n output spontaneously\n Hematology: Serial Hct, stable at 28 - no melenic stools over night\n Endocrine: RISS\n Infectious Disease: Check cultures, continue to follow culture data,.\n Flagyl for CDIFF + \n Lines / Tubes / Drains: Foley, G-tube, Trach, aline d/c'ed overnight\n for lack of need - will d/c CVL as well\n Wounds: Dry dressings, no wounds that require chronic concern\n Imaging: CT scan head today, interval Head CT today\n Fluids: KVO\n Consults: Neuro surgery, GI\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure),\n Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:31 PM 70 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 06:47 PM\n PICC Line - 06:25 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Rehab Services",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 342653,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: fall / e888.9\n Reason of referral: Eval and Rx\n History of Present Illness / Subjective Complaint: 45 f adm s/p\n fall while walking dog, + hit head. Head CT at OSH showed IPH,\n occipital fx. Tx to . Repeat CT showed increased mass effect,\n hemmorhage and hydrocephalus with ? small SAH. Intubated, EVD placed.\n S/p suboccipital craniotomy .Trach and Peg placed. Cdiff +. Weaned\n to trach collar . Drain d/c'd .\n Past Medical / Surgical History: ESRD DM1 s/p LURT , cadaveric\n panc tx , CMV pancytopenia, hypothyroid, restless leg syndrome,\n flow-related heart murmer, L tib fib orif, B breast lumpectomies, laser\n surgery for retinopathy\n Medications: acetaminophen, fentanyl, insulin, labetalol,\n Radiology:\n Labs:\n 27.9\n 9.1\n 362\n 7.4\n [image002.jpg]\n Other labs:\n Activity Orders: OOB by RN, keep MAP >70\n Social / Occupational History: lives with 2 young children (5&6),\n husband recently passed away.\n Living Environment: unclear\n Functional Status / Activity Level: I PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: Opens eyes to stimuli,\n not tracking, not following commands.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 84\n 103/44\n 20\n 100% on 50%tm\n Rest\n /\n Sit\n 86\n 116/67\n 20\n 99% on 50%tm\n Activity\n /\n Stand\n /\n Recovery\n 71\n 110/46\n 20\n 99% on 50%tm\n Total distance walked:\n Minutes:\n Pulmonary Status: Trached. Even coordinated breathintg pattern.\n Integumentary / Vascular: Trached, foley, L hand splint, Peg. No areas\n of breakdown noted.\n Sensory Integrity: withdraws to pain all four extremities\n Pain / Limiting Symptoms: limited by mental status\n Posture: received supine in bed\n Range of Motion\n Muscle Performance\n WFL throughout\n Some RLE movement on the bed, otherwise, no active movement noted.\n Motor Function: Mild L adductor tone. + clonus BLE, non-sustained \n beat.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: N/A\n Rolling:\n Max x 2\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n Max x 2\n\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: No postural response at the edge of the bed. Sat EOB x 10\n minutes\n Education / Communication: Pt ed: role of PT. Case discussed with RN.\n Intervention: ROM to all extremities, Low level coma stimulation.\n Other:\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Balance, Impaired\n 3.\n Knowledge, Impaired\n 4.\n Motor Function, Impaired\n 5.\n Muscle Performace, Impaired\n 6.\n Transfers, Impaired\n Clinical impression / Prognosis: 45 f with IPH s/p evacuation presents\n with above impairments consistent with non-progressive CNS disorder.\n She is opening her eyes and per report intermittently following\n commands. She will require extensive neuro rehab. Positive prognostic\n indicators include age, prior level of functioning. Negative include\n extensive pmh. Recommend increasing pts activity throughotu the day to\n include dependent transfer to chair and normalizing day/night cycle.\n Goals\n Time frame: 2 weeks\n 1.\n Follow simple appendicular commands 25% of treatment\n 2.\n Track B\n 3.\n Open eyes to name\n 4.\n Sit EOB with mod A x 5 minutes\n 5.\n Move BLE\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-3x/wk x 2 wks\n Low level coma stimulation, Mobility/EOB training, ROM, therex/LE\n strengthening, D/C planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342189,
"text": "SICU\n HPI:\n HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Tachycardia, Other\n Assessment:\n Tachy to 120-130s, SBP labile 80s-90s.\n Action:\n Lopressor 5mg IV, placed back on Neo gtt.\n Response:\n HR 80s-90s. MAP 75-80 on Neo gtt.\n Plan:\n Continue to monitor, wean Neo as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic to high 30s-40s, sats 93-95% , volumes dropping slightly.\n Pt. appearing more labored.\n Action:\n Placed back on CPAP with PS of 12, suctioned for thick yellow sputum.\n Response:\n RR 27, appearing more comfortable. Sats improved.\n Plan:\n Continue to monitor, wean to trach collar in am.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342732,
"text": "Tachycardia, Other\n Assessment:\n HR 120s\n Action:\n 5 mg lopressor IV given q 6 prn\n Response:\n HR 90s\n Plan:\n Continue to monitor VS, decrease stimulation\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG. Trach collar in place with O2 infusing at 50%.\n Absent gag, impaired cough. Thick green sputum noted via ETT. Tube\n feeds infusing at 70 cc/hr.\n Action:\n Suction ETT prn, administer TF as ordered, q 2 neuro checks.\n Response:\n O2 sats maintained > 96%, RR 20-30\n Plan:\n Continue to assess VS, wean O2 as tolerated, suction prn, continue q 2\n neuro checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arouses to voice, pupils 3 mm equal & reactive. RUE lifts and falls\n back, other extremities weaker, but pt able to move spontaneously.\n Follows commands inconsistently. Denies pain by nodding head\n questions re: pain. Calm & cooperative with care.\n Action:\n Assess neuro status q2\n Response:\n Slight improvement noted in neuro status\n Plan:\n Continue to assess neuro status q2\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342186,
"text": "Demographics\n Day of mechanical ventilation: 16\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Pt was on CPAP/PS at start of shift. Called to increase PSV level to\n keep RR in the 20s. PS increased to 12. AM RSBI-86\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342187,
"text": "Tachycardia, Other\n Assessment:\n Tachy to 120-130s, SBP labile 80s-90s.\n Action:\n Lopressor 5mg IV, placed back on Neo gtt.\n Response:\n HR 80s-90s. MAP 75-80 on Neo gtt.\n Plan:\n Continue to monitor, wean Neo as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic to high 30s-40s, sats 93-95% , volumes dropping slightly.\n Pt. appearing more labored.\n Action:\n Placed back on CPAP with PS of 12, suctioned for thick yellow sputum.\n Response:\n RR 27, appearing more comfortable. Sats improved.\n Plan:\n Continue to monitor, wean to trach collar in am.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342270,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nutrition",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 342352,
"text": "Subjective\n Pt waxing/\n Objective\n Labs:\n Value\n Date\n Glucose\n 129 mg/dL\n 02:53 AM\n Glucose Finger Stick\n 133\n 04:00 PM\n BUN\n 22 mg/dL\n 02:53 AM\n Creatinine\n 0.8 mg/dL\n 02:53 AM\n Sodium\n 135 mEq/L\n 02:53 AM\n Potassium\n 3.8 mEq/L\n 02:53 AM\n Chloride\n 105 mEq/L\n 02:53 AM\n TCO2\n 24 mEq/L\n 02:53 AM\n PO2 (arterial)\n 99. mm Hg\n 02:48 PM\n PCO2 (arterial)\n 34 mm Hg\n 02:48 PM\n pH (arterial)\n 7.43 units\n 02:48 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 02:48 PM\n Albumin\n 3.9 g/dL\n 04:02 AM\n Calcium non-ionized\n 9.8 mg/dL\n 02:53 AM\n Phosphorus\n 2.9 mg/dL\n 02:53 AM\n Ionized Calcium\n 1.19 mmol/L\n 02:09 PM\n Magnesium\n 1.9 mg/dL\n 02:53 AM\n Amylase\n 123 IU/L\n 02:53 AM\n WBC\n 12.1 K/uL\n 02:53 AM\n Hgb\n 9.5 g/dL\n 02:53 AM\n Hematocrit\n 28.1 %\n 02:53 AM\n Current diet order / nutrition support: FS Replete w/ Fiber@ 50cc/hr\n GI: Abd soft/dist/+flatus/ (+) BS\n Assessment of Nutritional Status\n Pt S/P fall, w/ ICH, S/P PEG/trach, monitoring neurological status. On\n TF currently @ 50cc/hr, tol well without issues. Na improving (was 129,\n rec trial of different TF formula) but slowly improving now. Noted BUN\n decreasing.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. c/w TF: FS Replete w/ Fiber @70cc/hr to provide 1680kcals and\n 104g prot/day to meet 100% of est. needs.\n 2. Check residual q4-6hrs, hold TF if >150cc\n 3. Continue to monitor lytes.\n 4. Monitor hydration status.\n Will f/u with progress.\n Pls pge w/ issues/concerns #\n 16:10\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341511,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolyte lab results\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. ICP 12-16. Pupils equal and reactive, withdrawls extremities\n to nailbed pressure, does not follow commands, opens eyes\n spontaneously.\n Action:\n Assess neuro status q2, assess ventricular drainage, monitor ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, monitor ICP\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach, on ventilator CPAP & PS 15, 40% FiO2, 5 PEEP, tidal\n volumes approx 400. O2 sats 93%-94%, RR 20-30. PEG tube with replete\n with fiber tube feeds infusing at 50 cc/hr.\n Action:\n ETT suctioned for small amounts of thick yellow sputum q 2-3 hrs. Mouth\n suctioned for copious amounts of clear secretions.\n Response:\n O2 sats maintained >93%\n Plan:\n Continue to suction prn, assess lung sounds, assess VS.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 342766,
"text": "Tachycardia, Other\n Assessment:\n HR 120s\n Action:\n 5 mg lopressor IV given q 6 prn\n Response:\n HR 90s\n Plan:\n Continue to monitor VS, decrease stimulation\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG. Trach collar in place with O2 infusing at 50%.\n Absent gag, impaired cough. Thick green sputum noted via ETT. Tube\n feeds infusing at 70 cc/hr.\n Action:\n Suction ETT prn, administer TF as ordered, q 2 neuro checks.\n Response:\n O2 sats maintained > 96%, RR 20-30\n Plan:\n Continue to assess VS, wean O2 as tolerated, suction prn, continue q 2\n neuro checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arouses to voice, pupils 3 mm equal & reactive. RUE lifts and falls\n back, other extremities weaker, but pt able to move spontaneously.\n Follows commands inconsistently. Denies pain by nodding head\n questions re: pain. Calm & cooperative with care.\n Action:\n Assess neuro status q2\n Response:\n Slight improvement noted in neuro status\n Plan:\n Continue to assess neuro status q2\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 342775,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Tachycardia, Other\n Assessment:\n HR 120s\n Action:\n 5 mg lopressor IV given q 6 prn\n Response:\n HR 90s\n Plan:\n Continue to monitor VS, decrease stimulation\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG. Trach collar in place with O2 infusing at 50%.\n Absent gag, impaired cough. Thick green sputum noted via ETT. Tube\n feeds infusing at 70 cc/hr.\n Action:\n Suction ETT prn, administer TF as ordered, q 2 neuro checks.\n Response:\n O2 sats maintained > 96%, RR 20-30\n Plan:\n Continue to assess VS, wean O2 as tolerated, suction prn, continue q 2\n neuro checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arouses to voice, pupils 3 mm equal & reactive. RUE lifts and falls\n back, other extremities weaker, but pt able to move spontaneously.\n Follows commands inconsistently. Denies pain by nodding head\n questions re: pain. Calm & cooperative with care.\n Action:\n Assess neuro status q2\n Response:\n Slight improvement noted in neuro status\n Plan:\n Continue to assess neuro status q2\n Demographics\n Attending MD:\n \n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 81.5 kg\n Daily weight:\n 82.7 kg\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: ESRD r/t uncontrolled DM I , renal transplant ,\n pancreas transplant \n recent left wrist fracture - casted at this time (cast d/c'd on\n )\n Surgery / Procedure and date: - Craniotomy\n trach and peg\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:125\n Temperature:\n 100.3\n Arterial BP:\n S:152\n D:66\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 125 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 99% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,996 mL\n 24h total out:\n 3,135 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:38 AM\n Potassium:\n 3.9 mEq/L\n 02:38 AM\n Chloride:\n 105 mEq/L\n 02:38 AM\n CO2:\n 22 mEq/L\n 02:38 AM\n BUN:\n 21 mg/dL\n 02:38 AM\n Creatinine:\n 0.7 mg/dL\n 02:38 AM\n Glucose:\n 136 mg/dL\n 02:38 AM\n Hematocrit:\n 27.9 %\n 02:38 AM\n Finger Stick Glucose:\n 141\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 1118\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 342776,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Tachycardia, Other\n Assessment:\n HR 120s\n Action:\n 5 mg lopressor IV given q 6 prn\n Response:\n HR 90s\n Plan:\n Continue to monitor VS, decrease stimulation\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG. Trach collar in place with O2 infusing at 50%.\n Absent gag, impaired cough. Thick green sputum noted via ETT. Tube\n feeds infusing at 70 cc/hr.\n Action:\n Suction ETT prn, administer TF as ordered, q 2 neuro checks.\n Response:\n O2 sats maintained > 96%, RR 20-30\n Plan:\n Continue to assess VS, wean O2 as tolerated, suction prn, continue q 2\n neuro checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arouses to voice, pupils 3 mm equal & reactive. RUE lifts and falls\n back, other extremities weaker, but pt able to move spontaneously.\n Follows commands inconsistently. Denies pain by nodding head\n questions re: pain. Calm & cooperative with care.\n Action:\n Assess neuro status q2\n Response:\n Slight improvement noted in neuro status\n Plan:\n Continue to assess neuro status q2\n Demographics\n Attending MD:\n \n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 81.5 kg\n Daily weight:\n 82.7 kg\n Allergies/Reactions:\n Codeine\n Nausea/Vomiting\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: ESRD r/t uncontrolled DM I , renal transplant ,\n pancreas transplant \n recent left wrist fracture - casted at this time (cast d/c'd on\n )\n Surgery / Procedure and date: - Craniotomy\n trach and peg\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:125\n Temperature:\n 100.3\n Arterial BP:\n S:152\n D:66\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 125 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Aerosol-cool\n O2 saturation:\n 99% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,996 mL\n 24h total out:\n 3,135 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:38 AM\n Potassium:\n 3.9 mEq/L\n 02:38 AM\n Chloride:\n 105 mEq/L\n 02:38 AM\n CO2:\n 22 mEq/L\n 02:38 AM\n BUN:\n 21 mg/dL\n 02:38 AM\n Creatinine:\n 0.7 mg/dL\n 02:38 AM\n Glucose:\n 136 mg/dL\n 02:38 AM\n Hematocrit:\n 27.9 %\n 02:38 AM\n Finger Stick Glucose:\n 141\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 1118\n Date & time of Transfer: \n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342502,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on 50% cool aerosol via trach mask , breath sounds\n essentially clear, suctioned for moderate thick pale-yellow secretions,\n SPO2 remains upper 90s, no respiratory distress occurred, will continue\n with routine trach check.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341510,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolyte lab results\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. ICP 12-16. Pupils equal and reactive, withdrawls extremities\n to nailbed pressure, does not follow commands, opens eyes\n spontaneously.\n Action:\n Assess neuro status q2, assess ventricular drainage, monitor ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, monitor ICP\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach, on ventilator CPAP & PS 15, 40% FiO2, 5 PEEP, tidal\n volumes approx 400. O2 sats 93%-94%, RR 20-30. PEG tube with replete\n with fiber tube feeds infusing at 50 cc/hr.\n Action:\n ETT suctioned for small amounts of thick yellow sputum q 2-3 hrs. Mouth\n suctioned for copious amounts of clear secretions.\n Response:\n O2 sats maintained >93%\n Plan:\n Continue to suction prn, assess lung sounds, assess VS.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342499,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arouses to voice, occasionally follows commands. Moves all\n extremities spontaneously. Pupils 3-4 mm equal and reactive.\n Occasionally denies pain by nodding\n. Increase in non-purposeful\n movement.\n Action:\n Assess neuro status q2\n Response:\n Slight improvement in neuro status\n Plan:\n Continue to assess neuro signs q2 hrs.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG, thick green sputum via trach, absent gag, impaired\n cough. On trach collar 50% FiO2 with RR 20-30 and O2 sats > 96%. Tube\n feeds infusing via PEG at 70 cc/hr. Lungs coarse upper lobes,\n decreased at bases.\n Action:\n suction prn, assess lung sounds, assess respiratory status.\n Response:\n Pt remains well ventilated on trach collar\n Plan:\n Continue to assess lung sounds, assess respiratory status, suction prn,\n administer tube feeds as ordered.\n Tachycardia, Other\n Assessment:\n HR 120s\n Action:\n Reposition pt, decrease stimulation, administer lopressor 5 mg IV q 6\n prn as ordered\n Response:\n HR 90s-low 100s\n Plan:\n Continue to assess HR, VS, decrease stimulation as necessary\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Black tarry stool noted this AM, HCT slowly decreasing\n Action:\n Guiac stool\n Response:\n Stool result: guiac +\n Plan:\n Continue to assess stool output, guiac stool, assess HCT results.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 342331,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Chief complaint:\n IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n IV access: Peripheral line Order date: @ 1829 15. Magnesium\n Sulfate IV Sliding Scale Order date: @ 1829\n 2. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 0955 16. MetRONIDAZOLE\n (FLagyl) 500 mg IV Q8H Order date: @ 0933\n 3. Acetaminophen 650 mg PO Q6H:PRN fever Order date: @ 1712 17.\n Metoprolol Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order date:\n @ 0543\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 1829 18.\n Midodrine 10 mg PO TID Order date: @ 1039\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 1829 19.\n Mycophenolate Mofetil 250 mg PO BID Order date: @ 1829\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1829 20. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO \n Order date: @ 1639\n 7. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1829 21.\n Potassium Chloride IV Sliding Scale Order date: @ 1829\n 8. Famotidine 20 mg IV Q12H Order date: @ 1145 22. Potassium\n Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0358\n 9. Fentanyl Citrate 25-50 mcg IV Q2H:PRN pain Order date: @ 2309\n 23. Senna 1 TAB PO BID:PRN Order date: @ 1829\n 10. IV access request: PICC Place, Restart Indication: Antibiotics\n Urgency: STAT Order date: @ 1550 24. Sodium Chloride 0.9% Flush 3\n mL IV PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1829\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0735 25. Sodium Chloride 0.9%\n Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1152\n 12. Labetalol 10 mg IV Q2H:PRN\n SBP>180 and HR>120 Order date: @ 2320 26. Sodium Chloride 0.9%\n Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 0955\n 13. Levothyroxine Sodium 100 mcg PO DAILY Order date: @ 1829 27.\n Sulfameth/Trimethoprim SS 1 TAB PO DAILY Order date: @ 1829\n 14. LeVETiracetam 500 mg PO BID Order date: @ 2034 28.\n Tacrolimus 2.5 mg PO Q12H\n Dose to be admin. at 6am and 6pm Order date: @ 0850\n 24 Hour Events:\n Post operative day:\n POD#16 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ciprofloxacin - 12:07 AM\n Vancomycin - 12:29 AM\n Metronidazole - 06:15 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:45 AM\n Other medications:\n Flowsheet Data as of 10:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.7\nC (99.8\n HR: 89 (76 - 130) bpm\n BP: 82/54(68) {75/50(63) - 173/118(122)} mmHg\n RR: 22 (17 - 32) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.5 kg (admission): 81.5 kg\n Height: 60 Inch\n CVP: 12 (6 - 31) mmHg\n Total In:\n 2,533 mL\n 1,154 mL\n PO:\n Tube feeding:\n 1,201 mL\n 507 mL\n IV Fluid:\n 702 mL\n 466 mL\n Blood products:\n Total out:\n 2,980 mL\n 1,520 mL\n Urine:\n 2,530 mL\n 1,520 mL\n NG:\n Stool:\n 450 mL\n Drains:\n Balance:\n -447 mL\n -366 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 320 (309 - 410) mL\n PS : 8 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 88\n PIP: 14 cmH2O\n SPO2: 98%\n ABG: 7.43/32/104/24/-1\n Ve: 7.3 L/min\n PaO2 / FiO2: 260\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n ), (Sternum: Stable )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Noxious stimuli, No(t) Unresponsive)\n Labs / Radiology\n 461 K/uL\n 9.5 g/dL\n 129 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 105 mEq/L\n 135 mEq/L\n 28.1 %\n 12.1 K/uL\n [image002.jpg]\n 03:00 AM\n 04:09 AM\n 04:15 AM\n 09:56 AM\n 10:00 AM\n 02:09 PM\n 04:17 AM\n 04:32 AM\n 06:50 PM\n 02:53 AM\n WBC\n 9.3\n 9.8\n 14.3\n 12.1\n Hct\n 29.7\n 29.4\n 28.8\n 29.8\n 28.1\n Plt\n 393\n 377\n 556\n 461\n Creatinine\n 0.9\n 0.9\n 0.9\n 0.8\n TCO2\n 22\n 21\n 25\n 22\n Glucose\n 131\n 112\n 129\n 142\n 118\n 129\n Other labs: PT / PTT / INR:13.9/24.8/1.2, Amylase / Lipase:113/98,\n Differential-Neuts:71.2 %, Lymph:24.5 %, Mono:2.9 %, Eos:1.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.9 g/dL, Ca:9.8 mg/dL, Mg:1.9 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, waxes and wanes, off\n sedation...poor prognosis\n Cardiovascular: neo prn for MAP>70; resite a-line\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), attempt to wean\n Gastrointestinal / Abdomen: tolerating feeds\n Nutrition: Tube feeding, replete w/fiber full at goal\n Renal: Foley, Adequate UO, autodiuresis, BUN and Na improving\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: flagyl for c diff (2 week course)\n Lines / Tubes / Drains: Foley, G-tube, Trach, central line, a-line\n Wounds: Dry dressings, staples removed\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis: (Hemorrhage, NOS), Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:27 AM 50.\n mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 04:35 PM\n 20 Gauge - 05:09 PM\n Multi Lumen - 06:47 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments: recommend to resume SQ heparin, if not recommend IVC filter\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342603,
"text": "Hypotension (not Shock)\n Assessment:\n Pt BP drifted from 160s systolically to 80s at start of shift, u/o\n dropped off to 19-25cc/hr\n Action:\n Given 500 NS bolus\n Response:\n SBP back into 100-140s, u/o improved\n Plan:\n Monitor BPs, pt has been labile\n Altered mental status (not Delirium)\n Assessment:\n Pt less responsive when BP low into 80s/40s. Required deep sternal rub\n to elicit response. No spontaneous movement noted in extremities during\n this episode\n Action:\n Pt bloused for low BP, frequent neuro checks, NSURG up to assess\n patient\n Response:\n Pt with increased responsiveness when BP elevated\n Plan:\n Continue to follow neuro exams\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342177,
"text": "Tachycardia, Other\n Assessment:\n Tachy to 120-130s, SBP labile 80s-90s.\n Action:\n Lopressor 5mg IV, placed back on Neo gtt.\n Response:\n HR 80s-90s. MAP 75-80 on Neo gtt.\n Plan:\n Continue to monitor, wean Neo as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic to high 30s-40s, sats 93-95% , volumes dropping slightly.\n Pt. appearing more labored.\n Action:\n Placed back on CPAP with PS of 12, suctioned for thick yellow sputum.\n Response:\n RR 27, appearing more comfortable. Sats improved.\n Plan:\n Continue to monitor, wean to trach collar in am.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 342478,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR done\n -Pt with fever, Pan cultured. Labetalol decreased back to 100 tid as\n pt hypotensive\n -Labile BP overnight, resp distress. placed on AC by RT\n - allowed to autoregulate, consulted orthopedics for arm fracture,\n following urine/serum osmoles\n -started lasix/albumin and Neo to maintain SBP>100. Neuro status:\n responding to verbal commands. Labetalol prn for HTN/tachy responds\n well.\n - Continues to have fevers. Ventriculostomy clamped, call NS if ICP\n >30.\n - afebrile until midnight, PO Vanc started for suspected CDiff,\n CDiff sent, tacro adjusted, four hours of trach collar, CVL placed\n without incidient in LSC, reduced to a pressure support of five\n : stopped vanco\n Chief complaint:\n IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n . 2. 3. Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Famotidine 9. Fentanyl Citrate 10.\n Heparin 11. 12. Insulin 13. Labetalol\n 14. Levothyroxine Sodium 15. LeVETiracetam 16. Magnesium Sulfate 17.\n MetRONIDAZOLE (FLagyl) 18. Metoprolol Tartrate\n 19. Midodrine 20. Mycophenolate Mofetil 21. Phenylephrine 22. Potassium\n Chloride 23. Potassium Phosphate\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Sodium Chloride 0.9% Flush\n 28. Sulfameth/Trimethoprim SS 29. Tacrolimus Suspension\n 24 Hour Events:\n ARTERIAL LINE - START 02:15 PM\n placed above old site, new stick\n ARTERIAL LINE - STOP 02:17 PM\n 100.7 overnight, melenic stools continue\n Post operative day:\n POD#17 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 12:29 AM\n Metronidazole - 05:58 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 11:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 37.1\nC (98.8\n HR: 108 (74 - 120) bpm\n BP: 158/76(108) {88/42(58) - 174/88(147)} mmHg\n RR: 28 (16 - 33) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83 kg (admission): 81.5 kg\n Height: 60 Inch\n CVP: 15 (5 - 30) mmHg\n Total In:\n 3,096 mL\n 941 mL\n PO:\n Tube feeding:\n 1,201 mL\n 559 mL\n IV Fluid:\n 855 mL\n 262 mL\n Blood products:\n Total out:\n 3,510 mL\n 1,055 mL\n Urine:\n 3,310 mL\n 855 mL\n NG:\n Stool:\n 200 mL\n 200 mL\n Drains:\n Balance:\n -414 mL\n -114 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 380 (336 - 380) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.40/39/103/25/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 206\n Physical Examination\n General Appearance: No acute distress, Well nourished, Overweight /\n Obese\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), No(t) Moves all extremities, (RUE:\n Weakness), (LUE: Weakness), (RLE: Weakness), (LLE: Weakness)\n Labs / Radiology\n 358 K/uL\n 9.2 g/dL\n 119 mg/dL\n 0.8 mg/dL\n 25 mEq/L\n 4.0 mEq/L\n 20 mg/dL\n 104 mEq/L\n 135 mEq/L\n 27.3 %\n 6.7 K/uL\n [image002.jpg]\n 10:00 AM\n 02:09 PM\n 04:17 AM\n 04:32 AM\n 06:50 PM\n 02:53 AM\n 02:48 PM\n 06:41 PM\n 02:10 AM\n 02:21 AM\n WBC\n 14.3\n 12.1\n 6.7\n Hct\n 29.8\n 28.1\n 27.3\n Plt\n 556\n 461\n 358\n Creatinine\n 0.9\n 0.8\n 0.8\n TCO2\n 21\n 25\n 22\n 23\n 23\n 25\n Glucose\n 142\n 118\n 129\n 119\n Other labs: PT / PTT / INR:13.9/24.8/1.2, Amylase / Lipase:123/116,\n Differential-Neuts:71.2 %, Lymph:24.5 %, Mono:2.9 %, Eos:1.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.9 g/dL, Ca:10.0 mg/dL, Mg:2.2 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, Pain controlled, pain well\n controlled; remove fentanyl; improving neurologic status - responding\n to name and able to minimally follow commands\n Notable for being the best day of neurologic function\n Cardiovascular: d/c labetalol and continue midodrine for MAP > 70 -\n will d/c neo; BP < 160/170\n Pulmonary: Trach, tolerating trach collar - for almost 24 hours\n Gastrointestinal / Abdomen: continued melenic stools, but\n hemodynamically stable with drifting hct - hct still stable and only\n requires daily maintenance -\n Nutrition: Tube feeding, tube feeds at goal; nutrtition lab\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, daily\n Endocrine: RISS\n Infectious Disease: Check cultures, stable - will continue to follow\n culture data; no current evidence of infection; ?need for IV flagyl for\n suspected CDiff\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today, viewed by SICU fellow\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Respiratory distress: Failure), Closed head injury,\n Other: GIBleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:22 AM 50.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 06:47 PM\n Arterial Line - 02:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin (will continue hep for dvt prophylaxis in\n setting of melenic stool - will consider serial hcts)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n"
},
{
"category": "Social Work",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Social Work",
"row_id": 342228,
"text": "TITLE:\n Family meeting held on with Attending, RN, pt\ns brother and\n sister and social work. Family encouraged by MD\ns medical update.\n Met with Brother and sister following the meeting to discuss how the\n children are coping with the hosp[tializaiton and planning for a\n meeting with the children as this hosptial course is expected to be\n lengthy with an ou\\unknown outcome. Discussed pt\ns parents and\n difficulties they are experiencing given the multiple[le medical\n problems that the pt has endured through out her life. Brother and\n sister requesting this worker meet with children to assess coping and\n make recommendations to the family in terms of supporting them.\n Brother has been working with pt\ns lawyer to obtain temporary\n guardianship of pt and children. SICU resident completed the medical\n portion of the guardianship papers. Guardianship documents faxed to\n pt\ns lawyer Mr. .\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 342229,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Chief complaint:\n ICH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n IV access: Peripheral line Order date: @ 1829 16. Metoprolol\n Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order date: @ 2036\n 2. Acetaminophen 650 mg PO Q6H:PRN fever Order date: @ 1712 17.\n Midodrine 10 mg PO TID Order date: @ 1039\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 1829 18.\n Mycophenolate Mofetil 250 mg PO BID Order date: @ 1829\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1829 19.\n Pantoprazole 40 mg IV Q12H Order date: @ \n 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1829 20. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO \n Order date: @ 1639\n 6. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1829 21.\n Potassium Chloride IV Sliding Scale Order date: @ 1829\n 7. Fentanyl Citrate 25-50 mcg IV Q2H:PRN pain Order date: @ 2309\n 22. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0358\n 8. IV access request: PICC Place, Restart Indication: Antibiotics\n Urgency: STAT Order date: @ 1550 23. Senna 1 TAB PO BID:PRN\n Order date: @ 1829\n 9. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0735 24. Sodium Chloride 0.9%\n Flush 3 mL IV PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1829\n 10. Labetalol 10 mg IV Q2H:PRN\n SBP>180 and HR>120 Order date: @ 2320 25. Sodium Chloride 0.9%\n Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1152\n 11. Levothyroxine Sodium 100 mcg PO DAILY Order date: @ 1829 26.\n Sulfameth/Trimethoprim SS 1 TAB PO DAILY Order date: @ 1829\n 12. LeVETiracetam 500 mg PO BID Order date: @ 2034 27.\n Tacrolimus 2.5 mg PO Q12H\n Dose to be admin. at 6am and 6pm Order date: @ 0850\n 13. Magnesium Sulfate IV Sliding Scale Order date: @ 1829 28.\n Vancomycin 750 mg IV Q 12H\n hold A.M dose...give PM dose Order date: @ \n 14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 0933 29.\n Vancomycin Oral Liquid 125 mg PO Q6H Order date: @ 1204\n 15. Metoprolol Tartrate 5 mg IV ONCE MR1 Duration: 1 Doses Order date:\n @ 1506\n 24 Hour Events:\n Post operative day:\n POD#15 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ciprofloxacin - 12:07 AM\n Vancomycin - 12:29 AM\n Metronidazole - 06:03 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 09:00 PM\n Pantoprazole (Protonix) - 09:00 AM\n Other medications:\n Flowsheet Data as of 11:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.9\nC (100.3\n HR: 76 (76 - 117) bpm\n BP: 94/75(87) {81/37(48) - 160/128(136)} mmHg\n RR: 23 (20 - 38) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 82.4 kg (admission): 81.5 kg\n Height: 60 Inch\n CVP: 8 (2 - 12) mmHg\n Total In:\n 2,587 mL\n 1,199 mL\n PO:\n Tube feeding:\n 1,201 mL\n 578 mL\n IV Fluid:\n 816 mL\n 350 mL\n Blood products:\n Total out:\n 3,045 mL\n 1,100 mL\n Urine:\n 3,045 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -458 mL\n 99 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 443 (373 - 443) mL\n PS : 12 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 86\n PIP: 18 cmH2O\n SPO2: 98%\n ABG: 7.44/35/90./22/0\n Ve: 10 L/min\n PaO2 / FiO2: 225\n Physical Examination\n Labs / Radiology\n 556 K/uL\n 10.0 g/dL\n 118 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 102 mEq/L\n 134 mEq/L\n 29.8 %\n 14.3 K/uL\n [image002.jpg]\n 05:30 PM\n 09:39 PM\n 03:00 AM\n 04:09 AM\n 04:15 AM\n 09:56 AM\n 10:00 AM\n 02:09 PM\n 04:17 AM\n 04:32 AM\n WBC\n 12.6\n 9.3\n 9.8\n 14.3\n Hct\n 31.1\n 28.3\n 29.7\n 29.4\n 28.8\n 29.8\n Plt\n 433\n 393\n 377\n 556\n Creatinine\n 0.9\n 0.9\n 0.9\n TCO2\n 22\n 21\n 25\n Glucose\n 131\n 112\n 129\n 142\n 118\n Other labs: PT / PTT / INR:14.0/23.2/1.2, Amylase / Lipase:113/98,\n Differential-Neuts:71.2 %, Lymph:24.5 %, Mono:2.9 %, Eos:1.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.9 g/dL, Ca:10.2 mg/dL, Mg:2.0 mg/dL, PO4:3.0\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, unresponsive to pain\n Cardiovascular: Beta-blocker, on neo\n Pulmonary: Trach, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: none\n Nutrition: replete w/fiber 50cc/hr\n Renal: Foley, Adequate UO, nephrology following for renal tp--daily\n tacro levels\n Hematology: stable\n Endocrine: RISS, glc stable\n Infectious Disease: cdiff +, tx with vanco PO, IV flagyl, IV vanco--for\n presumed pneumonia\n Lines / Tubes / Drains: Foley, Trach, LSC, R a line\n Wounds: sutures and staples to be removed today\n Imaging: CXR today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure),\n Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:31 AM 50.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:35 PM\n 20 Gauge - 05:09 PM\n Multi Lumen - 06:47 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342171,
"text": "Demographics\n Day of mechanical ventilation: 16\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Pt was on CPAP/PS at start of shift. Called to increase PSV level to\n keep RR in the 20s. PS increased to 12.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342150,
"text": "Hypertension, benign\n Assessment:\n Pt cont with labile SBP, 90s-170s. A line and BP cuff correlating.\n Action:\n Pt completely off neo gtt. Increased PO Midodrine to 10mg TID.\n Response:\n Pt able to maintain MAP goal ~80.\n Plan:\n Cont PO Midodrine. Monitor hemodynamics.\n Tachycardia, Other\n Assessment:\n Tachy to 130s ~1030. Pt appeared agitated/ restless. Occasionally, pt\n is tachy to 110s-120s at complete rest when appears comfortable.\n Action:\n Given 50mcg Fentanyl with minimal effect. IVP Lopressor 5mg given with\n good effect.\n Response:\n HR down to 90s with minimal effect on lowering SBP.\n Plan:\n Lopressor 5mg for episodes of tachycardia to 130s. HR of ~100-110\n acceptable per order resident Dr. .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats 92-98%. LS coarse-clear, diminished bases. Pt dropped sat to\n 91% x2 today, during episodes of tachycardia to 130.\n Action:\n Pt on trach collar all day. Increased to 70% FiO2 when O2 sat dropped\n to 91%.\n Response:\n ABG WNL, Pa O2 of 78 acceptable per SICU resident Dr. . Pt\n tolerating trach collar.\n Plan:\n Cont weaning pt off vent as pt tolerates-- ?resting overnight as pt\n needs. Monitor O2 sats/ABGs/ s/s of distress.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342304,
"text": "Tachycardia, Other\n Assessment:\n HR 80-120s. tachycardic episodes transiently through out night both\n when pt anxious and at complete rest.\n Action:\n No betablockers given, SICU resident made aware.\n Response:\n Pt resolved episodes on her own.\n Plan:\n Cont to monitor hemodynamics. Betablocker available if pt tachycardic\n for extended periods of time.\n Altered mental status (not Delirium)\n Assessment:\n Pt more lethargic tonight. Not following any commands through out\n shift. Opened eyes occasionally spontaneously, mostly to pain/noxious\n stimuli. MAE on bed except for LUE. Some purposeful movement noted. Pt\n appears more restless/agitated than moving purposefully.\n Action:\n Neuro checks q 2.\n Response:\n Pt continued to have unimpressive neuro exams. SICU resident\n Dr. made aware.\n Plan:\n Monitor neuro status closely\nq 2 exams. If pt cont decrease in MS,\n ?repeat CT.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade fevers 99-100.9.\n Action:\n 650mg PO acetaminophen given x1. Cold bath given.\n Response:\n Minimal effects from bathing/ antipyretics. Pt broke to temp of 99\n later in shift.\n Plan:\n Cont to monitor for fever, s/s worsening infection.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342305,
"text": "Tachycardia, Other\n Assessment:\n HR 80-120s. tachycardic episodes transiently through out night both\n when pt anxious and at complete rest.\n Action:\n No betablockers given, SICU resident made aware.\n Response:\n Pt resolved episodes on her own.\n Plan:\n Cont to monitor hemodynamics. Betablocker available if pt tachycardic\n for extended periods of time.\n Altered mental status (not Delirium)\n Assessment:\n Pt more lethargic tonight. Not following any commands through out\n shift. Opened eyes occasionally spontaneously, mostly to pain/noxious\n stimuli. MAE on bed except for LUE. Some purposeful movement noted. Pt\n appears more restless/agitated than moving purposefully.\n Action:\n Neuro checks q 2.\n Response:\n Pt continued to have unimpressive neuro exams. SICU resident\n Dr. made aware.\n Plan:\n Monitor neuro status closely\nq 2 exams. If pt cont decrease in MS,\n ?repeat CT.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade fevers 99-100.9.\n Action:\n 650mg PO acetaminophen given x1. Cold bath given.\n Response:\n Minimal effects from bathing/ antipyretics. Pt broke to temp of 99\n later in shift.\n Plan:\n Cont to monitor for fever, s/s worsening infection.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341734,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.4\n Action:\n Blood, urine & sputum cultures sent, CXR done; 650 mg Tylenol po given\n Response:\n Temp decreased to 99.7\n Plan:\n Continue to monitor VS\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342007,
"text": "Hypotension (not Shock)\n Assessment:\n SBP labile from 80s-160s.\n Action:\n Neo gtt weaned to off, started on PO mididrine\n Response:\n Pt remains labile with SBP dipping to 80s off neo temporarily. Rebounds\n with some stimulation/transient use of neo gtt again.\n Plan:\n Wean neo to off and cont PO mididrine. ?increase dose mididrine.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt cont with loose/liquid black stool x3 this AM. Continuing to stool\n through out shift.\n Action:\n Flexiseal inserted for continuous black liquid stool. CDIFF specimen\n sent.\n Response:\n Containment of stool successful.\n Plan:\n Cont use of flexiseal as long as stool is liquid/loose enough for safe\n containment. CDIFF specimens x2 need to be sent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats 97-100%. RR 20s. LS clear-coarse.\n Action:\n Pt placed on trach collar, 50% all day. Suctioned several times for\n thick yellow secretion.\n Response:\n ABGs WNL. Pt appears to be tolerating trach collar with minimal\n increase in RR and no sign of WOB.\n Plan:\n Cont trach collar during days as tol. Rest pt back on vent for nights.\n Cont monitor RR, ABGs, O2 sat.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 342104,
"text": "SICU\n HPI:\n HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR done\n -Pt with fever, Pan cultured. Labetalol decreased back to 100 tid as\n pt hypotensive\n -Labile BP overnight, resp distress. placed on AC by RT\n - allowed to autoregulate, consulted orthopedics for arm fracture,\n following urine/serum osmoles\n -started lasix/albumin and Neo to maintain SBP>100. Neuro status:\n responding to verbal commands. Labetalol prn for HTN/tachy responds\n well.\n - Continues to have fevers. Ventriculostomy clamped, call NS if ICP\n >30.\n - afebrile until midnight, PO Vanc started for suspected CDiff,\n CDiff sent, tacro adjusted, four hours of trach collar, CVL placed\n without incidient in LSC, reduced to a pressure support of five\n Chief complaint:\n IPH, respiratory failure\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n 1. 2. 500 mL NS 3. Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Ciprofloxacin 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\n 11. Insulin 12. Labetalol\n 13. Levothyroxine Sodium 14. LeVETiracetam 15. Magnesium Sulfate 16.\n MetRONIDAZOLE (FLagyl) 17. Midodrine\n 18. Midazolam 19. Mycophenolate Mofetil 20. Pantoprazole 21.\n Phenylephrine 22. Potassium Chloride\n 23. Potassium Phosphate 24. Senna 25. Sodium Chloride 0.9% Flush 26.\n Sodium Chloride 0.9% Flush\n 27. Sulfameth/Trimethoprim SS 28. Tacrolimus 29. Tacrolimus 30.\n Vancomycin 31. Vancomycin Oral Liquid\n 24 Hour Events:\n MULTI LUMEN - START 06:47 PM\n MULTI LUMEN - STOP 08:16 PM\n triple lumen catheter placed\n Post operative day:\n POD#14 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Ciprofloxacin - 12:07 AM\n Metronidazole - 06:15 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 06:30 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.4\nC (99.3\n HR: 121 (62 - 131) bpm\n BP: 130/60(83) {90/38(52) - 160/94(102)} mmHg\n RR: 30 (0 - 38) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.4 kg (admission): 81.5 kg\n Height: 60 Inch\n CVP: 9 (-1 - 11) mmHg\n Total In:\n 3,817 mL\n 1,218 mL\n PO:\n Tube feeding:\n 1,201 mL\n 510 mL\n IV Fluid:\n 1,876 mL\n 468 mL\n Blood products:\n Total out:\n 3,685 mL\n 1,015 mL\n Urine:\n 3,485 mL\n 1,015 mL\n NG:\n Stool:\n 200 mL\n Drains:\n Balance:\n 132 mL\n 203 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: CPAP\n Vt (Spontaneous): 309 (292 - 349) mL\n PS : 5 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 99\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.43/34/105/22/-2\n Ve: 9.8 L/min\n PaO2 / FiO2: 210\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Rhonchorous : )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands\n Labs / Radiology\n 377 K/uL\n 9.8 g/dL\n 129 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 4.1 mEq/L\n 30 mg/dL\n 100 mEq/L\n 130 mEq/L\n 29.4 %\n 9.8 K/uL\n [image002.jpg]\n 03:57 AM\n 09:47 AM\n 01:28 PM\n 04:40 PM\n 04:54 PM\n 05:30 PM\n 09:39 PM\n 03:00 AM\n 04:09 AM\n 04:15 AM\n WBC\n 9.1\n 12.6\n 9.3\n 9.8\n Hct\n 30.9\n 30.4\n 31.1\n 28.3\n 29.7\n 29.4\n Plt\n 356\n 433\n 393\n 377\n Creatinine\n 0.9\n 0.9\n TCO2\n 25\n 24\n 26\n 22\n Glucose\n 131\n 112\n 129\n Other labs: PT / PTT / INR:13.6/25.5/1.2, Amylase / Lipase:113/98,\n Differential-Neuts:71.2 %, Lymph:24.5 %, Mono:2.9 %, Eos:1.0 %, Lactic\n Acid:1.2 mmol/L, Albumin:3.9 g/dL, Ca:10.2 mg/dL, Mg:2.0 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH)\n Assessment and Plan: 45 year old female with IPH, respiratory failure\n Neurologic: Neurologic exam stable, Goal MAP >80 for CPP as per NS,\n midaz/fentanyl prn for pain/aggiation.\n Cardiovascular: Goal MAp>80, on Midodrine, phenylephrine gtt as\n needed. patient tachycardic, feel secondary to aggitation.\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), Wean on and off to TC\n as tollerated.\n Gastrointestinal / Abdomen: PEG, melanotic stools, follow CBC\n Nutrition: Tube feeding, @ goal\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: on Tx for Cdiff, VAP.- will d/c Cipro, change to po\n Vanco for continued diarhhea\n Lines / Tubes / Drains: G-tube, Trach\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural),\n (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:35 AM 50.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:35 PM\n 20 Gauge - 05:09 PM\n Multi Lumen - 06:47 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 30 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2106-08-17 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 341247,
"text": "Objective\n Labs:\n Value\n Date\n Glucose\n 137 mg/dL\n 02:16 AM\n Glucose Finger Stick\n 160\n 10:00 AM\n BUN\n 28 mg/dL\n 02:16 AM\n Creatinine\n 1.0 mg/dL\n 02:16 AM\n Sodium\n 129 mEq/L\n 02:16 AM\n Potassium\n 5.3 mEq/L\n 02:16 AM\n Chloride\n 99 mEq/L\n 02:16 AM\n TCO2\n 23 mEq/L\n 02:16 AM\n PO2 (arterial)\n 81. mm Hg\n 02:28 AM\n PCO2 (arterial)\n 31 mm Hg\n 02:28 AM\n pH (arterial)\n 7.49 units\n 02:28 AM\n pH (urine)\n 7.0 units\n 12:33 PM\n CO2 (Calc) arterial\n 24 mEq/L\n 02:28 AM\n Calcium non-ionized\n 9.8 mg/dL\n 02:16 AM\n Phosphorus\n 2.8 mg/dL\n 02:16 AM\n Ionized Calcium\n 1.26 mmol/L\n 02:37 PM\n Magnesium\n 2.0 mg/dL\n 02:16 AM\n WBC\n 12.2 K/uL\n 02:16 AM\n Hgb\n 13.4 g/dL\n 02:16 AM\n Hematocrit\n 38.1 %\n 02:16 AM\n Current diet order / nutrition support: FS Replete w/ Fiber@ 50cc/hr\n GI: Abd soft, +BS\n Assessment of Nutritional Status\n Pt S/P fall, w/ ICH s/p crani/evacuation. Pt w/ trach/PEG, receiving\n TF, FS Replete w/ Fiber@ 50cc/hr that provides 1200kcals and 74g\n prot/day, not meeting 100% est calorie needs. Noted BG mngt w/ insulin\n drip, currently @ 4units/hr\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Increase goal TF rate to FS Replete w/ Fiber@ 70cc/hr to\n provide 1680kcals and 104g prot/day (25kcals/kg adj BW)\n 2. Check residual q 4-6hrs, hold TF if >150cc\n 3. c/w lyte and BG mngt\n Will f/u with progress.\n 16:11\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341480,
"text": "Airway\n Airway Placement Data\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 341809,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Chief complaint:\n IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n IV access: Peripheral line Order date: @ 1829 15. Magnesium\n Sulfate IV Sliding Scale Order date: @ 1829\n 2. IV access: Temporary central access (ICU) Location: Right Subclavian\n Order date: @ 1152 16. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Order date: @ 0933\n 3. Acetaminophen 650 mg PO Q6H:PRN fever Order date: @ 1712 17.\n Mycophenolate Mofetil 250 mg PO BID Order date: @ 1829\n 4. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 1829 18.\n Pantoprazole 40 mg IV Q12H Order date: @ \n 5. Calcium Gluconate IV Sliding Scale Order date: @ 1829 19.\n Potassium Chloride IV Sliding Scale Order date: @ 1829\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1829 20. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0358\n 7. Ciprofloxacin 400 mg IV Q12H Order date: @ 0933 21. Senna 1\n TAB PO BID:PRN Order date: @ 1829\n 8. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1829 22.\n Sodium Chloride 0.9% Flush 3 mL IV PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1829\n 9. Fentanyl Citrate 25-50 mcg IV Q2H:PRN pain Order date: @ 2309\n 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1152\n 10. Furosemide 1 mg/hr IV DRIP INFUSION Order date: @ 1418 24.\n Sulfameth/Trimethoprim SS 1 TAB PO DAILY Order date: @ 1829\n 11. Heparin 5000 UNIT SC TID Order date: @ 1438 25. Tacrolimus 3\n mg PO QAM\n Dose to be administered 6pm and 6am Order date: @ 1553\n 12. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0735 26. Tacrolimus 2 mg PO QPM\n Dose to be admin. at 6am and 6pm Order date: @ 1553\n 13. Labetalol 10 mg IV Q2H:PRN\n SBP>180 and HR>120 Order date: @ 2320 27. Vancomycin 750 mg IV Q\n 12H Order date: @ 1108\n 14. Levothyroxine Sodium 100 mcg PO DAILY Order date: @ 1829\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n SPUTUM CULTURE - At 01:00 AM\n FEVER - 101.4\nF - 08:00 PM\n Post operative day:\n POD#12 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Ciprofloxacin - 12:17 AM\n Metronidazole - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Flowsheet Data as of 11:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.1\nC (100.6\n HR: 110 (99 - 135) bpm\n BP: 109/48(65) {95/38(58) - 176/74(109)} mmHg\n RR: 27 (25 - 35) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 81.9 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 12 (4 - 22) mmHg\n Total In:\n 3,114 mL\n 1,175 mL\n PO:\n Tube feeding:\n 1,240 mL\n 545 mL\n IV Fluid:\n 1,434 mL\n 420 mL\n Blood products:\n 200 mL\n Total out:\n 2,749 mL\n 785 mL\n Urine:\n 2,655 mL\n 785 mL\n NG:\n Stool:\n Drains:\n 94 mL\n Balance:\n 365 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 354 (292 - 408) mL\n PS : 12 cmH2O\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 141\n PIP: 18 cmH2O\n SPO2: 95%\n ABG: 7.43/35/106/23/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 265\n Physical Examination\n Labs / Radiology\n 445 K/uL\n 11.1 g/dL\n 118 mg/dL\n 1.2 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 65 mg/dL\n 99 mEq/L\n 131 mEq/L\n 33.9 %\n 15.7 K/uL\n [image002.jpg]\n 02:28 AM\n 03:08 AM\n 03:31 AM\n 06:06 AM\n 10:03 PM\n 04:02 AM\n 04:15 AM\n 04:05 PM\n 04:04 AM\n 04:21 AM\n WBC\n 12.9\n 12.3\n 15.7\n Hct\n 38.9\n 37.5\n 33.9\n Plt\n 452\n 397\n 445\n Creatinine\n 0.9\n 1.0\n 1.0\n 1.2\n TCO2\n 24\n 26\n 27\n 29\n 29\n 24\n Glucose\n 138\n 135\n 139\n 136\n 129\n 131\n 118\n Other labs: Amylase / Lipase:113/98, Lactic Acid:1.2 mmol/L,\n Albumin:3.9 g/dL, Ca:10.4 mg/dL, Mg:2.3 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan:\n Neurologic: head ct--if stable remove ventriculostomy drain\n Cardiovascular: pt is autoregulated...no issues\n Pulmonary: Trach, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, replete w/fiber 50cc/hr\n Renal: lasix at 1\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: tx w/vanco/cipro/flagyl\n Lines / Tubes / Drains: Foley, G-tube, a-line, triple lumen, d/c vent\n drain\n Wounds: Dry dressings\n Imaging: CT scan head today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:41 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 341811,
"text": "Objective\n Pertinent medications:\n Meds noted\n Labs:\n Value\n Date\n Glucose\n 118 mg/dL\n 04:21 AM\n Glucose Finger Stick\n 145\n 10:00 AM\n BUN\n 65 mg/dL\n 04:04 AM\n Creatinine\n 1.2 mg/dL\n 04:04 AM\n Sodium\n 131 mEq/L\n 04:04 AM\n Potassium\n 5.0 mEq/L\n 04:04 AM\n Chloride\n 99 mEq/L\n 04:04 AM\n TCO2\n 23 mEq/L\n 04:04 AM\n PO2 (arterial)\n 106 mm Hg\n 04:21 AM\n PCO2 (arterial)\n 35 mm Hg\n 04:21 AM\n pH (arterial)\n 7.43 units\n 04:21 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 04:21 AM\n Albumin\n 3.9 g/dL\n 04:02 AM\n Calcium non-ionized\n 10.4 mg/dL\n 04:04 AM\n Phosphorus\n 3.5 mg/dL\n 04:04 AM\n Magnesium\n 2.3 mg/dL\n 04:04 AM\n Amylase\n 113 IU/L\n 04:04 AM\n WBC\n 15.7 K/uL\n 04:04 AM\n Hgb\n 11.1 g/dL\n 04:04 AM\n Hematocrit\n 33.9 %\n 04:04 AM\n Current diet order / nutrition support: FS Replete w/ Fiber@50cc/hr\n GI: Abd soft, (+)BS, (+)BM\n Assessment of Nutritional Status\n Pt adm w/ ICH, ICU day 12, S/P trach/PEG, ICP monitor. Pt receiving TF,\n FS Replete w/ Fiber@ 50cc/hr without issues, current regimen provides\n 1200kcals and 74g prot/day.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. c/w TF for nutrition support.\n 2. Rec trial of changing TF goal to FS Fibersource HN w/ 15g\n Beneprotein @ 50cc/hr to provide 1494kcals and 77g prot/day to better\n meet nutrition needs (1.2kcal/cc)\n 3. Free H20 flushes for high BUN (noted low Na as well)\n 4. Check residual q 4-6hrs, hold TF if >150cc\n 5. Monitor hydration status (low Na/ high BUN)\n 6. c/w lytes mngt as you are\n 7. Electronically signed by , MS, RD, LDN, CNSD\n 11:14\n 8.\n 9.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342076,
"text": "Demographics\n Day of mechanical ventilation: 15\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: PSV increased from 5 to 10 due to drop in Vts into 200s/RR\n 40s/tachycardia. RR still remained 33-35/Vts increased to 300s\n Plan\n Next 24-48 hours: Trach collar trials during the day.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n AM RSBI-99\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341246,
"text": "Altered mental status (not Delirium)\n Assessment:\n Neuro exam stable without change remains with low grade temp, tmax\n 100.5\n Action:\n Dr in on rounds Ventriculostomy level increased to 25\n above tragus.\n Antibiotics adjusted per SICU team, random vancomycin level sent prior\n to third dose.\n Neo gtt wean initiated, to keep sbp >100.\n Response:\n ICP transiently to 21 (expected), current 18.\n Sbp>100\n Plan:\n Continue q2hr neuro checks, trend ICP, notify neurosurg of value >25.\n Family meeting tentatively scheduled for this Thursday.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 100.5, wbc 12.2, Multi lumen catheter day 6, site clean and dry\n with slight pinkness.\n ETT secretions moderate, pale thick yellow.\n Action:\n MLC site assessed , VAP protocol maintained.\n Response:\n No further temp spike noted, MLC site remains unchanged.\n Plan:\n Follow temp trends, ETT secretions and culture data, observe for s/s\n sepsis.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342003,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: trach mask trials as tolerates\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Trach mask initiated at 11:30 am, per rounds allow rr up to 35\n ,following abgs, vent on standby.\n"
},
{
"category": "Social Work",
"chartdate": "2106-08-16 00:00:00.000",
"description": "progress note",
"row_id": 340929,
"text": "TITLE:\n Pt is a 45 yr old widowed woman, mother of two girls ages 5 & 6,\n transferred from TSICU to SICU. Pt known to the transplant team here\n at s/p kidney and pancreas transplant within the last 5 yrs. Pt\n admitted s/p bleed, pt fell while walking friend\ns dog.\n Outreach phone call to pt\ns brother, , to introduce myself as\n the social worker here to assist family with this tragic event.\n Brother has initiated contact with his lawyer for guardianship for pt\n and her two children. Informed brother that I would assist in\n facilitating paperwork is needed.\n Brother also requested help with helping the children to understand\n and cope with this hospitalization. Family will contact me when they\n are able to come in with the children.\n Will discuss case with the team and prepare for meeting with the\n children.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339743,
"text": "45 y.o.f. s/p fall backward from standing, w occipital fx & cerebellar\n hematoma, s/p crani/evacuation (), now POD 4.\n Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n head bleed.\n Action:\n Titrated labetolol drip according to BP, assessed accuracy of ABP w/\n manual occlusion test.\n Response:\n SBP 120s-160s.\n Plan:\n Titrate labetolol to maintain SBP < 160, while maintaining CPP > 60.\n Alkalosis, respiratory; secondary to central neurologic breathing\n pattern.\n Assessment:\n Patient continues to be hypocarbic, although PaCO2 improving.\n Action:\n Weaning pressure support as tolerated.\n Response:\n Oxygenating well, maintaining SpO2 > 98%\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated.\n Altered mental status, s/p cerebellar parenchymal hemorrhage & frontal\n SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy.\n Response:\n Patient unresponsive, no changes in neuro exams, exams remain\n inconsistent. ICPs <20. Ventric draining bloody tinged output every\n hour- pigmentation of drainage noted to increase in color, NSurg\n immediately notified.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for seizure prophylaxis.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 339747,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Pt was being ventilated on PSV 15/5 that was wean down to 8/5. Pt vt\n ranging from 400-560 and RR in the high teens. Abg continues to\n alkalatic with good oxygenation. Pt suctioned for scant tan\n secretions. Plan to continue weaning off PSV as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341475,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation\n Altered mental status (not Delirium)\n Assessment:\n Occasional periods of alertness, nodded head\n when asked if\n picture was of her daughters.\n Period of hypotension to sbp <90 this afternoon.\n Action:\n Ventriculostomy drain changed to 15cm above tragus, pt reoriented to\n place and events with neuro exams.\n 500cc fluid bolus NS, neo gtt initiated.\n team updated on pt condition.\n Response:\n ICP drained 18cc and then 10cc hourly before returning to baseline\n output. ICP down to 12-13.\n SBP promptly increased to >100, current value 136/55/\n Pt pan cultured for hypotensive event. CSF culture obtained by\n NP.\n Plan:\n Q2hr neuro exams, titrate neo gtt to keep sbp >100, follow\n Ventriculostomy output, ICPs, culture data. Notify of any\n decline in exam.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.1, C.diff culture + x1, Most recent culture data negative or\n pending. WBC 12.9\n Action:\n Tylenol 650mg x1\n Response:\n Temp down to 100.4\n Plan:\n Continue antibiotic coverage, follow culture data, pressor support as\n above.\n Electrolyte & fluid disorder, other\n Assessment:\n Serum Na 129, unchanged from yesterday. Fluid balance 10L+, Urine osmo\n wnl\n Action:\n Lasix 5mg IVP x1, lasix gtt initiated at 1mg/hr, albumin 25gm ordered\n q6hr.\n Response:\n Pt diuresed 500cc in response to initial lasix dose, current\n uo>200cc/hr\n Plan:\n Continue diuresis (hyponatremia fluid overload), follow serum\n sodium, minimize fluid intake\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 341619,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR done\n -Pt with fever, Pan cultured. Labetalol decreased back to 100 tid as\n pt hypotensive\n -Labile BP overnight, resp distress. placed on AC by RT\n - allowed to autoregulate, consulted orthopedics for arm fracture,\n following urine/serum osmoles\n -started lasix/albumin and Neo to maintain SBP>100. Neuro status:\n responding to verbal commands. Labetalol prn for HTN/tachy responds\n well.\n Chief complaint:\n IPH, sepsis, respiratory\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n 1. 2. 3. 500 mL NS 4. Acetaminophen 5. Albumin 25% (12.5g / 50mL) 6.\n Bisacodyl 7. Calcium Gluconate\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 9. Ciprofloxacin 10.\n Docusate Sodium (Liquid) 11. Fentanyl Citrate\n 12. Furosemide 13. Furosemide 14. Heparin 15. Insulin 16. Labetalol 17.\n Labetalol 18. Levothyroxine Sodium\n 19. Magnesium Sulfate 20. MetRONIDAZOLE (FLagyl) 21. Metoprolol\n Tartrate 22. Mycophenolate Mofetil\n 23. Pantoprazole 24. Potassium Chloride 25. Potassium Phosphate 26.\n Senna 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Sulfameth/Trimethoprim SS 30.\n Tacrolimus 31. Tacrolimus 32. Vancomycin\n 24 Hour Events:\n CSF CULTURE - At 03:08 PM\n PAN CULTURE - At 04:33 PM\n FEVER - 101.1\nF - 12:00 PM\n Post operative day:\n POD#11 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Ciprofloxacin - 12:11 AM\n Metronidazole - 04:00 AM\n Vancomycin - 08:40 AM\n Infusions:\n Furosemide (Lasix) - 1 mg/hour\n Other ICU medications:\n Furosemide (Lasix) - 02:59 PM\n Heparin Sodium (Prophylaxis) - 06:02 AM\n Pantoprazole (Protonix) - 08:48 AM\n Other medications:\n Flowsheet Data as of 10:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 38.2\nC (100.7\n HR: 101 (88 - 136) bpm\n BP: 112/45(60) {96/44(55) - 196/72(100)} mmHg\n RR: 21 (17 - 31) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 82.9 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 7 (7 - 19) mmHg\n Total In:\n 3,484 mL\n 1,407 mL\n PO:\n Tube feeding:\n 1,200 mL\n 523 mL\n IV Fluid:\n 1,809 mL\n 625 mL\n Blood products:\n 200 mL\n 138 mL\n Total out:\n 3,774 mL\n 1,474 mL\n Urine:\n 3,655 mL\n 1,385 mL\n NG:\n Stool:\n Drains:\n 119 mL\n 89 mL\n Balance:\n -290 mL\n -67 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 374 (350 - 401) mL\n PS : 15 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 117\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SPO2: 94%\n ABG: 7.43/42/151/26/3\n Ve: 8.1 L/min\n PaO2 / FiO2: 377\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n , Rhonchorous : )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: unchanged neurologic exam\n Labs / Radiology\n 397 K/uL\n 12.3 g/dL\n 129 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.8 mEq/L\n 31 mg/dL\n 95 mEq/L\n 129 mEq/L\n 37.5 %\n 12.3 K/uL\n [image002.jpg]\n 08:21 AM\n 10:50 AM\n 02:16 AM\n 02:28 AM\n 03:08 AM\n 03:31 AM\n 06:06 AM\n 10:03 PM\n 04:02 AM\n 04:15 AM\n WBC\n 12.2\n 12.9\n 12.3\n Hct\n 38.1\n 38.9\n 37.5\n Plt\n \n Creatinine\n 1.0\n 0.9\n 1.0\n 1.0\n TCO2\n 24\n 24\n 24\n 26\n 27\n 29\n Glucose\n 137\n 138\n 135\n 139\n 136\n 129\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Albumin:3.9\n g/dL, Ca:10.4 mg/dL, Mg:2.0 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45 year old female with IPH, VAP\n Neurologic: ICP monitor, Ventriculostomy, neurologic exam unchaged,\n Ventric raised to 25 cm\n Cardiovascular: Continue Liberal BP control allowing patient to\n selfautoregulate.\n Pulmonary: (Ventilator mode: CPAP + PS), Conitnue to wean as tolerated\n Gastrointestinal / Abdomen: PEG\n Nutrition: Tube feeding, @ goal\n Renal: Foley, Adequate UO, on Lasix gtt\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Check cultures, on VAP tx with Cipro, Vanco. On po\n flagyl. Goal of Vanco trough is >20 for Gram + coverage in pulmonary\n infection, no current data to indicate nephrotoxicity of these Vanco\n Troughs\n Lines / Tubes / Drains: G-tube, Trach\n Wounds:\n Imaging: Cxray today\n Fluids: KVO\n Consults: Neuro surgery, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:00 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent 30 minutes:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341666,
"text": "Tachycardia, Other\n Assessment:\n HR in the 120\ns sinus tach\n Action:\n Given 650 mg of Tylenol for fever. 10mg Labetalol IV, stimulation in\n room decreased\n Response:\n HR returned to 100-110\n Plan:\n Continue to monitor\n Hypertension, benign\n Assessment:\n SBP 170\n-180\n Action:\n 10 mg Labetalol\n Response:\n SBP in the 150\n Plan:\n Continue to monitor\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.1\n Action:\n Given 650 mg tylenol\n Response:\n pending\n Plan:\n Continue to monitor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypnic in high 30\ns, rhonchorus breath sounds, Moderate amount of\n thick white secretions\n Action:\n Increased pressure support from 10 to 12, chest pt\n Response:\n RR improved to low 30\n Plan:\n Continue to monitor, pulmonary toileting\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341663,
"text": "Tachycardia, Other\n Assessment:\n HR in the 120\ns sinus tach\n Action:\n Given 650 mg of Tylenol for fever. 10mg Labetalol IV, stimulation in\n room decreased\n Response:\n HR returned to 100-110\n Plan:\n Continue to monitor\n Hypertension, benign\n Assessment:\n SBP 170\n-180\n Action:\n 10 mg Labetalol\n Response:\n SBP in the 150\n Plan:\n Continue to monitor\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.1\n Action:\n Given 650 mg tylenol\n Response:\n pending\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341362,
"text": "HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Tachycardia, Other\n Assessment:\n HR 110s-120s\n Action:\n 5-10 mg IV lopressor given as ordered\n Response:\n HR decreased <110\n Plan:\n Continue to assess HR, assess pain level, decrease stimuli\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.5\n Action:\n 650 mg Tylenol given via PEG tube, administer antibiotics as ordered\n Response:\n Fever decreased to 100.3\n Plan:\n Continue to assess VS, administer Tylenol & antibiotics as ordered,\n cool cloths to face\n Hypertension, benign\n Assessment:\n BP increased 180s/80s\n Action:\n 10 mg hydralazine IV given as ordered\n Response:\n BP decreased 120s-140s/50s\n Plan\n Continue to monitor BP, assess pain, decrease stimuli\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP & PS 50% FiO2, 5 PEEP, 15 PS, tidal volumes approx\n 400, RR 20-30, O2 sat >96%, + secretions, absent gag, impaired cough,\n ABG PaO2=170.\n Action:\n Suctioned q2 hours for small to moderate amounts of thick, yellow\n sputum from ETT, suctioned copious amounts of clear secretions from\n mouth, assess lung sounds, FiO2 level decreased to 40% by respiratory\n therapist.\n Response:\n O2 sats maintained > 95%, RR remains 20-30, repeat ABG pending.\n Plan:\n Continue to assess lung sounds, suction prn, assess VS, assess lab\n results.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opens eyes spontaneously, does not follow commands, withdrawls all\n extremities to nailbed pressure, pupils 3 mm equal & reactive, vent\n drain 25 @ tragus draining small amounts of clear fluid.\n Action:\n Assess neuro status, assess vent drainage\n Response:\n No change in neuro status\n Plan:\n Continue Q2 neuro checks, maintain vent drain.\n ------ Protected Section ------\n Addendum 06:45: pt + c diff, Dr. . Repeat ABG pt slightly\n alkalotic, PO2 128, no vent changes made. 3 mg prograf given as\n ordered.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:49 ------\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 341983,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Chief complaint:\n IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n 1. 2. 3. 500 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Ciprofloxacin 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Heparin 12. Insulin 13. Labetalol\n 14. Levothyroxine Sodium 15. LeVETiracetam 16. LeVETiracetam 17.\n Lorazepam 18. Magnesium Sulfate\n 19. MetRONIDAZOLE (FLagyl) 20. Mycophenolate Mofetil 21. Pantoprazole\n 22. Phenylephrine 23. Potassium Chloride\n 24. Potassium Phosphate 25. Senna 26. Sodium Chloride 0.9% Flush 27.\n Sodium Chloride 0.9% Flush\n 28. Sulfameth/Trimethoprim SS 29. Tacrolimus 30. Tacrolimus 31.\n Vancomycin\n 24 Hour Events:\n ICP CATHETER - STOP 11:00 AM\n focal partial seizure activity evaluated by Neurology, GUAIAC positive\n melenic stools\n Post operative day:\n POD#13 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ciprofloxacin - 12:37 AM\n Metronidazole - 04:01 AM\n Vancomycin - 08:29 AM\n Infusions:\n Phenylephrine - 1.8 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:20 AM\n Pantoprazole (Protonix) - 08:29 AM\n Other medications:\n Flowsheet Data as of 11:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 38\nC (100.4\n HR: 62 (62 - 121) bpm\n BP: 146/56(86) {86/40(52) - 178/78(116)} mmHg\n RR: 24 (14 - 32) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.4 kg (admission): 81.5 kg\n Height: 60 Inch\n CVP: 18 (2 - 18) mmHg\n Total In:\n 3,715 mL\n 2,168 mL\n PO:\n Tube feeding:\n 829 mL\n 565 mL\n IV Fluid:\n 2,426 mL\n 1,043 mL\n Blood products:\n Total out:\n 2,335 mL\n 1,730 mL\n Urine:\n 2,335 mL\n 1,730 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,380 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 350 (318 - 490) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 18 cmH2O\n SPO2: 99%\n ABG: 7.38/41/106/24/0\n Ve: 7.9 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands\n Labs / Radiology\n 622 K/uL\n 10.5 g/dL\n 116 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 4.9 mEq/L\n 42 mg/dL\n 103 mEq/L\n 134 mEq/L\n 30.9 %\n 18.2 K/uL\n [image002.jpg]\n 04:02 AM\n 04:15 AM\n 04:05 PM\n 04:04 AM\n 04:21 AM\n 05:33 PM\n 10:37 PM\n 03:49 AM\n 03:57 AM\n 09:47 AM\n WBC\n 12.3\n 15.7\n 16.9\n 18.2\n Hct\n 37.5\n 33.9\n 31.0\n 31.4\n 31.1\n 30.9\n Plt\n 397\n 445\n 562\n 622\n Creatinine\n 1.0\n 1.2\n 1.1\n 0.9\n TCO2\n 29\n 29\n 24\n 25\n Glucose\n 136\n 129\n 131\n 118\n 130\n 116\n Other labs: PT / PTT / INR:14.6/35.3/1.3, Amylase / Lipase:113/98,\n Lactic Acid:1.2 mmol/L, Albumin:3.9 g/dL, Ca:10.2 mg/dL, Mg:2.1 mg/dL,\n PO4:3.4 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, ICP monitor\n Cardiovascular: discontinue subcut heparin\n Pulmonary: (Ventilator mode: CPAP + PS), wean pressure support\n Gastrointestinal / Abdomen: tolerating tube feeds but with continuing\n loose stools over night\n Nutrition: Tube feeding, continuing without difficulty\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: Check cultures, CDIFF + , GPC in sputum culture,\n changing to PO VANC, removing CVL and culturing the tip\n Lines / Tubes / Drains: Foley, Trach\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), Other: occipital fracture\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:16 PM 50.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341008,
"text": "45 yo woman with complicated past medical history of\n live donor renal translplant , cavaderic pancreas transplant\n , CMV infection, pancreatic head AV fistula s/p embolization\n , medication induced pancytopenia, DM 1, history of ESRD,\n retinopathy, lumpectomy, restless leg syndrome, hypothryoidism\n who sustained intraparenchymal cerebellar hemorrhage after a fall\n and occipital fracture.\n : admitted. EVD placed. Went to OR in afternoon for crani and\n evacuation.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max today 101.5.\n Action:\n 650 mg Tylenol po given as ordered.\n Response:\n Repeat temp 100.3.\n Plan:\n Continue to monitor temp, VS.\n Hypertension, benign\n Assessment:\n BP 180s/80s.\n Action:\n 10 mg Labetalol IV given as ordered\n Response:\n BP decreased to 170s/70s.\n Plan:\n Continue to monitor BP, VS.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach/PEG, on CPAP & PS, Tube feedings infusing via PEG,\n copious amounts of thick white sputum from ETT, copious secretions\n noted in mouth, impaired gag, impaired cough, coarse lung sounds heard\n bilat.\n Action:\n Suction prn, draw and assess ABGs, work with respiratory to adjust vent\n settings as indicated, administer TF as ordered\n Response:\n O2 sat maintained >95%, RR 20-30.\n Plan:\n Continue to assess lung sounds, ABGs, suction prn, adjust vent as\n indicated, assess VS.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pupils 3 mm equal & reactive, pt does not follow commands, pt does not\n move upper extremities, moves lower extremities to nail bed pressure,\n no spontaneous movement noted. Pt opens eyes spontaneously, but does\n not respond to verbal stimuli.\n Action:\n Inform team re: neuro status, CT done as ordered.\n Response:\n No change in neuro status\n Plan:\n Continue to assess neuro signs Q2, maintain pt safety, report changes\n in neuron status to team.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339740,
"text": "45 y.o.f. s/p fall backward from standing, w occipital fx & cerebellar\n hematoma, s/p crani/evacuation (), now POD 4.\n Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n head bleed.\n Action:\n Titrated labetolol drip according to BP, assessed accuracy of ABP w/\n manual occlusion test.\n Response:\n SBP 120s-160s.\n Plan:\n Titrate labetolol to maintain SBP < 160, while maintaining CPP > 60.\n Alkalosis, respiratory; secondary to central neurologic breathing\n pattern.\n Assessment:\n Patient continues to be hypocarbic, although PaCO2 improving.\n Action:\n Weaning pressure support as tolerated.\n Response:\n Oxygenating well, maintaining SpO2 > 98%\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated.\n Altered mental status, s/p cerebellar parenchymal hemorrhage & frontal\n SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy.\n Response:\n Patient unresponsive, no changes in neuro exams, exams remain\n inconsistent. ICPs <20. Ventric draining bloody tinged output every\n hour- pigmentation of drainage noted to increase in color, NSurg\n immediately notified.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for seizure prophylaxis.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339742,
"text": "45 y.o.f. s/p fall backward from standing, w occipital fx & cerebellar\n hematoma, s/p crani/evacuation (), now POD 4.\n Hypertension\n Assessment:\n Patient remains relatively hypertensive, increasing risk of worsening\n head bleed.\n Action:\n Titrated labetolol drip according to BP, assessed accuracy of ABP w/\n manual occlusion test.\n Response:\n SBP 120s-160s.\n Plan:\n Titrate labetolol to maintain SBP < 160, while maintaining CPP > 60.\n Alkalosis, respiratory; secondary to central neurologic breathing\n pattern.\n Assessment:\n Patient continues to be hypocarbic, although PaCO2 improving.\n Action:\n Weaning pressure support as tolerated.\n Response:\n Oxygenating well, maintaining SpO2 > 98%\n Plan:\n Continue pulm toilet, frequent repositioning, f/u with sputum culture,\n wean vent settings as tolerated.\n Altered mental status, s/p cerebellar parenchymal hemorrhage & frontal\n SAH\n Assessment:\n Patient continues to be unresponsive.\n Action:\n Q1 hour neuro exams, monitoring ICPs with ventriculostomy.\n Response:\n Patient unresponsive, no changes in neuro exams, exams remain\n inconsistent. ICPs <20. Ventric draining bloody tinged output every\n hour- pigmentation of drainage noted to increase in color, NSurg\n immediately notified.\n Plan:\n Continue q1h neuro checks. Monitor ICPs. Monitor ventriculostomy\n output. ? start dilantin for seizure prophylaxis.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342049,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Tachycardia, Other\n Assessment:\n Tachycardic w/low grade temps.\n Action:\n Tylenol and Fentanyl for discomfort.\n Response:\n HR decreased to 100-115, appearing more comfortable.\n Plan:\n Continue to monitor HR, temp curve and comfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic w/low volumes.\n Action:\n PSV increased to 10.\n Response:\n RR decreased , breathing more comfortably.\n Plan:\n Re-attempt vent wean in am.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342051,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n PMH:ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric\n pancreas tx , CMV pancytopenia, hypothyroid, retinopathy, restless\n legs syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Tachycardia, Other\n Assessment:\n Tachycardic w/low grade temps.\n Action:\n Tylenol and Fentanyl for discomfort.\n Response:\n HR decreased to 100-115, appearing more comfortable.\n Plan:\n Continue to monitor HR, temp curve and comfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic w/low volumes.\n Action:\n PSV increased to 10.\n Response:\n RR decreased , breathing more comfortably.\n Plan:\n Re-attempt vent wean in am.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340901,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs\n Chief complaint:\n IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n IV access: Peripheral line Order date: @ 1829 14. Magnesium\n Sulfate IV Sliding Scale Order date: @ 1829\n 2. IV access: Temporary central access (ICU) Location: Right Subclavian\n Order date: @ 1152 15. Mycophenolate Mofetil 250 mg PO BID Order\n date: @ 1829\n 3. Bisacodyl 10 mg PO/PR DAILY:PRN Order date: @ 1829 16.\n Pantoprazole 40 mg IV Q12H Order date: @ \n 4. Calcium Gluconate IV Sliding Scale Order date: @ 1829 17.\n Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP >100, CBP>60\n Order date: @ \n 5. CefazoLIN 2 g IV Q12H Order date: @ 1835 18. Potassium\n Chloride IV Sliding Scale Order date: @ 1829\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1829 19. Potassium Phosphate IV Sliding Scale\n Infuse over 6 hours Order date: @ 0358\n 7. Docusate Sodium (Liquid) 100 mg PO BID Order date: @ 1829 20.\n Senna 1 TAB PO BID:PRN Order date: @ 1829\n 8. Fentanyl Citrate 25-50 mcg IV Q2H:PRN pain Order date: @ 2309\n 21. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1829\n 9. Heparin 5000 UNIT SC TID Order date: @ 1438 22. Sodium\n Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1152\n 10. HydrALAzine 10 mg IV Q6H:PRN Order date: @ 0019 23.\n Sulfameth/Trimethoprim SS 1 TAB PO DAILY Order date: @ 1829\n 11. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 0735 24. Tacrolimus 3 mg PO QAM\n Dose to be administered 6pm and 6am Order date: @ 1553\n 12. Labetalol 100 mg PO TID Order date: @ 1618 25. Tacrolimus 2\n mg PO QPM\n Dose to be admin. at 6am and 6pm Order date: @ 1553\n 13. Levothyroxine Sodium 100 mcg PO DAILY Order date: @ 1829\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 04:00 PM\n placed on trach collar\n febrile, respiratory fxn deteriorating, switch to AC\n Post operative day:\n POD#8 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 09:00 AM\n Cefazolin - 04:07 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 10:59 PM\n Heparin Sodium - 06:39 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 09:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (101\n T current: 37.9\nC (100.3\n HR: 115 (81 - 115) bpm\n BP: 149/69(93) {118/46(71) - 170/90(120)} mmHg\n RR: 26 (18 - 37) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 16 (8 - 23) mmHg\n Total In:\n 3,169 mL\n 858 mL\n PO:\n Tube feeding:\n 2,698 mL\n 464 mL\n IV Fluid:\n 411 mL\n 224 mL\n Blood products:\n Total out:\n 1,763 mL\n 628 mL\n Urine:\n 1,675 mL\n 573 mL\n NG:\n Stool:\n Drains:\n 88 mL\n 55 mL\n Balance:\n 1,406 mL\n 230 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 332 (266 - 402) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 103\n PIP: 16 cmH2O\n Plateau: 23 cmH2O\n Compliance: 25 cmH2O/mL\n SPO2: 95%\n ABG: 7.43/35/101/23/0\n Ve: 10.5 L/min\n PaO2 / FiO2: 202\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Paradoxical), (Breath Sounds: Crackles\n : )\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 373 K/uL\n 13.3 g/dL\n 131 mg/dL\n 0.9 mg/dL\n 23 mEq/L\n 5.3 mEq/L\n 30 mg/dL\n 102 mEq/L\n 133 mEq/L\n 40.2 %\n 10.0 K/uL\n [image002.jpg]\n 06:19 AM\n 01:53 AM\n 02:13 AM\n 02:13 AM\n 09:00 AM\n 10:00 AM\n 01:00 AM\n 02:36 AM\n 02:41 AM\n 08:21 AM\n WBC\n 8.7\n 9.2\n 10.0\n Hct\n 40.4\n 41.5\n 40.2\n Plt\n \n Creatinine\n 0.9\n 0.9\n 0.9\n TCO2\n 25\n 24\n 22\n 26\n 24\n Glucose\n 126\n 157\n 130\n 122\n 131\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Ca:9.9\n mg/dL, Mg:2.2 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan:\n Neurologic: Neuro checks Q: 2 hr, icp monitor, ventriculostomy\n Cardiovascular: increase BP limit to less than 180\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), new right sided\n basilar infiltrate, BAL, start ABX--vent assisted pneumonia, if rate\n goes up increase pressure support, decrease FiO2 to 40%\n Gastrointestinal / Abdomen:\n Nutrition: PEG TF atgoal\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: Check cultures, immunosuppressive drugs,\n prophylaxis for h/o renal/kidney transplant\n Lines / Tubes / Drains: NGT, Trach\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Trauma surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:00 PM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341001,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt tachypnic into 30s at times\n IPS increased to 12 with some improvement.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1500\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340879,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 100.5 overnight\n Action:\n Continues on cefazolin q12h. pancultured on days. Cont to observe for\n source of temp. Incision lines clean. Suctioning for copious amts of\n thick tan bl tinge sputum. Wbc this am 10\n Response:\n Unchanged\n Plan:\n Cont to check for culture results.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Ventriculostomy drain remains at 20cm at tragus draining bl tinge to to\n clear fld Neuro status remains unchanged. Perl rarely opens eyes, not\n tracking ¬ following commands, no corneals, no gag, impaired cough\n reflex. Inconsistently withdraws to deep nailbed pressure to both\n lower extremeties, no movement upper extremeties.\n Action:\n Icu team made aware of neuro exam.\n Response:\n Icp 15-18\n Plan:\n Continue to monitor\n Hypertension, benign\n Assessment:\n Initial on neo weaned off for hypertension sbp >160 rr also 30-35 on\n trach collar.\n Action:\n Neo off, htn persisted, hydralazine 10mg iv w transient improvement in\n sbp. w htn and tachypneic ,placed back on vent from trach mask.\n Resp alkalosis improved on vent.\n Response:\n Htn waxing and . Received labetolol 100mg as ordered at 0200 w\n sbp dwn < 130 req neo\n Plan:\n Check w team re: lowering labetolol dosing. Utilize hydralazine prn as\n ordered to achieve Goal sbp 140-160 w cpp >60\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Tachypneic, tachycardic and htn on trach collar w sats 94% 7 copious\n thick tan bl tinged secretions.\n Action:\n Placed back on vent and abg obtained. Resp alkalosis and tachypnea\n persisted-> placed on cmv mode. Pcxr done this am.\n Response:\n Improved abg, on cmv mode and resolution of tachypnea,tachycardia and\n labile htn.\n Plan:\n Back to cpap mode per Sicu team to continue to exercise pt on vent.\n Cont to monitor closely, repeat abg on cpap mode.Pulm toilet Continue\n Vap protocol.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-17 00:00:00.000",
"description": "Intensivist Note",
"row_id": 341167,
"text": "SICU\n HPI:\n HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR done\n -Pt with fever, Pan cultured. Labetalol decreased back to 100 tid as\n pt hypotensive\n -Labile BP overnight, resp distress. placed on AC by RT\n Chief complaint:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n . 2. 3. Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Ciprofloxacin 9. Docusate Sodium (Liquid) 10. Fentanyl Citrate 11.\n Heparin 12. HydrALAzine 13. Insulin\n 14. Labetalol 15. Labetalol 16. Levothyroxine Sodium 17. Magnesium\n Sulfate 18. MetRONIDAZOLE (FLagyl)\n 19. Metoprolol Tartrate 20. Mycophenolate Mofetil 21. Pantoprazole 22.\n Phenylephrine 23. Potassium Chloride\n 24. Potassium Phosphate 25. Senna 26. Sodium Chloride 0.9% Flush 27.\n Sodium Chloride 0.9% Flush\n 28. Sulfameth/Trimethoprim SS 29. Tacrolimus 30. Tacrolimus 31.\n Vancomycin\n 24 Hour Events:\n CSF CULTURE - At 10:00 AM\n STOOL CULTURE - At 10:00 AM\n c diff sent\n FEVER - 101.5\nF - 12:00 PM\n tachycradic htn--labetolol/hydralazine, on neo--to maintain CPP >60.\n neuro status decreased. no contrast used in ct. copious secretions.\n Post operative day:\n POD#9 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Ciprofloxacin - 11:00 AM\n Cefazolin - 04:00 AM\n Metronidazole - 04:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Phenylephrine - 0.7 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 05:00 PM\n Pantoprazole (Protonix) - 08:04 PM\n Hydralazine - 12:11 AM\n Heparin Sodium - 06:18 AM\n Other medications:\n Flowsheet Data as of 10:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.5\n T current: 38.2\nC (100.7\n HR: 95 (88 - 129) bpm\n BP: 134/58(79) {107/50(68) - 182/81(111)} mmHg\n RR: 25 (22 - 34) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 85.9 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 17 (10 - 23) mmHg\n Total In:\n 2,999 mL\n 1,133 mL\n PO:\n Tube feeding:\n 1,203 mL\n 494 mL\n IV Fluid:\n 1,566 mL\n 578 mL\n Blood products:\n Total out:\n 1,471 mL\n 978 mL\n Urine:\n 1,376 mL\n 910 mL\n NG:\n Stool:\n Drains:\n 95 mL\n 68 mL\n Balance:\n 1,528 mL\n 155 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 403 (314 - 508) mL\n PS : 15 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 131\n PIP: 21 cmH2O\n SPO2: 97%\n ABG: 7.49/31/81./23/1\n Ve: 9.2 L/min\n PaO2 / FiO2: 135\n Physical Examination\n General Appearance: No acute distress\n HEENT: Pupils fixed and dilated\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Pulse - Dorsalis pedis: Present)\n Neurologic: (Responds to: Noxious stimuli)\n Labs / Radiology\n 369 K/uL\n 13.4 g/dL\n 137 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 5.3 mEq/L\n 28 mg/dL\n 99 mEq/L\n 129 mEq/L\n 38.1 %\n 12.2 K/uL\n [image002.jpg]\n 02:13 AM\n 09:00 AM\n 10:00 AM\n 01:00 AM\n 02:36 AM\n 02:41 AM\n 08:21 AM\n 10:50 AM\n 02:16 AM\n 02:28 AM\n WBC\n 9.2\n 10.0\n 12.2\n Hct\n 41.5\n 40.2\n 38.1\n Plt\n \n Creatinine\n 0.9\n 0.9\n 1.0\n TCO2\n 22\n 26\n 24\n 24\n 24\n Glucose\n 157\n 130\n 122\n 131\n 137\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Ca:9.8\n mg/dL, Mg:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w occipital\n fx/cerebellar hematoma, s/p crani/evacuation (), PEG and trach\n Neurologic: ICP monitor, Ventriculostomy, Pt still minimally\n responsive. ICPs 16. Maintain CPP.\n Cardiovascular: Titrate BP meds to maintain CPP (MAP-ICP). Labetaol\n prn, Hydralzine prn, neo prn\n Pulmonary: (Ventilator mode: CPAP + PS), wean as tolerated\n Gastrointestinal / Abdomen: PEG\n Nutrition: Tube feeding, @ goal\n Renal: Foley, Adequate UO. Check serum/urine osmols to r/o SIADH\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, Tx for VAP on vanco,Cipro, Bactrim\n prophylaxis, flagy; d/c ancef, as pt has vanco to cover gram +\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:29 AM 50 mL/hour\n Glycemic Control:\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341277,
"text": "Altered mental status (not Delirium)\n Assessment:\n Neuro exam stable without change remains with low grade temp, tmax\n 100.5\n Action:\n Dr in on rounds Ventriculostomy level increased to 25\n above tragus.\n Antibiotics adjusted per SICU team, random vancomycin level sent prior\n to third dose.\n Neo gtt wean initiated, to keep sbp >100.\n Response:\n ICP transiently to 21 (expected), current 18.\n Sbp>100\n Plan:\n Continue q2hr neuro checks, trend ICP, notify neurosurg of value >25.\n Family meeting tentatively scheduled for this Thursday.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.3 wbc 12.2, Multi lumen catheter day 6, site clean and dry\n with slight pinkness.\n ETT secretions moderate, pale thick yellow.\n Action:\n MLC site assessed , VAP protocol maintained, Tylenol 650mg via NGT\n Response:\n MCL site unchanged, secretions less.\n Plan:\n Follow temp trends, ETT secretions and culture data, continue to\n monitor central line site, consider site change and tip culture.\n Electrolyte & fluid disorder, other\n Assessment:\n Serum sodium 129 down from 132, serum 5.4 In range from last several\n days, bun/cr wnl, uo 100cc+/hr\n Action:\n Fluid intake minimized, serum and urine osmo obtained.\n Response:\n Tube feeds at 50cc/hr, current IV antibiotics in smallest volumes, neo\n gtt off\n Plan:\n Follow lytes, bun/cr, and serum/urine osmo results. Continue to limit\n fluid intake.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341717,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341878,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Black tarry stool with guiac positive hemocult. Elevated BUN\n Action:\n Tube feeds held, HCT drawn, sicu resident notified\n Response:\n HCT 31 from 34.9\n Plan:\n Continue to monitor HCT and guiac stools\n Intracerebral hemorrhage (ICH)\n Assessment:\n While patient became hypotensive (see below) patient noted to be less\n responsive and lethargic\n Action:\n Neurosurg team notified, Neo gtt started to maintain MAP > 80, SBP >\n 100\n Response:\n Currently opens eyes to stimulation and withdraws all extremities to\n nailbed pressure, however still remains less alert than previously\n (neurosurg aware)\n Plan:\n Continue on q 2 hrs neuro checks, maintain MAP and SBP goals\n Tachycardia, Other\n Assessment:\n HR consistently 130\n Action:\n Given 10 mg of Labetalol\n Response:\n Decreased to 100-110\n Plan:\n Continue to monitor\n Hypotension (not Shock)\n Assessment:\n HR 120\ns, SBP 80\ns-90\n Action:\n Given 2 500cc fluid bolus\n of NS, Neo started and titrated to MAP >80,\n SBP 100-180\n Response:\n MAP and SBP maintained within goals\n Plan:\n Continue to monitor and titrate Neo to MAP >80, SBP 100-180\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342047,
"text": "Tachycardia, Other\n Assessment:\n Tachycardic w/low grade temps.\n Action:\n Tylenol and Fentanyl for discomfort.\n Response:\n HR decreased to 100-115, appearing more comfortable.\n Plan:\n Continue to monitor HR, temp curve and comfort.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tachypneic w/low volumes.\n Action:\n PSV increased to 10.\n Response:\n RR decreased , breathing more comfortably.\n Plan:\n Re-attempt vent wean in am.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341508,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolytes\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. ICP 12-16. Pupils equal and reactive, withdrawls extremities\n to nailbed pressure, does not follow commands, opens eyes\n spontaneously.\n Action:\n Assess neuro status q2, assess ventricular drainage, monitor ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, monitor ICP\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach, on ventilator CPAP & PS 15, 40% FiO2, 5 PEEP, tidal\n volumes\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341509,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolytes\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. ICP 12-16. Pupils equal and reactive, withdrawls extremities\n to nailbed pressure, does not follow commands, opens eyes\n spontaneously.\n Action:\n Assess neuro status q2, assess ventricular drainage, monitor ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, monitor ICP\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach, on ventilator CPAP & PS 15, 40% FiO2, 5 PEEP, tidal\n volumes approx 400. O2 sats 93%-94%, RR 18-24. PEG tube with replete\n with fiber tube feeds infusing at 50 cc/hr.\n Action:\n ETT suctioned for small amounts of thick yellow sputum q 2-3 hrs. Mouth\n suctioned for copious amounts of clear secretions.\n Response:\n O2 sats maintained >93%\n Plan:\n Continue to suction prn, assess lung sounds, assess VS.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 339961,
"text": "Patient is a 44 yo female s/p fall while walking, striking head\n directly. Patient found down, unknown length of time. Sustained IVH,\n cerebellar hemorrhage. Patient to OR night of admission, for\n craniotomy and hematoma evacuation. Neuro exam remains poor, patient\n remains intubated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n s/p craniotomy, ventriculostomy placement. Neuro exam remains poor,\n brain stem reflexes intact except for corneals. Not opening eyes, no\n communication of any kind. Only response is to painful stimulus.\n Action:\n Serial neuro exams, low environmental stimulus, icp drain raised to\n 15cm above tragus, continuing to drain 5-10cc/h. icp\ns stable.\n Response:\n As above, exam poor, gag and cough slowly improving. Withdrawing to\n nailbed pressure, at times w/ spont posturing of all limbs.\n Plan:\n Cont serial neuro exams, follow icp\ns and drainage from EVD ongoing.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient remains intubated via ett at this time, mech ventilated on\n cpap+ps mode.\n Action:\n Weaned psv to 5 from 8, tol well for short while, becoming tachypneic,\n returned to prev. settings.\n Response:\n As above, able to only tolerate lower psv for short time. Patient\n hypocarbic at times despite changes in settings d/t central breathing\n pattern.\n Plan:\n Cont to attempt weaning of psv as tolerated, full vent support as\n needed. For trach procedure tomorrow.\n .H/O transplant, pancreas\n Assessment:\n s/p pancreas txp , kidney txp .\n Action:\n Tacrolimus level 2.6 today, txp team following. Glucose levels stable,\n sliding scale coverage prn.\n Response:\n Tacro dose increased as per txp team rec\n Plan:\n Follow daily levels, glucose levels ongoing.\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340032,
"text": "TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1. 2. 3. 500 mL NS 4. Bisacodyl 5. Calcium Gluconate 6. CefazoLIN 7.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10. Heparin 11. Insulin\n 12. Labetalol IV/PO 13. Levothyroxine Sodium 14. Magnesium Sulfate 15.\n Mycophenolate Mofetil 16. Neutra-Phos 17. Pantoprazole 18.\n Phenylephrine 19. Potassium Chloride 20. Potassium Phosphate 21. Senna\n 22. Sodium Chloride 0.9% Flush 23. Sodium Chloride 0.9% Flush 24.\n Sulfameth/Trimethoprim SS 25. Tacrolimus 26. Hydralazine prn\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 PM\n URINE CULTURE - At 12:24 PM\n BLOOD CULTURED - At 01:00 PM\n FEVER - 101.6\nF - 12:00 PM\n () Temp 101, blood/urine cx sent. Consented for Trach/PEG.\n Neurosurg raised drain to 15cm.\n Post operative day:\n POD#5 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 03:55 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:25 PM\n Pantoprazole (Protonix) - 06:00 PM\n Other medications:\n Flowsheet Data as of 04:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.6\n T current: 37.3\nC (99.1\n HR: 83 (75 - 105) bpm\n BP: 105/49(72) {85/46(63) - 166/77(110)} mmHg\n RR: 23 (17 - 35) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.8 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 17 (10 - 18) mmHg\n Total In:\n 2,934 mL\n 384 mL\n PO:\n Tube feeding:\n 1,680 mL\n 280 mL\n IV Fluid:\n 804 mL\n 44 mL\n Blood products:\n Total out:\n 3,526 mL\n 675 mL\n Urine:\n 3,330 mL\n 630 mL\n NG:\n Stool:\n Drains:\n 196 mL\n 45 mL\n Balance:\n -592 mL\n -291 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 389 (331 - 400) mL\n PS : 15 cmH2O\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 48\n PIP: 21 cmH2O\n SPO2: 99%\n ABG: 7.43/32/185/20/-1\n Ve: 11.9 L/min\n PaO2 / FiO2: 308\n Physical Examination\n General Appearance: intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), postures to painful stimuli\n UE, on LE- withdraws to painful stimuli\n Labs / Radiology\n 211 K/uL\n 13.9 g/dL\n 157 mg/dL\n 0.7 mg/dL\n 20 mEq/L\n 4.3 mEq/L\n 19 mg/dL\n 107 mEq/L\n 136 mEq/L\n 41.5 %\n 8.9 K/uL\n [image002.jpg]\n 02:12 AM\n 01:12 PM\n 02:00 AM\n 02:21 AM\n 02:38 AM\n 07:43 AM\n 01:54 AM\n 01:59 AM\n 02:37 PM\n 02:07 AM\n WBC\n 10.2\n 9.2\n 8.9\n Hct\n 40.4\n 41.4\n 41.5\n Plt\n 199\n 187\n 211\n Creatinine\n 0.8\n 0.8\n 0.7\n TCO2\n 19\n 19\n 21\n 20\n 23\n 22\n Glucose\n 135\n 151\n 145\n 141\n 157\n Other labs: Amylase / Lipase:86/57, Lactic Acid:1.2 mmol/L, Ca:9.2\n mg/dL, Mg:1.9 mg/dL, PO4:2.0 mg/dL\n Imaging: CT head: No new regions of intracranial hemorrhage\n identified w/ stable appearance to R cerebellar hemorrhage and\n intraventricular hemorrhage. Decreased conspicuity to L frontal\n subarachnoid hemorrhage c/w evolving blood products.\n CT head:Interval decrease in size of R cerebellar hemorrhage\n postoperatively, w/expected pneumocephalus. R frontal approach drain\n terminates w/tip in 3rd ventricle, w/no evidence of ventriculomegaly.\n Unchanged size/appearance of small L frontal subarachnoid hemorrhage.\n CT Cspine: no acute fx; 3mm calcific density subjacent to\n anterior arch of C1 (stable from ), which may be dystrophic\n ligamentous calcification as there is no identifiable \"donor\" fracture\n site (FINAL)\n echo: EF >65%, 1+ TR, 1+ AR\n Microbiology: Blood cx, urine cx: P\n CSF cx: 2+PMNs, no orgs\n sputum cx: P\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w/occipital\n fx/cerebellar hematoma s/p drainage ()\n Neurologic: Neuro checks Q: 2 hr, ICP monitor, Ventriculostomy, Keep\n ICP <25, Neuro checks Q2hr, Ventriculostomy in\n place @15cm, draining.\n Cardiovascular: Beta-blocker, BP controlled with PO labetalol, prn\n hydralazine\n Pulmonary: (Ventilator mode: CPAP + PS), Trach today\n Gastrointestinal / Abdomen: PEG today\n Nutrition: NPO, TF held for Trach/PEG today\n Renal: Foley, Adequate UO, Tacrolimus 4mg q12h with qd levels in AM\n Hematology: hct stable\n Endocrine: RISS, s/p pancreas/renal transplant for DM1, off glycemic\n medications at home.\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341650,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: At times tachypneic but appearing comfortable\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341875,
"text": "Tachycardia, Other\n Assessment:\n HR consistently 130\n Action:\n Given 10 mg of Labetalol\n Response:\n Decreased to 100-110\n Plan:\n Continue to monitor\n Hypotension (not Shock)\n Assessment:\n HR 120\ns, SBP 80\ns-90\n Action:\n Given 2 500cc fluid bolus\n of NS, Neo started and titrated to MAP >80,\n SBP 100-180\n Response:\n MAP and SBP maintained within goals\n Plan:\n Continue to monitor and titrate Neo to MAP >80, SBP 100-180\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341507,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolytes\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. Pupils equal and reactive,\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341947,
"text": "Demographics\n Day of mechanical ventilation: 14\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt on CPAP/PS 12/5 all shift/Vts 300-400\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: AM RSBI 76\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341328,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Psv 15/5\n Visual assessment of breathing pattern: occ episodic tachypnea,\n resolves spontaneously\n Assessment of breathing comfort: Nard\n Invasive ventilation assessment:\n Trigger work assessment: satisfactory\n Dysynchrony assessment: none noted\n Comments:\n Plan\n Next 24-48 hours: Rsbi 147: Pt not ready to wean yet, abundant\n secretions, thick yell to tan\n Reason for continuing current ventilatory support: secretions,\n increased dead space, ? neuro\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341332,
"text": "HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Tachycardia, Other\n Assessment:\n HR 110s-120s\n Action:\n 5-10 mg IV lopressor given as ordered\n Response:\n HR decreased <110\n Plan:\n Continue to assess HR, assess pain level, decrease stimuli\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.5\n Action:\n 650 mg Tylenol given via PEG tube, administer antibiotics as ordered\n Response:\n Fever decreased to 100.3\n Plan:\n Continue to assess VS, administer Tylenol & antibiotics as ordered,\n cool cloths to face\n Hypertension, benign\n Assessment:\n BP increased 180s/80s\n Action:\n 10 mg hydralazine IV given as ordered\n Response:\n BP decreased 120s-140s/50s\n Plan\n Continue to monitor BP, assess pain, decrease stimuli\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP & PS 50% FiO2, 5 PEEP, 15 PS, tidal volumes approx\n 400, RR 20-30, O2 sat >96%, + secretions, absent gag, impaired cough,\n ABG PaO2=170.\n Action:\n Suctioned q2 hours for small to moderate amounts of thick, yellow\n sputum from ETT, suctioned copious amounts of clear secretions from\n mouth, assess lung sounds, FiO2 level decreased to 40% by respiratory\n therapist.\n Response:\n O2 sats maintained > 95%, RR remains 20-30, repeat ABG pending.\n Plan:\n Continue to assess lung sounds, suction prn, assess VS, assess lab\n results.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opens eyes spontaneously, does not follow commands, withdrawls all\n extremities to nailbed pressure, pupils 3 mm equal & reactive, vent\n drain 25 @ tragus draining small amounts of clear fluid.\n Action:\n Assess neuro status, assess vent drainage\n Response:\n No change in neuro status\n Plan:\n Continue Q2 neuro checks, maintain vent drain.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341943,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Guiac + black tarry stool x 3\n Action:\n Serial hcts drawn.\n Response:\n Hct stable 31 range\n Plan:\n Tube feeds resumed per HO.\n Tachycardia, Other\n Assessment:\n Episodes stachycardia 120\ns w sbp > 160\n Action:\n Labetolol 10mg iv x 1\n Response:\n Hr 90-100 nsr.\n Plan:\n Continue to monitor hr > 100. rx w labetolol prn if sbp adequate\n Hypotension (not Shock)\n Assessment:\n Spontaneous drop in sbp 80\ns w hr 60-70\ns. Neuro exam unchanged except\n pt more difficult to arouse(HO aware).cvp 6-8. uop > 50cc/hr\n Action:\n Neo gtt resumed\n Response:\n Map > 80 on neo 2mcg/kg/m\n Plan:\n Continue to monitor Map and cvp.Wean neo as tol for map > 80\n Intracerebral hemorrhage (ICH)\n Assessment:\n Inconsistently awake and following commands x 1 only. Neuro exam\n unchanged. More difficult to arouse w sbp < 120. Continues to withdraw\n to nailbed pressure all 4 extremeties. While more awake, lifts head off\n pillow spontaneously not to command.\n Action:\n Titrating neo to goal map > 80. Frequent reorient pt to surroundings\n while awake.\n Response:\n Maintained map > 80 with neo.\n Plan:\n Continue on q2hr neuro checks, maintain map> 80.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341325,
"text": "HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Tachycardia, Other\n Assessment:\n HR 110s-120s\n Action:\n 5-10 mg IV lopressor given as ordered\n Response:\n HR decreased <110\n Plan:\n Continue to assess HR, assess pain level, decrease stimuli\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.5\n Action:\n 650 mg Tylenol given via PEG tube, administer antibiotics as ordered\n Response:\n Fever decreased to 100.3\n Plan:\n Continue to assess VS, administer Tylenol & antibiotics as ordered,\n cool cloths to face\n Hypertension, benign\n Assessment:\n BP increased 180s/80s\n Action:\n 10 mg hydralazine IV given as ordered\n Response:\n BP decreased 120s-140s/50s\n Plan\n Continue to monitor BP, assess pain, decrease stimuli\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP & PS 50% FiO2, 5 PEEP, 15 PS, tidal volumes approx\n 400, RR 20-30, O2 sat >96%, + secretions, absent gag, impaired cough,\n ABG PaO2=170.\n Action:\n Suctioned q2 hours for small to moderate amounts of thick, yellow\n sputum from ETT, suctioned copious amounts of clear secretions from\n mouth, assess lung sounds, FiO2 level decreased to 40% by respiratory\n therapist.\n Response:\n O2 sats maintained > 95%, RR remains 20-30, repeat ABG pending.\n Plan:\n Continue to assess lung sounds, suction prn, assess VS, assess lab\n results.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340548,
"text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Still randomly opening eyes and withdrawing. No neuro improvement\n noted, ICP <20\n Action:\n Labetalol for HTN changed 300mg to 100mg due to decreased CPP ,\n Hypotension and low u/o\n MRI this pm to assess for cerebral infarct. On trach collar this\n afternoon.\n Response:\n BP better, up to 160-170 this pm. CPP > 60 . 1^st dose of 100 mg\n labetalol given at 6pm. U/o up to 30cc/hr.\n SaO2 > 98% on trach collar. Resp even and unlabored.\n Plan:\n Continue ICP open to drainage at 15 cm, Q2H neuro exams, Monitor BP and\n resp status. Keep CPP > 60. Remain on trach collar as tol.\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341856,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 0900\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 342040,
"text": "Demographics\n Day of mechanical ventilation: 15\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Known difficult intubation: No\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: PSV increased from 5 to 10 due to drop in Vts into 200s/RR\n 40s/tachycardia. RR still remained 33-35/Vts increased to 300s\n Plan\n Next 24-48 hours: Trach collar trials during the day.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341547,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolyte lab results\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. ICP 12-16. Pupils equal and reactive, withdrawls extremities\n to nailbed pressure, does not follow commands, opens eyes\n spontaneously.\n Action:\n Assess neuro status q2, assess ventricular drainage, monitor ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, monitor ICP\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach, on ventilator CPAP & PS 15, 40% FiO2, 5 PEEP, tidal\n volumes approx 400. O2 sats 93%-94%, RR 20-30. PEG tube with replete\n with fiber tube feeds infusing at 50 cc/hr.\n Action:\n ETT suctioned for small amounts of thick yellow sputum q 2-3 hrs. Mouth\n suctioned for copious amounts of clear secretions.\n Response:\n O2 sats maintained >93%\n Plan:\n Continue to suction prn, assess lung sounds, assess VS.\n ------ Protected Section ------\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg Labetalol IV q 2 hrs prn\n Response:\n BP decreased 120s-140s/50s-60s\n Plan:\n Continue to assess BP, VS\n ------ Protected Section Addendum Entered By: , RN\n on: 05:54 ------\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341749,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.4\n Action:\n Blood, urine & sputum cultures sent, CXR done; 650 mg Tylenol po given\n Response:\n Temp decreased to 99.7\n Plan:\n Continue to monitor VS\n Electrolyte & fluid disorder, other\n Assessment:\n On lasix gtt at 1 cc/hr, 300 cc + at midnight, 8L + for LOS, trace\n edema noted upper extremities.\n Action:\n Continue lasix gtt at 1 cc/hr per Dr. .\n Response:\n Urine output approx 60-100 cc/hr\n Plan:\n Assess fluid status, assess electrolyte lab results, assess VS,\n continue lasix gtt as ordered\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent drain 25 cm @ tragus, transduced, ICP 6-11 with increase to 20s\n with collection of sputum sample. Withdrawls extremities to nailbed\n pressure, does not follow commands, opens eyes spontaneously. Absent\n gag, impaired cough. Unarousable at times.\n Action:\n Neuro checks q2, assess ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, assess ICP, VS\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Trach & PEG with copious secretions, on CPAP & PS 12, 5 PEEP, 40% FiO2,\n tidal volumes 300s.\n Action:\n Suction prn, maintain tube feeds at 50 cc/hr, ABG as ordered\n Response:\n RR 20-30s, O2 sat >93%, ABG WNL\n Plan:\n Continue to assess respiratory status, assess lung sounds, assess ABG\n values, maintain TF\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 340542,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient successfully weaned down to cool-mist via trach collar, is now\n on 40%, ventilator in stand-by, SPO2 upper 90s, breath sounds\n bilaterally clear, suctioned for moderate thick yellow secretion, cuff\n remains inflated, patient traveled to MRI, no distress occurred, was on\n MRI , continues to be followed.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341544,
"text": "45F fall w/ IPH/occiptal fx. complicated PMH:live donor renal\n translplant , cavaderic pancreas transplant , CMV infection,\n pancreatic head AV fistula s/p embolization , medication induced\n pancytopenia, DM 1,ESRD,retinopathy, lumpectomy, restless leg syndrome,\n hypothryoidism\n : EVD placed. OR for crani/evacuation.\n Hypertension, benign\n Assessment:\n BP 180s/80s\n Action:\n 10 mg labetalol IV q2 prn\n Response:\n BP decreased 130s-140s/50-60s\n Plan:\n Continue to assess VS, BP\n Electrolyte & fluid disorder, other\n Assessment:\n Pt on lasix gtt at 1 cc/hr, approx 300 cc negative at midnight, Na=130\n Action:\n Continue lasix gtt\n Response:\n Urine output approx 200 cc/hr\n Plan:\n Continue lasix gtt, assess fluid status, assess electrolyte lab results\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with vent drain 15 cm @ tragus draining approx 6-15 cc clear fluid\n per hour. ICP 12-16. Pupils equal and reactive, withdrawls extremities\n to nailbed pressure, does not follow commands, opens eyes\n spontaneously.\n Action:\n Assess neuro status q2, assess ventricular drainage, monitor ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, monitor ICP\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with trach, on ventilator CPAP & PS 15, 40% FiO2, 5 PEEP, tidal\n volumes approx 400. O2 sats 93%-94%, RR 20-30. PEG tube with replete\n with fiber tube feeds infusing at 50 cc/hr.\n Action:\n ETT suctioned for small amounts of thick yellow sputum q 2-3 hrs. Mouth\n suctioned for copious amounts of clear secretions.\n Response:\n O2 sats maintained >93%\n Plan:\n Continue to suction prn, assess lung sounds, assess VS.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341638,
"text": "45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Altered mental status (not Delirium)\n Assessment:\n Patient opening eyes, nodding head to questions, following commands.\n ICP 9-16\n Action:\n Pt reoriented to place and events.\n ventriculostomy drain raised to 25cm>tragus.\n Response:\n Pt appears to understand explanations and is calm in demeanor.\n Ventriculostomy draining clear fluid at 0-10cc/hr.\n Plan:\n Continue q2hr neuro exams, reorient prn.\n Follow ICP\ns, ventriculostomy output.\n Notify team of any decline in neuro exam.\n Electrolyte & fluid disorder, other\n Assessment:\n Serum sodium 129-130.\n LOS fluid balance 8L.\n BUN slightly elevated at 31/cr 1.0\n Action:\n Data discussed with ICU team on rounds.\n Pt examined by renal fellow.\n Response:\n Lasix gtt continued at 1mg/hr\n UO >100cc/hr clear yellow\n Plan:\n Daily bun/cr, serum sodium, hourly uo. Re-evaluate in am with ICU team\n Adendum: Family meeting this morning with Dr., pts brother\n and Sister , nursing and social worker. Please see notes.\n Family allowed time to voice concerns and questions which were answered\n to their satisfaction. Decision made to continue current course of\n treatment with future family meeting in 10 days or so or as warranted\n if pts condition changes.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341744,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.4\n Action:\n Blood, urine & sputum cultures sent, CXR done; 650 mg Tylenol po given\n Response:\n Temp decreased to 99.7\n Plan:\n Continue to monitor VS\n Electrolyte & fluid disorder, other\n Assessment:\n On lasix gtt at 1 cc/hr, 300 cc + at midnight, 8L + for LOS, trace\n edema noted upper extremities.\n Action:\n Continue lasix gtt at 1 cc/hr per Dr. .\n Response:\n Urine output approx\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent drain 25 cm @ tragus, transduced, ICP 6-11 with increase to 20s\n with collection of sputum sample. Withdrawls extremities to nailbed\n pressure, does not follow commands, opens eyes spontaneously. Absent\n gag, impaired cough. Unarousable at times.\n Action:\n Neuro checks q2, assess ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, assess ICP, VS\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 341746,
"text": "Demographics\n Day of mechanical ventilation: 13\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n AM RSBI-141. Pt on CPAP/PS 12/5/.40.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340781,
"text": "Altered mental status (not Delirium)\n Assessment:\n Inconsistent neuro status\n Action:\n Frequent neuro exam unresponsive to sternal rub with exception of\n alertness +nodding appropriately x1 only . neurosurg resident notified.\n Response:\n unchanged\n Plan:\n Continue frequent neuro checks\n Hypertension, benign\n Assessment:\n hypertension\n Action:\n Labetolol given as ordered\n Response:\n Hypotension with subsequent decreased cpp. Neo intiated with\n improvement\n Plan:\n Wean neo as tolerated by cpp >60\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Stable respiratory status on cpap\n Action:\n Trache collar\n Response:\n Stable respiratory status, sats >95%\n Plan:\n Continue trach collar as tolerated\n Intracerebral hemorrhage (ICH)\n Assessment:\n Ventriculostomy drain increased to 20 cm h2o at tragus Increased icp by\n neurosurg at 0900. increased icp to 23.\n Action:\n Neurosurgery notified\n Response:\n Icp 19-20\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341324,
"text": "HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Tachycardia, Other\n Assessment:\n HR 110s-120s\n Action:\n 5-10 mg IV lopressor given as ordered\n Response:\n HR decreased <110\n Plan:\n Continue to assess HR, assess pain level, decrease stimuli\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.5\n Action:\n 650 mg Tylenol given via PEG tube, administer antibiotics as ordered\n Response:\n Fever decreased to 100.3\n Plan:\n Continue to assess VS, administer Tylenol & antibiotics as ordered,\n cool cloths to face\n Hypertension, benign\n Assessment:\n BP increased 180s/80s\n Action:\n 10 mg hydralazine IV given as ordered\n Response:\n BP decreased 120s-140s/50s\n Plan\n Continue to monitor BP, assess pain, decrease stimuli\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP & PS 50% FiO2, 5 PEEP, 15 PS, tidal volumes approx\n 400, RR 20-30, O2 sat >96%, + secretions, absent gag, impaired cough,\n ABG PaO2=170.\n Action:\n Suctioned q2 hours for small to moderate amounts of thick, yellow\n sputum from ETT, suctioned copious amounts of clear secretions from\n mouth, assess lung sounds, FiO2 level decreased to 40% by respiratory\n therapist.\n Response:\n O2 sats maintained > 95%,\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341741,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.4\n Action:\n Blood, urine & sputum cultures sent, CXR done; 650 mg Tylenol po given\n Response:\n Temp decreased to 99.7\n Plan:\n Continue to monitor VS\n Electrolyte & fluid disorder, other\n Assessment:\n On lasix gtt at 1 cc/hr,\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent drain 25 cm @ tragus, transduced, ICP 6-11 with increase to 20s\n with collection of sputum sample. Withdrawls extremities to nailbed\n pressure, does not follow commands, opens eyes spontaneously. Absent\n gag, impaired cough. Unarousable at times.\n Action:\n Neuro checks q2, assess ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, assess ICP, VS\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341742,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.4\n Action:\n Blood, urine & sputum cultures sent, CXR done; 650 mg Tylenol po given\n Response:\n Temp decreased to 99.7\n Plan:\n Continue to monitor VS\n Electrolyte & fluid disorder, other\n Assessment:\n On lasix gtt at 1 cc/hr, 300 cc + at midnight, 8L + for LOS,\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent drain 25 cm @ tragus, transduced, ICP 6-11 with increase to 20s\n with collection of sputum sample. Withdrawls extremities to nailbed\n pressure, does not follow commands, opens eyes spontaneously. Absent\n gag, impaired cough. Unarousable at times.\n Action:\n Neuro checks q2, assess ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, assess ICP, VS\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341745,
"text": "HPI:45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.4\n Action:\n Blood, urine & sputum cultures sent, CXR done; 650 mg Tylenol po given\n Response:\n Temp decreased to 99.7\n Plan:\n Continue to monitor VS\n Electrolyte & fluid disorder, other\n Assessment:\n On lasix gtt at 1 cc/hr, 300 cc + at midnight, 8L + for LOS, trace\n edema noted upper extremities.\n Action:\n Continue lasix gtt at 1 cc/hr per Dr. .\n Response:\n Urine output approx 60-100 cc/hr\n Plan:\n Assess fluid status, assess electrolyte lab results, assess VS,\n continue lasix gtt as ordered\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent drain 25 cm @ tragus, transduced, ICP 6-11 with increase to 20s\n with collection of sputum sample. Withdrawls extremities to nailbed\n pressure, does not follow commands, opens eyes spontaneously. Absent\n gag, impaired cough. Unarousable at times.\n Action:\n Neuro checks q2, assess ICP\n Response:\n Neuro status unchanged\n Plan:\n Continue to assess neuro status, assess ICP, VS\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Trach & PEG with copious secretions, on CPAP & PS\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 340418,
"text": "TITLE:\n TSICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation\n Chief complaint:\n intracranial bleed\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n Current medications:\n 1Bisacodyl 4. Calcium Gluconate 5. CefazoLIN 6. Chlorhexidine Gluconate\n 0.12% Oral Rinse 7. Docusate Sodium (Liquid) 8. Fentanyl Citrate 9.\n Heparin 10. HydrALAzine 11. Insulin 12. Labetalol 3. Levothyroxine\n Sodium 14. Magnesium Sulfate 15. Mycophenolate Mofetil 16. Pantoprazole\n 17. Potassium Chloride\n 18. Potassium Phosphate 19. Senna 20. Sodium Chloride 0.9% Flush 21.\n Sodium Chloride 0.9% Flush 22. Sulfameth/Trimethoprim SS 23. Tacrolimus\n 24 Hour Events:\n BLOOD CULTURED - At 12:24 PM\n URINE CULTURE - At 12:24 PM\n BLOOD CULTURED - At 01:00 PM\n FEVER - 101.6\nF - 12:00 PM\n Bradycardia to 30s during positioning for Trach placement\n Post operative day:\n POD#6 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 04:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.1\n T current: 36.8\nC (98.2\n HR: 65 (64 - 113) bpm\n BP: 126/51(76) {105/49(69) - 166/70(103)} mmHg\n RR: 14 (14 - 33) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 25 (13 - 28) mmHg\n Total In:\n 1,502 mL\n 40 mL\n PO:\n Tube feeding:\n 280 mL\n IV Fluid:\n 1,112 mL\n 40 mL\n Blood products:\n Total out:\n 2,244 mL\n 209 mL\n Urine:\n 2,080 mL\n 175 mL\n NG:\n Stool:\n Drains:\n 164 mL\n 34 mL\n Balance:\n -742 mL\n -169 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 315 (185 - 385) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 87\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: 7.47/32/111/22/0\n Ve: 8.5 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese trach ok\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present, Obese peg site\n ok\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: now opens eyes\n Labs / Radiology\n 252 K/uL\n 13.6 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 22 mEq/L\n 5.5 mEq/L\n 23 mg/dL\n 103 mEq/L\n 133 mEq/L\n 40.4 %\n 8.7 K/uL\n [image002.jpg]\n 02:21 AM\n 02:38 AM\n 07:43 AM\n 01:54 AM\n 01:59 AM\n 02:37 PM\n 02:07 AM\n 06:19 AM\n 01:53 AM\n 02:13 AM\n WBC\n 10.2\n 9.2\n 8.9\n 8.7\n Hct\n 40.4\n 41.4\n 41.5\n 40.4\n Plt\n 199\n 187\n 211\n 252\n Creatinine\n 0.8\n 0.8\n 0.7\n 0.9\n TCO2\n 21\n 20\n 23\n 22\n 25\n 24\n Glucose\n 151\n 145\n 141\n 157\n 126\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Ca:9.4\n mg/dL, Mg:2.2 mg/dL, PO4:3.8 mg/dL\n Imaging: CT head:Hypodensities are now apparent at the superior\n aspect of the cerebellum could be due to acute infarcts. MRI can help\n for further assessment. No new hemorrhages seen. There has been\n decrease in mass effect with better appreciated basal cisterns on the\n current study\n CT head: No new regions of intracranial hemorrhage identified w/\n stable appearance to R cerebellar hemorrhage and intraventricular\n hemorrhage. Decreased conspicuity to L frontal subarachnoid hemorrhage\n c/w evolving blood products.\n CT head:Interval decrease in size of R cerebellar hemorrhage\n postoperatively, w/expected pneumocephalus. R frontal approach drain\n terminates w/tip in 3rd ventricle, w/no evidence of ventriculomegaly.\n Unchanged size/appearance of small L frontal subarachnoid hemorrhage.\n CT Cspine: no acute fx; 3mm calcific density subjacent to\n anterior arch of C1 (stable from ), which may be dystrophic\n ligamentous calcification as there is no identifiable \"donor\" fracture\n site (FINAL)\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45F s/p fall backward from standing, w/occipital\n fx/cerebellar hematoma s/p drainage\n Neurologic: Keep ICP <25, Neuro checks Q2hr, Ventriculostomy in\n place @15cm, draining.\n Cardiovascular: Hemodynamically stable, on labatelol PO, off gtt:\n target SBP < 160, CPP > 60.\n Pulmonary: Trach, S/P trach psv yo 5\n Gastrointestinal / Abdomen: Soft, nontender, + BS. PEG placed NPO\n except for meds for 24 hours, holding tube feeds, will restart in AM at\n goal of 70\n Nutrition: NPO, TF held after PEG, will restart at 20 with goal of 70\n Renal: Foley, Foley, Adequate UO. Tacrolimus 4mg q12h with qd levels in\n AM\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: monitor WBC, afebrile. F/U sputum and CSF cx.\n On Bactrim for prophylaxis. negative thus far, BLD PND\n Lines / Tubes / Drains: Foley, Trach, Foley, ventriculostomy, Aline\n Wounds:\n Imaging: Brain MRI today\n Fluids: NS\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340782,
"text": "Altered mental status (not Delirium)\n Assessment:\n Inconsistent neuro status\n Action:\n Frequent neuro exam unresponsive to sternal rub with exception of\n alertness +nodding appropriately x1 only . neurosurg resident notified.\n Response:\n unchanged\n Plan:\n Continue frequent neuro checks\n Hypertension, benign\n Assessment:\n hypertension\n Action:\n Labetolol given as ordered\n Response:\n Hypotension with subsequent decreased cpp. Neo intiated with\n improvement\n Plan:\n Wean neo as tolerated by cpp >60\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Stable respiratory status on cpap\n Action:\n Trache collar\n Response:\n Stable respiratory status, sats >95%\n Plan:\n Continue trach collar as tolerated\n Intracerebral hemorrhage (ICH)\n Assessment:\n Ventriculostomy drain increased to 20 cm h2o at tragus Increased icp by\n neurosurg at 0900. increased icp to 23.\n Action:\n Neurosurgery notified\n Response:\n Icp 19-20\n Plan:\n Continue to monitor\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101\n Action:\n pancultured\n Response:\n unchanged\n Plan:\n Follow up cultures\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341319,
"text": "HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Tachycardia, Other\n Assessment:\n HR 110s-120s\n Action:\n 5-10 mg IV lopressor given as ordered\n Response:\n HR decreased <110\n Plan:\n Continue to assess HR, assess pain level, decrease stimuli\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.5\n Action:\n 650 mg Tylenol given via PEG tube, administer antibiotics as ordered\n Response:\n Fever decreased to 100.3\n Plan:\n Continue to assess VS, administer Tylenol & antibiotics as ordered,\n cool cloths to face\n Hypertension, benign\n Assessment:\n BP increased 180s/80s\n Action:\n 10 mg hydralazine IV given as ordered\n Response:\n BP decreased 120s-140s/50s\n Plan\n Continue to monitor BP, assess pain, decrease stimuli\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP & PS 50% FiO2, 5 PEEP, 15 PS, tidal volumes\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 342013,
"text": "Hypotension (not Shock)\n Assessment:\n SBP labile from 80s-160s.\n Action:\n Neo gtt weaned to off, started on PO mididrine\n Response:\n Pt remains labile with SBP dipping to 80s off neo temporarily. Rebounds\n with some stimulation/transient use of neo gtt again.\n Plan:\n Wean neo to off and cont PO mididrine. ?increase dose mididrine.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt cont with loose/liquid black stool x3 this AM. Continuing to stool\n through out shift.\n Action:\n Flexiseal inserted for continuous black liquid stool. CDIFF specimen\n sent.\n Response:\n Containment of stool successful.\n Plan:\n Cont use of flexiseal as long as stool is liquid/loose enough for safe\n containment. CDIFF specimens x2 need to be sent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats 97-100%. RR 20s. LS clear-coarse.\n Action:\n Pt placed on trach collar, 50% all day. Suctioned several times for\n thick yellow secretion.\n Response:\n ABGs WNL. Pt appears to be tolerating trach collar with minimal\n increase in RR and no sign of WOB.\n Plan:\n Cont trach collar during days as tol. Rest pt back on vent for nights.\n Cont monitor RR, ABGs, O2 sat.\n"
},
{
"category": "Nursing",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 341318,
"text": "HPI: 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation ()\n Tachycardia, Other\n Assessment:\n HR 110s-120s\n Action:\n 5-10 mg IV lopressor given as ordered\n Response:\n HR decreased <110\n Plan:\n Continue to assess HR, assess pain level, decrease stimuli\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.5\n Action:\n 650 mg Tylenol given via PEG tube, administer antibiotics as ordered\n Response:\n Fever decreased to 100.3\n Plan:\n Continue to assess VS, administer Tylenol & antibiotics as ordered,\n cool cloths to face\n Hypertension, benign\n Assessment:\n BP increased 180s/80s\n Action:\n 10 mg hydralazine IV given as ordered\n Response:\n BP decreased 120s-140s/50s\n Plan\n Continue to monitor BP, assess pain, decrease stimuli\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP & PS\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2106-08-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 341416,
"text": "SICU\n HPI:\n 45F s/p fall backward from standing, w occipital fx/cerebellar\n hematoma, s/p crani/evacuation (), PEG and trach. Currently stable\n BP and ICPs.\n Events:\n : EVD placed. OR for crani/evacuation. Following commands x4\n :Head CT stable\n :Does not follow commands, ICP 21-24, Labetalol started for BP >160\n :Withdraws lower ext to pain, ICP 14-16, CSF drawn from EVD:no\n growth\n :Exam unchanged, Q2hr neuro checks, EVD raised to 15.\n : ICP's ;STAT HCT for abrupt positional changes,without drain\n adjustment and increased output, trach/PEG, CT:hematologically stable;\n however infarcts seen in cerebellum not noted on prior images.\n transferred to SICU, MR done\n -Pt with fever, Pan cultured. Labetalol decreased back to 100 tid as\n pt hypotensive\n -Labile BP overnight, resp distress. placed on AC by RT\n - allowed to autoregulate, consulted orthopedics for arm fracture,\n following urine/serum osmoles\n Chief complaint:\n respiratory failure, sepsis, IPH\n PMHx:\n ESRD secondary to uncontrolled DM1, s/p LURT ; cadaveric pancreas\n tx , CMV pancytopenia, hypothyroid, retinopathy, restless legs\n syndrome, flow-related heart murmur\n SURGICAL Hx: LURT , cadaveric pancreas txp , L tib/fib\n fixation, s/p b/l breast lumpectomies many yrs ago, s/p laser surgery\n for retinopathy\n Current medications:\n 1. 2. 3. Acetaminophen 4. Bisacodyl 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Ciprofloxacin 8. Docusate Sodium (Liquid) 9. Fentanyl Citrate 10.\n Heparin 11. HydrALAzine 12. Insulin\n 13. Levothyroxine Sodium 14. Magnesium Sulfate 15. MetRONIDAZOLE\n (FLagyl) 16. Metoprolol Tartrate\n 17. Metoprolol Tartrate 18. Metoprolol Tartrate 19. Metoprolol Tartrate\n 20. Mycophenolate Mofetil\n 21. Pantoprazole 22. Potassium Chloride 23. Potassium Phosphate 24.\n Senna 25. Sodium Chloride 0.9% Flush\n 26. Sodium Chloride 0.9% Flush 27. Sulfameth/Trimethoprim SS 28.\n Tacrolimus 29. Tacrolimus 30. Vancomycin\n 24 Hour Events:\n STOOL CULTURE - At 12:30 PM\n STOOL CULTURE - At 04:30 AM\n 3rd c diff sent\n FEVER - 101.3\nF - 04:00 PM\n Post operative day:\n POD#10 - crani\n Allergies:\n Codeine\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Ciprofloxacin - 12:01 AM\n Metronidazole - 04:00 AM\n Vancomycin - 07:57 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:00 PM\n Hydralazine - 01:30 AM\n Metoprolol - 05:30 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 11:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 38.2\nC (100.8\n HR: 115 (90 - 124) bpm\n BP: 156/66(94) {122/48(69) - 183/74(113)} mmHg\n RR: 27 (19 - 30) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84.7 kg (admission): 81.5 kg\n Height: 60 Inch\n ICP: 19 (13 - 23) mmHg\n Total In:\n 3,058 mL\n 1,421 mL\n PO:\n Tube feeding:\n 1,200 mL\n 580 mL\n IV Fluid:\n 1,768 mL\n 626 mL\n Blood products:\n Total out:\n 2,394 mL\n 1,370 mL\n Urine:\n 2,280 mL\n 1,325 mL\n NG:\n Stool:\n Drains:\n 114 mL\n 45 mL\n Balance:\n 664 mL\n 51 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 386 (352 - 403) mL\n PS : 15 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 147\n PIP: 21 cmH2O\n SPO2: 95%\n ABG: 7.47/36/128/24/3\n Ve: 10.4 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Labs / Radiology\n 452 K/uL\n 13.0 g/dL\n 135 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.0 mEq/L\n 29 mg/dL\n 97 mEq/L\n 129 mEq/L\n 38.9 %\n 12.9 K/uL\n [image002.jpg]\n 01:00 AM\n 02:36 AM\n 02:41 AM\n 08:21 AM\n 10:50 AM\n 02:16 AM\n 02:28 AM\n 03:08 AM\n 03:31 AM\n 06:06 AM\n WBC\n 10.0\n 12.2\n 12.9\n Hct\n 40.2\n 38.1\n 38.9\n Plt\n 373\n 369\n 452\n Creatinine\n 0.9\n 1.0\n 0.9\n TCO2\n 22\n 26\n 24\n 24\n 24\n 26\n 27\n Glucose\n 131\n 137\n 138\n 135\n Other labs: Amylase / Lipase:97/83, Lactic Acid:1.2 mmol/L, Ca:9.9\n mg/dL, Mg:2.0 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n INTRACEREBRAL HEMORRHAGE (ICH), .H/O TRANSPLANT, KIDNEY (RENAL\n TRANSPLANT), .H/O TRANSPLANT, PANCREAS\n Assessment and Plan: 45 year old female with IPH, now with Cdiff +, VAP\n Neurologic: ICP monitor, Ventriculostomy, unchanged neurologic exam.\n Continue to drain for Ventriculostomy. require VP shunt\n Cardiovascular: Lopressor prn for HR control, however liberalize BP\n control as d/w with NS will allow pt to autoregulate\n Pulmonary: Trach, (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: PEG\n Nutrition: Tube feeding, @ goal\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, + cdiff, on Flagyl, Vanco, Cipro\n for VAP coverage. Follow Vanc trough. Plan 1 week course for VAP\n coverage\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds:\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Nephrology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural),\n (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:29 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 03:30 PM\n Arterial Line - 04:35 PM\n Multi Lumen - 11:50 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Family meeting planning Comments: NS to have family\n meeting tommorow\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1031316,
"text": " 12:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? changes in head bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman t/f form OSH w/ cerebellar bleed\n REASON FOR THIS EXAMINATION:\n ? changes in head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT WITHOUT CONTRAST\n\n INDICATION: 45-year-old woman transferred from an outside hospital with\n cerebellar hemorrhage, presumably traumatic.\n\n COMPARISON: Not available at . Note is made of a non-contrast head CT,\n performed earlier at the outside institution, which is not available on PACS\n at the time of this dictation.\n\n NON-CONTRAST HEAD CT: There is an acute parenchymal hemorrhage in the right\n cerebellar hemisphere, measuring approximately 4.7 x 4.0 cm in the maximal\n axial dimensions, with thin rim of surrounding edema, producing mass effect\n with compression of the fourth ventricle and mass effect on medulla oblongata,\n The right cisterna ambiens is obliterated, and there is flattening of the\n right cerebral peduncle, findings consistent with upward herniation of the\n vermis. The suprasellar cistern is normal. There is no hydrocephalus at this\n time.\n\n Small amount of subarachnoid hemorrhage may be present in the left frontal\n lobe (v. partial volume phenomenon of the floor of the anterior cranial\n fossa). The cerebral - white matter differentiation is preserved.\n\n There is acute nondisplaced fracture of the right occipital bone. Imaged\n mastoid air cells and paranasal sinuses are well aerated. Extensive\n aterosclerotic carotid artery calcifications are noted.\n\n IMPRESSION:\n 1. Large right cerebellar parenchymal hemorrhage, grossly increased in size,\n when compared to prior head CT (the latter not available at the time of\n attending review), with findings consistent with ascending transtentorial\n herniation. It is not clear whether this hemorrhage is traumatic or the fall\n was secondary to the hemorrhage. MR with contrast can be performed to assess\n for underlying lesion.\n 2. Questionable, small left frontal subarachnoid hemorrhage, v. partial\n volume artifact from floor of left side of anterior cranial fossa.\n 3. Nondisplaced right occipital fracture.\n 2. Right occipital subgaleal hematoma.\n\n Findings were discussed with Dr. immediately after scanning was\n completed.\n\n (Over)\n\n 12:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? changes in head bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1031317,
"text": " 12:53 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman t/f form OSH w/ cerebellar bleed\n REASON FOR THIS EXAMINATION:\n ? fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CT CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 45-year-old woman with cerebellar traumatic hemorrhage.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images of the cervical spine were obtained without\n administration of intravenous contrast. Coronal and sagittal reformatted\n images were obtained.\n\n There is no acute fracture or abnormal alignment in the cervical spine,\n however, the assessment is slightly limited by motion artifact. Prevertebral\n soft tissues are normal. The airway is patent. Evaluation of lung apices is\n severely limited by motion, bilateral ground glass opacities are noted,\n compatible with airtrapping. Bilateral atelectasis is noted in the dependent\n posterior locations.\n\n Nondisplaced right occipital bone fracture and associated soft tissue swelling\n in the overlying scalp is noted. Large right cerebellar hemorrhage is better\n evaluated on separate head CT, performed on the same day.\n\n IMPRESSION:\n 1. Nondisplaced right occipital bone fracture.\n 2. Large cerebellar hemorrhage, better assessed on separate study performed\n on the same day.\n 3. No fracture of the cervical spine.\n\n ADDENDUM AT ATTENDING REVIEW: There is a 3mm calcific density subjacent to the\n anterior arch of C1, which may be dystrophic ligamentous calcification as\n there is no identifiable \"donor\" fracture site.\n\n There is prominent atherosclerotic calcification of the common carotid\n bifurcations.\n\n Both of these amended findings were noted on the prior CT scan of the cervical\n spine, from .\n\n If there is any clinical concern for a non-traumatic origin of the cerebellar\n hemorrhage, a follow-up brain MR study with MR angiography would be helpful.\n\n (Over)\n\n 12:53 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? fx\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031762,
"text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusions, atelectasis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F s/p fall backward from standing, w occipital fx/cerebellar hematoma, s/p\n crani/evacuation ()\n REASON FOR THIS EXAMINATION:\n eval for effusions, atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cerebellar hematoma, to evaluate for effusions or atelectasis.\n\n FINDINGS: In comparison with the study of , the endotracheal tube remains\n only about 1.2 cm above the carina. Increased opacification persists in the\n retrocardiac region as well as probably at the right base, consistent with\n atelectasis or even superimposed aspiration.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031320,
"text": " 1:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro intubation placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with ich and s/p ett.\n REASON FOR THIS EXAMINATION:\n ro intubation placement\n ______________________________________________________________________________\n FINAL REPORT\n ET TUBE PLACEMENT.\n\n COMPARISON: .\n\n HISTORY: ET tube placement.\n\n FINDINGS: An ET tube is identified terminating approximately 1.5 cm above the\n carina. There is no evidence of pneumothorax. Slightly exaggerated\n mediastinal contour is likely due to portable technique. The cardiac\n silhouette is stable. Mild prominence of bronchovasculature may be suggestive\n of mild fluid overload. There is no definite consolidation or effusions.\n Increased retrocardiac opacity likely represents atelectasis. Incidental note\n is made of large amount of gastric distention and old bilateral rib\n fractures.\n\n IMPRESSION:\n 1. ET tube 1.5 cm above the carina.\n 2. Possible mild fluid overload.\n 3. Gastric distention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1031368,
"text": " 9:50 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: NG TUBE PLACEMENT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX MON 9:54 AM\n No change in appearance of lungs. Endotracheal tube 1.3 cm above carina.\n Nasogastric tube in place.\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST PORTABLE\n\n HISTORY: NG tube placement.\n\n One view. Increased interstitial markings suggest the possibility of\n pulmonary vascular congestion as before. There is no focal consolidation.\n The heart and mediastinal structures are unchanged. Endotracheal tube\n terminates approximately 1.2 cm above the carina. A nasogastric tube has been\n inserted and terminates below the diaphragm, its side hole in the left upper\n quadrant. The stomach is no longer distended with gas.\n\n IMPRESSION: Placement of nasogastric tube. Endotracheal tube somewhat low.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1031353,
"text": " 7:47 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: change in hemorrhage post op?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with intraparenchymal cerebellar hemorrhage s/p fall now s/p\n crani and evacuation\n REASON FOR THIS EXAMINATION:\n change in hemorrhage post op?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc MON 12:59 AM\n Interval decrease in size of right cerebellar hemorrhage postoperatively, with\n expected pneumocephalus. Right frontal approach drain terminates with the tip\n in the third ventricle, with no evidence of ventriculomegaly. Unchanged size\n and appearance of small left frontal subarachnoid hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old female with intraparenchymal cerebellar hemorrhage\n status post fall, now status post craniectomy and evacuation. Please evaluate\n for change in hemorrhage postoperatively.\n\n COMPARISON: Non-contrast head CT earlier the same day.\n\n TECHNIQUE: Axial imaging was performed from the cranial vertex to the foramen\n magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: A right occipital craniotomy has been performed.\n There has been interval decrease in size of the right cerebellar hemorrhage,\n now measuring approximately 2.7 x 1.8 cm (2:8), which is decreased from\n previous measurements of 4.7 x 4.0 cm. There is associated postoperative\n pneumocephalus in the right cerebellar hemisphere, as well as within the\n occipital soft tissues. There has been a right sided intraventricular drain\n placement, traversing the frontal of the right lateral ventricle, and the\n tip terminating in the third ventricle. Right sided subgaleal hematoma is not\n changed in appearance.\n\n IMPRESSION:\n\n 1. S/P right occipital craniotomy, with interval decrease in size of right\n cerebellar hemispheric hemorrhage and surrounding edema, with postoperative\n pneumocephalus.\n\n 2. Right frontal intraventricular drain, terminating in the third ventricle,\n with no evidence of ventriculomegaly.\n\n\n\n (Over)\n\n 7:47 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: change in hemorrhage post op?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1031369,
"text": ", NSURG TSICU 9:50 PM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: NG TUBE PLACEMENT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n PFI REPORT\n No change in appearance of lungs. Endotracheal tube 1.3 cm above carina.\n Nasogastric tube in place.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031566,
"text": " 8:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate NGT position\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F s/p fall backward from standing, w occipital fx/cerebellar hematoma, s/p\n crani/evacuation\n REASON FOR THIS EXAMINATION:\n evaluate NGT position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To evaluate nasogastric tube following trauma.\n\n FINDINGS: In comparison with the study of , the nasogastric tube extends\n at least to the distal stomach. Some prominence of central pulmonary vessels\n suggests overhydration. The tip of the endotracheal tube lies only 1 cm above\n the carina and should be pulled back. This information was telephoned to Dr.\n .\n\n There is some increased opacification in the retrocardiac region at the left\n and possibly also right base, raising the possibility of atelectasis or even\n aspiration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1031435,
"text": " 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p fall with cerebellar bleed\n REASON FOR THIS EXAMINATION:\n assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe MON 10:46 AM\n No new regions of intracranial hemorrhage identified with stable appearance to\n right cerebellar hemorrhage and intraventricular hemorrhage. Decreased\n conspicuity to left frontal subarachnoid hemorrhage consistent with evolving\n blood products.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cerebellar bleed, evaluate for interval change.\n\n NON-CONTRAST HEAD CT\n\n Comparison is made to examinations.\n\n FINDINGS: No new regions of intracranial hemorrhage are identified, with no\n significant interval change and in the postoperative appearance of the right\n cerebellar hemorrhagic region. A small amount of blood is noted within the\n lateral ventricles bilaterally, without evidence of hydrocephalus. Previously\n described left frontal subarachnoid hemorrhage is less conspicuous on today's\n examination, consistent with evolving blood products.\n\n The fourth ventricle remains predominantly effaced, related to the adjacent\n cerebellar edema. The positioning of right-sided intraventricular drain with\n its tip in the third ventricle is stable. No acute major vascular territorial\n infarction is noted. Subcutaneous emphysema along the ventriculostomy catheter\n site and craniotomy site persists as is a small amount of soft tissue\n swelling.\n\n Globes are intact, and there is unchanged appearance of the nondisplaced right\n occipital fracture. Mastoid air cells and paranasal sinuses remain well\n aerated,with fluid and secretions noted within the oro- and nasopharynx,\n consistent with the patient's intubated status.\n\n IMPRESSION:\n\n No new regions of intraparenchymal hemorrhage, with stable appearance of\n remaining right cerebellar hemorrhage and intraventricular hemorrhage, without\n evidence of hydrocephalus. Less conspicuous left frontal subarachnoid\n hemorrhage, consistent with evolving blood products.\n\n\n (Over)\n\n 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1031436,
"text": ", NSURG TSICU 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman s/p fall with cerebellar bleed\n REASON FOR THIS EXAMINATION:\n assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No new regions of intracranial hemorrhage identified with stable appearance to\n right cerebellar hemorrhage and intraventricular hemorrhage. Decreased\n conspicuity to left frontal subarachnoid hemorrhage consistent with evolving\n blood products.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1031354,
"text": ", NSURG TSICU 7:47 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: change in hemorrhage post op?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with intraparenchymal cerebellar hemorrhage s/p fall now s/p\n crani and evacuation\n REASON FOR THIS EXAMINATION:\n change in hemorrhage post op?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Interval decrease in size of right cerebellar hemorrhage postoperatively, with\n expected pneumocephalus. Right frontal approach drain terminates with the tip\n in the third ventricle, with no evidence of ventriculomegaly. Unchanged size\n and appearance of small left frontal subarachnoid hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1031826,
"text": ", NSURG TSICU 12:04 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for ptx\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F s/p fall backward from standing, w occipital fx/cerebellar hematoma, s/p\n crani/evacuation () now s/p CVL placement\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n PFI REPORT\n Since earlier today, ETT tip is still 1.6 cm above the carina, could be pulled\n back 1.5 cm for optimal placement. Nasogastric tube ends in the stomach.\n Right subclavian catheter was installed with its tip in the right atrium,\n could be pulled back 4 cm for optimal placement. Bibasilar opacity, due to\n atelectasis versus aspiration, is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032304,
"text": " 2:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 5:33 PM\n Hypodensities are now apparent at the superior aspect of the cerebellum could\n be due to acute infarcts. MRI can help for further assessment. No new\n hemorrhages seen. There has been decrease in mass effect with better\n appreciated basal cisterns on the current study.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD\n\n CLINICAL INFORMATION: Patient with hemorrhage, for followup.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n\n Comparison was made with previous CT of .\n\n FINDINGS: There are now well-defined hypodensities seen at the superior\n aspects of both cerebellar hemispheres, which are suggestive of acute superior\n cerebellar artery infarcts. These infarcts are now apparent since the\n previous study. The previously noted hemorrhage in the right cerebellum is\n again visualized with foci of blood without new hemorrhage since the previous\n study. Since the previous study, the mass effect on the brainstem and the\n obliteration of the basal cistern has decreased indicating decrease in edema.\n There is a right frontal catheter identified extending to the region of\n foramen .\n\n IMPRESSION: Newly apparent hypodensities in both superior cerebellar regions\n suspicious for superior cerebellar infarcts. For further evaluation, MRI and\n MRA of the head are recommended. No new areas of hemorrhage seen. Since the\n previous study, the basal cisterns are now better appreciated indicating\n decreasing mass effect.\n\n Findings were discussed with at the time of interpretation of\n this study on at 4:30 p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032305,
"text": ", NSURG TSICU 2:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Hypodensities are now apparent at the superior aspect of the cerebellum could\n be due to acute infarcts. MRI can help for further assessment. No new\n hemorrhages seen. There has been decrease in mass effect with better\n appreciated basal cisterns on the current study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1031825,
"text": " 12:04 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for ptx\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45F s/p fall backward from standing, w occipital fx/cerebellar hematoma, s/p\n crani/evacuation () now s/p CVL placement\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc WED 3:53 PM\n Since earlier today, ETT tip is still 1.6 cm above the carina, could be pulled\n back 1.5 cm for optimal placement. Nasogastric tube ends in the stomach.\n Right subclavian catheter was installed with its tip in the right atrium,\n could be pulled back 4 cm for optimal placement. Bibasilar opacity, due to\n atelectasis versus aspiration, is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORT LINE.\n\n REASON FOR EXAM: 45-year-old female status post fall backward from standing\n with occipital fracture and cerebellar hematoma status post\n craniotomy/evacuation, now status post CVL placement. R\\O pneumothorax.\n\n Since earlier today, right subclavian catheter was installed with its tip in\n the right atrium, could be pulled back 4 cm for optimal placement. ETT tip is\n still 1.6 cm above the carina, could be pulled back 1.5 cm for optimal\n placement. Nasogastric tube ends in the stomach.\n\n Bibasilar opacities are unchanged, probably due to atelectasis, less likely\n aspiration. No other change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033601,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure, to evaluate for change.\n\n FINDINGS: In comparison with study of , bibasilar atelectatic changes are\n again seen. Suggestion of some increased opacification at the right base\n laterally, though this may merely be an artifact due to multiple overlying\n structures. Tracheostomy tube and right subclavian catheter remain in place.\n\n IMPRESSION: Probably little change. However, multiple overlying artifacts\n would make a repeat study helpful.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032651,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n FINDINGS: In comparison with the study of , the endotracheal tube has been\n removed and replaced with a tracheostomy tube. No evidence of pneumothorax or\n pneumomediastinum. Nasogastric tube has been removed, although the central\n catheter remains in place.\n\n Atelectatic streaks are seen at both bases. A more coalescent area of\n increased opacification is seen at the right base medially. Although this\n could also represent atelectatic change, the possibility of a superimposed\n consolidation must be excluded. A lateral view would be most helpful for\n further evaluation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1034739,
"text": " 10:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate status prior to patient discharge to assess\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with previous brain injury\n REASON FOR THIS EXAMINATION:\n please evaluate status prior to patient discharge to assess if any improvement\n or deterioration\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:14 PM\n PFI: Ventricular catheter has been removed. There has been interval\n development of a small, 1 cm, subdural collection at the former site of entry.\n There is no significant mass effect. Expected evolution of cerebellar\n hemorrhage. No evidence for new hemorrhage, hydrocephalus, herniation, or\n ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old woman with cerebellar hemorrhage, status post\n decompression.\n\n COMPARISON: CT of the head from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: The ventricular catheter has been removed. In the right frontal\n region, underlying the site of previous catheter entry, there is interval\n development of a low-density subdural collection. This measures 1 cm at\n maximal width. There is no significant mass effect.\n\n There is continued evolution of the previous cerebellar hemorrhage, with\n decreased density of the blood products. There is no evidence for new\n cerebellar hemorrhage. Bilateral cerebellar hypodensities, of unclear\n etiology but possibly consistent with prior infarcts, are unchanged.\n\n The ventricles and sulci are normal in caliber and configuration. There is no\n shift of normally midline structures. There is no evidence for herniation.\n The cisterns are normal in appearance.\n\n Post-surgical changes from decompressive craniectomy are unchanged. There is\n a burr hole at the right frontal region from prior ventricular catheter.\n Osseous structures are otherwise unremarkable. There is opacification of the\n mastoid air cells bilaterally. There is mucosal thickening in the bilateral\n sphenoid sinuses and ethmoid air cells.\n\n IMPRESSION:\n 1. Removal of ventricular catheter. Interval development of small subdural\n collection at the previous site of catheter entry, without significant\n associated mass effect.\n 2. Continued evolution of cerebellar hemorrhage, without evidence for new\n (Over)\n\n 10:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate status prior to patient discharge to assess\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bleed.\n 3. Stable hypodensities of the bilateral cerebellar hemispheres, of unclear\n etiology, likely chronic.\n 4. Stable mucosal thickening in the paranasal sinuses with partial\n opacification of the mastoid air cells.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1034740,
"text": ", NSURG SICU-B 10:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate status prior to patient discharge to assess\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with previous brain injury\n REASON FOR THIS EXAMINATION:\n please evaluate status prior to patient discharge to assess if any improvement\n or deterioration\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Ventricular catheter has been removed. There has been interval\n development of a small, 1 cm, subdural collection at the former site of entry.\n There is no significant mass effect. Expected evolution of cerebellar\n hemorrhage. No evidence for new hemorrhage, hydrocephalus, herniation, or\n ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034046,
"text": " 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tracheostomy. Interval change in infiltrates.\n\n FINDINGS: Supine portable chest radiograph is compared to \n and demonstrates slight improvement of a bilateral retrocardiac\n opacities and stable appearance of right lower lung atelectasis. No new\n opacities identified. The tracheostomy and left subclavian central venous\n line are unchanged. There is no pleural effusion. The lung volumes are low.\n\n IMPRESSION: Improvement ing retrocardiac opacities with persistent right\n lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1033905,
"text": " 7:59 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p L subclavian line pull back\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p L subclavian line pull back\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Left subclavian line pullback.\n\n FINDINGS:\n\n Comparison is made to the prior study of 19:37. The left subclavian line has\n been pulled back and now resides within the superior vena cava. Tracheostomy\n is in the midline. Again noted is a dense right perihilar infiltrate,\n unchanged. There is also a left retrocardiac infiltrate with air\n bronchograms. Heart and mediastinum are within normal limits.\n\n IMPRESSION:\n 1. Left subclavian line terminates in the superior vena cava.\n 2. Dense perihilar infiltrates unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034688,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interaval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interaval\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:47 AM\n Interval worsening of pulmonary vascular congestion and interval improvement\n in right lung base atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bedside AP chest radiograph.\n\n HISTORY: 45-year-old woman with respiratory failure.\n\n COMPARISON: Comparison is made to multiple chest radiographs from \n to .\n\n FINDINGS: Diffuse pulmonary vascular congestion is worse since .\n Right lung base atelectasis is improved since . There are no pleural\n effusions. Mild cardiomegaly is unchanged. Mediastinal contours are normal.\n\n A tracheostomy tube is in good position, unchanged. A left subclavian central\n line is visualized with tip at the upper SVC. A right PICC is visualized with\n tip in the right atrium.\n\n IMPRESSION:\n 1. Interval progression of pulmonary vascular congestion and interval\n improvement in right lung base atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034689,
"text": ", NSURG SICU-B 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interaval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interaval\n ______________________________________________________________________________\n PFI REPORT\n Interval worsening of pulmonary vascular congestion and interval improvement\n in right lung base atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034466,
"text": ", NSURG SICU-B 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n PFI REPORT\n Early CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032799,
"text": " 2:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with IPH\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 8:40 PM\n PFI: Stable right cerebellar intraparenchymal hemorrhage and postoperative\n hematoma without focus of new blood. There is decreased mass effect from\n cerebellar edema. Persistent bilateral superior cerebellar hypodensities are\n again suggestive of infarct.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old female with post-traumatic intraparenchymal hemorrhage.\n Referred for assessment of interval change.\n\n COMPARISON: Comparison is made to CT of the head from and\n as well as MR .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: There are persistent well-defined areas of low attenuation in the\n bilateral superior cerebellar hemispheres. These have the appearance of\n cytotoxic edema and strongly suggest superior cerebellar artery\n territorial infarcts. Resolving intraparenchymal hemorrhage in the right\n cerebellum with postoperative change from overlying craniectomy is again seen.\n There is also a small amount of subarachnoid blood tracking along the left\n lateral tentorium, also unchanged. There is no new focus of hemorrhage since\n .\n\n Since the prior study, the degree of tonsillar and upward transtentorial\n herniation has decreased. There is also less effacement of the basilar\n cisterns. This indicates a decrease in the degree of mass effect secondary to\n improving cerebellar edema.\n\n The right transfrontal intraventricular catheter is unchanged.\n\n IMPRESSION: Persistent hypodensities in the bilateral superior cerebellar\n hemispheres, suggestive of the superior cerebellar infarcts. Intraparenchymal\n hemorrhage and postsurgical hematoma in the right cerebellum is stable without\n new bleeding. The degree of mass effect resulting from cerebellar\n cytotoxic edema has decreased since prior study.\n (Over)\n\n 2:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1032800,
"text": ", NSURG SICU-B 2:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with IPH\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Stable right cerebellar intraparenchymal hemorrhage and postoperative\n hematoma without focus of new blood. There is decreased mass effect from\n cerebellar edema. Persistent bilateral superior cerebellar hypodensities are\n again suggestive of infarct.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032891,
"text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval if infiltrate worsening\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with evolving RLL infiltrate\n REASON FOR THIS EXAMINATION:\n eval if infiltrate worsening\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evolving right lower lobe infiltrate.\n\n FINDINGS: In comparison with the study of , the tracheostomy tube and\n right subclavian catheter remain in place. The coalescent area of\n opacification at the right base medially persists with some continued\n atelectatic changes at the bases. Again, a lateral view would be most helpful\n if the condition of the patient permits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-14 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1032460,
"text": " 3:10 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: 45 year old woman with traumatic brain injury, r/o injury to\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with traumatic brain injury, r/o injury to brainstem, stroke,\n \n REASON FOR THIS EXAMINATION:\n 45 year old woman with traumatic brain injury, r/o injury to brainstem, stroke,\n , new cerebellar infarcts, please use diffusion weighted images\n CONTRAINDICATIONS for IV CONTRAST:\n Renal transplant\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM\n\n HISTORY: Traumatic brain injury, evaluate for brainstem injury.\n\n Comparison is made with study from one day prior.\n\n There are changes from a right suboccipital craniotomy. There is extensive\n edema and bilateral cerebellar hemispheres with a moderate amount of blood\n products in the right cerebellar hemisphere causing mass effect and effacement\n of the fourth ventricle and ascending transtentorial herniation. There is\n only mild inferior tonsillar herniation. There is a small right frontal\n subdural hematoma. There is a small hemorrhagic contusion in the left frontal\n lobe with surrounding edema. There is gliosis along the right frontal\n ventriculostomy tract. Small bilateral parietal subdural fluid collections\n are seen. There are tiny amount of subarachnoid hemorrhage bilaterally. There\n is also edema involving bilateral middle cerebellar peduncles. There are\n additional areas of subcortical hyperintensity which could represent small\n vessel ischemic sequela. The ventricles are unchanged in size compared to the\n prior study.\n\n Bilateral mastoid opacification is seen. There are fluid levels in the left\n maxillary sinus. Bilateral ethmoid opacification is seen.\n\n Small bilateral intraventricular hemorrhage is seen. No convincing evidence\n for diffusion restriction is seen.\n\n MRA of the circle of demonstrates no definite evidence for aneurysm or\n stenosis.\n\n The right optic nerve appears to be somewhat stretched with questionable\n increased T2 signal. Recommend correlation with clinical examination and if\n there are visual changes on the right, an MRI dedicated to the orbit can be\n performed.\n\n IMPRESSION:\n (Over)\n\n 3:10 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: 45 year old woman with traumatic brain injury, r/o injury to\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Post-traumatic sequela in the brain. Blood products in bilateral cerebellar\n hemispheres with extensive surrounding edema. There is a small amount of\n edema in the right aspect of the pons and bilateral middle cerebellar\n peduncles. There is ascending transtentorial herniation. The ventricles are\n unchanged in size compared to the prior study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1033901,
"text": " 7:04 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: S/P L SUBCLAVIAN LINE PLACEMENT ALSO HAD R SUBCLAVIAN LINE THAT WE'RE GOING TO PULL SOON\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p R Subclavian line placement also has L subclavian line that we're going to\n pull soon\n ______________________________________________________________________________\n WET READ: SBNa SAT 8:00 PM\n right subclavian line in low svc. left subclavian line in RA/IVC\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE LINE PLACEMENT \n\n CLINICAL INFORMATION: Left subclavian line placement.\n\n FINDINGS:\n\n Left subclavian catheter terminates in the superior vena cava. Right\n subclavian line also terminates in superior vena cava. Tracheostomy is in the\n midline. There are bilateral pulmonary infiltrates, right middle lobe and\n left retrocardiac. Upper lung zones are clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1034628,
"text": " 5:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval PICC placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with new right sided PICC\n REASON FOR THIS EXAMINATION:\n eval PICC placement\n ______________________________________________________________________________\n WET READ: GWp WED 6:42 PM\n R PICC tip superior RA no PTX d/w IV team 6:26p GWlms\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of right side PICC line placement.\n\n Portable AP chest radiograph was compared to .\n\n The right PICC line was inserted with its tip projecting approximately at the\n level of cavoatrial junction. The tracheostomy tip is at the midline,\n approximately 4 cm above the carina. The cardiomediastinal silhouette is\n stable. The lungs are essentially clear. There is no right pleural effusion.\n Since left costophrenic angle was not included in the field of view the\n pleural effusion cannot be appreciated. There is no evidence of failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-17 00:00:00.000",
"description": "L WRIST, AP & LAT VIEWS LEFT",
"row_id": 1033026,
"text": " 4:10 PM\n WRIST, AP & LAT VIEWS LEFT Clip # \n Reason: evaluate distal radial fracture\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with old distal radial fractre\n REASON FOR THIS EXAMINATION:\n evaluate distal radial fracture\n ______________________________________________________________________________\n FINAL REPORT\n LEFT WRIST, TWO VIEWS\n\n INDICATION: Evaluate distal left radius fracture.\n\n FINDINGS: There is a cast in place that obscures fine bony detail. A\n slightly impacted healing fracture of the distal left radial metaphysis is\n noted. Evaluation of the ulnar styloid is suboptimal due to the overlying\n cast. Carpus appears intact. No additional fracture is definitely seen.\n\n IMPRESSION:\n\n Healing transversely oriented fracture of the distal left radial metaphysis.\n Overlying cast obscures more detailed evaluation of the underlying osseous\n structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034465,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 11:43 AM\n Early CHF.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:16 A.M., \n\n HISTORY: Respiratory failure.\n\n IMPRESSION: AP chest compared to through 16:\n\n New pulmonary vascular engorgement suggests borderline cardiac decompensation.\n Atelectasis in the right middle lobe has changed configuration, but not\n cleared. Heart size top normal. Left subclavian line ends at the junction of\n the brachiocephalic veins. Tracheostomy tube in standard placement. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1033653,
"text": " 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate hydrocephaleus\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with Hydrocephaleus\n REASON FOR THIS EXAMINATION:\n evaluate hydrocephaleus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 6:13 PM\n Expected evolution of right cerebellar bleed. Increase in ventral dilation.\n No new mass effect. Persistent cerebellar hypodensities of unclear etiology.\n No other interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 45-year-old woman with cerebellar hemorrhage, status post\n decompression, subsequent development of hydrocephalus.\n\n COMPARISON: CT of the head from .\n\n TECHNIQUE: Contiguous section images were obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: There is decreased density of the right cerebellar hemorrhage,\n consistent with natural evolution. There is no new focus of bleeding.\n Postoperative changes of prior craniectomy are unchanged. There is no\n increased mass effect. There is no effacement of the cisterns, ventricular\n compression, or shift of normally midline structures. The frontal approach\n ventricular catheter is in stable position, terminating in the third\n ventricle.\n\n There are persistent areas of low attenuation in the bilateral cerebellar\n hemispheres. Retrospectively, these have been present since initial CT scan\n on . An infarction cannot be excluded, but the precise\n etiology of these hypodensities is unclear. In the setting of hypertensive\n hemorrhage, hypertensive cerebellar edema is also a possibility.\n\n IMPRESSION:\n 1. Stable post-surgical change.\n 2. Continued evolution of the right cerebellar bleed.\n 3. Persistent hypodensities in the bilateral cerebellar hemispheres, of\n unclear etiology.\n 4. Mucosal thickening in the paranasal sinuses with partial opacification of\n the mastoid air cells.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1033654,
"text": ", NSURG SICU-B 9:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate hydrocephaleus\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with Hydrocephaleus\n REASON FOR THIS EXAMINATION:\n evaluate hydrocephaleus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Expected evolution of right cerebellar bleed. Increase in ventral dilation.\n No new mass effect. Persistent cerebellar hypodensities of unclear etiology.\n No other interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033379,
"text": " 5:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate infiltrates\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with ? VAP\n REASON FOR THIS EXAMINATION:\n evaluate infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:54 PM\n Partial resolution of right lower lobe opacity.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n increased. As a consequence, the size of the cardiac silhouette has\n decreased. The retrocardiac lung areas and the right lung base are markedly\n better ventilated than before. The pre-existing right basal opacity shows\n partial resolution. There is no evidence of pleural effusions. No\n overhydration. The monitoring and support devices are in unchanged position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1033380,
"text": ", NSURG SICU-B 5:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate infiltrates\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with ? VAP\n REASON FOR THIS EXAMINATION:\n evaluate infiltrates\n ______________________________________________________________________________\n PFI REPORT\n Partial resolution of right lower lobe opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-19 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1033566,
"text": " 9:08 PM\n CHEST (SINGLE VIEW) PORT; -76 BY SAME PHYSICIAN # \n Reason: r/o infiltrate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS FRI 10:32 AM\n PFI: No pneumonia. Bibasilar atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST\n\n HISTORY: Fever, rule out pneumonia.\n\n IMPRESSION: AP chest compared to and , 6:18 a.m.:\n\n Minimal bibasilar consolidation, probably atelectasis. Upper lungs clear.\n Heart size normal. No pneumothorax or appreciable pleural effusion.\n Tracheostomy tube and right subclavian line in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1034243,
"text": " 3:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with\n REASON FOR THIS EXAMINATION:\n interval\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tracheostomy, to evaluate infiltrate.\n\n FINDINGS: In comparison with study of , there is progressive decrease in\n the bibasilar opacifications consistent with atelectasis or aspiration. No\n new lesions identified. Tracheostomy tube remains in place, as does the left\n subclavian line.\n\n IMPRESSION: Progressive clearing of the bibasilar opacifications.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-19 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1033567,
"text": ", NSURG SICU-B 9:08 PM\n CHEST (SINGLE VIEW) PORT; -76 BY SAME PHYSICIAN # \n Reason: r/o infiltrate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with fever\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: No pneumonia. Bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-31 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1035652,
"text": " 12:02 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 45 year old woman with h/o pacreatic transplant. Please asse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with IPH/occipital fx h/o pancreatic transplant.\n REASON FOR THIS EXAMINATION:\n 45 year old woman with h/o pacreatic transplant. Please assess for pancreatitis\n and gall stones.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JWK TUE 5:27 PM\n 2-mm nonobstructing stone within the renal transplant which is unchanged.\n Aside from nonspecific unchanged perirenal stranding no significant\n abnormality is detected on this noncontrast CT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old female with history of pancreatic and renal\n transplant, admitted for intraparenchymal hemorrhage, now with elevated\n amylase and lipase.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images through the abdomen and pelvis were obtained\n without intravenous contrast. Multiplanar images were reformatted.\n\n FINDINGS: There is linear atelectasis within the visualized lung bases. The\n liver, gallbladder, spleen, and adrenal glands are unremarkable. The native\n kidneys and pancreas are atrophic. A G-tube lies within the stomach. There\n are no enlarged mesenteric or retroperitoneal lymph nodes. There is no free\n air or free fluid in the abdomen.\n\n CT PELVIS WITHOUT IV CONTRAST: Given the limitations of evaluation without\n intravenous contrast, the right lower quadrant pancreatic and left lower\n quadrant kidney transplants appear unchanged compared. A 2-mm nonobstructing\n stone is again identified within the lower pole of the transplanted kidney.\n Mild perinephric (transplant) stranding is unchanged and nonspecific. There is\n no free fluid in the pelvis.\n\n There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n\n 2-mm nonobstructing stone in the transplant kidney.\n\n No explaination for abnormal amylase and lipase identified (allowing for\n noncontrast technique).\n (Over)\n\n 12:02 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 45 year old woman with h/o pacreatic transplant. Please asse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-08-31 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1035653,
"text": ", NSURG FA11 12:02 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 45 year old woman with h/o pacreatic transplant. Please asse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with IPH/occipital fx h/o pancreatic transplant.\n REASON FOR THIS EXAMINATION:\n 45 year old woman with h/o pacreatic transplant. Please assess for pancreatitis\n and gall stones.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 2-mm nonobstructing stone within the renal transplant which is unchanged.\n Aside from nonspecific unchanged perirenal stranding no significant\n abnormality is detected on this noncontrast CT.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-09-02 00:00:00.000",
"description": "Report",
"row_id": 185684,
"text": "Sinus tachycardia. Baseline artifact. Non-specific ST-T wave changes.\nCompared to the previous tracing of artifact is more pronounced.\n\n"
},
{
"category": "ECG",
"chartdate": "2106-08-27 00:00:00.000",
"description": "Report",
"row_id": 185685,
"text": "Sinus tachycardia\nOtherwise probably normal ECG but baseline artifact in V1 makes assessment\ndifficult\nSince previous tracing of , sinus bradycardia absent, sinus tachycardia\nnow seen and ST-T wave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2106-08-08 00:00:00.000",
"description": "Report",
"row_id": 185686,
"text": "Sinus bradycardia\nNonspecific ST-T wave changes\nSince previous tracing of , sinus bradycardia now present\n\n"
}
] |
29,075 | 166,589 | 67 man with a history of multiple myeloma who presents with anemia, thrombocytopenia and melena. Patient presented to the ED with a hct of 12 and platelets of 10. His GI bleeding was thought to be secondary to known small bowel AVM's (seen on capsule study on prior admission for GIB in ), in the setting of severe thrombocytopenia. He received 6 units of PRBC's, 3 units platelets, and 2 units of FFP. His hct stabalized around 24-25. He was started on IV PPI . GI was consulted and were considering a repeat enteropscopy while in the ICU but the patient was in severe pain ( multiple myeloma) this was deferred. After further discussion with the patient's oncologist at the , Dr. , it was decided that further invasive studies to work up the GI bleeding would likely not yield any change in management since his bleeding is likey from AVMs which are difficult to control. His Hct was monitored and was stable. Later in the hospitalization, a family meeting was held with Dr. , and since his myeloma is refractory and end-stage, the goals of care were changed to comfort. Palliative care team and pain service followed throught the hospitalization. Multiple regimens were tried to treat his pain, with the final regimen being Fentanyl patch for long acting analgesic, with short acting dilaudid for breakthrough. Adjuvant treatment with dexamethasone and pamidronate were given at the direction of his oncologist, Dr. . Early in the morning on , the patient acute spiked a fever to 105, became tachycardic and hypotensive, along with further BRBPR. He was given IVF boluses but despite these efforts, BPs remained in the 60s systolic. Labs showed platelets of 21 and Hct 24. When his family arrived the IVF boluses were stopped and IV morphine was given instead of the oral dilaudid for pain and discomfort. The palliative care service followed closely. Other comfort measures were initiated, including tylenol, ativan, and scopolamine patch. His oncologist, Dr. was contact and made aware of the situation. The patient passed away on at 5:35 PM. | Baseline artifactSinus rhythmAtrial premature complexesOtherwise may be normal ECG but baseline artifact makes assessment difficultSince previous tracing of , sinus tachycardia absent and ST-T wavechanges decreased Remains A+O, c/o back pain- which he states is not new. Tiny left pneumothorax. Mso4 prn along with repositoning/hot packs/lidocaine patch. Sinus tachycardia is new. NKDA, foley to gravity, tlc groin line placed in ER. Sinus tachycardia. hx of multi gi bleeds. 1:52 PM CHEST (PORTABLE AP) Clip # Reason: Please eval for acute process. room air sao2 94-100. removing nasal . The left costophrenic angle is again blunted. There is calcification of the aortic arch. ; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # Reason: VAD PLACEMENT Admitting Diagnosis: GASTROINTESTINAL BLEED FINAL REPORT HISTORY: VAD placement. Sinus rhythmProbably normal ECG but baseline artifact makes assessment difficultSince previous tracing of , atrial ectopy absent FINDINGS: In comparison with study of , the patient has taken a substantially poor inspiration. Left subclavian catheter again extends to the lower portion of the SVC. Pt is DNR/DNI and pr his oncologist Dr to require considering CMO. FINDINGS: A single fluoroscopic image obtained without a radiologist shows placement of a catheter that appears to extend to the lower portion of the SVC or possibly even into the right atrium. Increased opacification with poor visualization of the left hemidiaphragm is again seen, consistent with atelectasis or possibly developing pneumonia. CHEST, SINGLE VIEW: Given the limitation of a rotated film, the cardiac size, mediastinal and hilar contours appear unremarkable. denies chest pain. FINAL REPORT INDICATION: Pre-operative chest x-ray. Needs cath placement and CXR for pre-op. As compared to the previous radiograph, the retrocardiac areas of atelectasis and subsequent blunting of the left costophrenic sinus have slightly increased. There is probably a very small pneumothorax seen far laterally in the apical region. Sequela of previous left rib fracture is again noted. Lower ext bilat. 1 lg bm guiac + this am. Compared to the previoustracing of ST-T wave changes are new. The left subclavian catheter extends to either the cavoatrial junction or into the right atrium itself. Sbp remaining greater than 95- see carevue flow sheet for all vital sx. 2 ffp for inr 1.3. Non-specific ST-T wave changes. 11:30 AM CHEST (SINGLE VIEW) IN O.R. Known left-sided rib fracture. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: r/o pneumothorax Admitting Diagnosis: GASTROINTESTINAL BLEED MEDICAL CONDITION: 67 year old man with MM, s/p L VAD/Port placement REASON FOR THIS EXAMINATION: r/o pneumothorax FINAL REPORT HISTORY: Status post VAD port placement to exclude pneumothorax. 1:31 PM CHEST PORT. REASON FOR THIS EXAMINATION: Evaluate for infiltrate FINAL REPORT HISTORY: Myeloma, now with high fever. 1:06 PM CHEST (PORTABLE AP) Clip # Reason: r/o infiltrate, effusion MEDICAL CONDITION: 67 year old man with acute GIB, hypotension REASON FOR THIS EXAMINATION: r/o infiltrate, effusion FINAL REPORT INDICATION: Acute GI bleed, hypertension, query infiltrate, effusion. Other pmh, cord compression, dvt's, peripheral neuropathy, schizophrenia, past suicide attempt, depression. There is no focal air space opacification but there is bibasal atelectasis worse on the left. with scars from burns received in . Atelectasis increasing or possibly supervening pneumonia at the left base. IMPRESSION: 1. Given his chronic pain and h/o spinal cord impingement, he can not stand for PA/Lat film REASON FOR THIS EXAMINATION: Please eval for acute process. Hx of multiple myeloma- curently residing in nursing home in . IMPRESSION: No acute cardiopulmonary process. 1:40 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate for infiltrate Admitting Diagnosis: GASTROINTESTINAL BLEED MEDICAL CONDITION: 67 year old man with multiple myeloma, anemia, thrombocytopenia, and melena, now with temp up to 104.8. COMPARISON: . COMPARISON: and . Admitting Diagnosis: GASTROINTESTINAL BLEED MEDICAL CONDITION: 67 year old man with multiple myeloma and chronic pain. Current plan is to continue to give blood products and pressors if needed, but if unresponsive to blood products will consider comfort care. nsg admit/progress note67 yo male to ER with bright red bleeding pr rectum- hct in ER 10- 2 units prbc and 6 liters ivf. | 9 | [
{
"category": "Radiology",
"chartdate": "2116-03-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1006192,
"text": " 1:31 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: r/o pneumothorax\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with MM, s/p L VAD/Port placement\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post VAD port placement to exclude pneumothorax.\n\n FINDINGS: Comparison is made with the study of . The left subclavian\n catheter extends to either the cavoatrial junction or into the right atrium\n itself. There is probably a very small pneumothorax seen far laterally in the\n apical region. Increased opacification with poor visualization of the left\n hemidiaphragm is again seen, consistent with atelectasis or possibly\n developing pneumonia. The left costophrenic angle is again blunted. The\n right lung is clear. Sequela of previous left rib fracture is again noted.\n\n IMPRESSION:\n 1. Tiny left pneumothorax.\n 2. Atelectasis increasing or possibly supervening pneumonia at the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1006969,
"text": " 1:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with multiple myeloma, anemia, thrombocytopenia, and melena,\n now with temp up to 104.8.\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Myeloma, now with high fever.\n\n FINDINGS: In comparison with study of , the patient has taken a\n substantially poor inspiration. However, there is no evidence of acute\n pneumonia, vascular congestion or pleural effusion.\n\n Left subclavian catheter again extends to the lower portion of the SVC.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005914,
"text": " 1:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for acute process.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with multiple myeloma and chronic pain. Needs cath placement\n and CXR for pre-op. Given his chronic pain and h/o spinal cord impingement, he\n can not stand for PA/Lat film\n REASON FOR THIS EXAMINATION:\n Please eval for acute process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-operative chest x-ray.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the retrocardiac areas of atelectasis\n and subsequent blunting of the left costophrenic sinus have slightly\n increased. Known left-sided rib fracture. Otherwise, no noticeable changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005500,
"text": " 1:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with acute GIB, hypotension\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute GI bleed, hypertension, query infiltrate, effusion.\n\n COMPARISON: and .\n\n CHEST, SINGLE VIEW: Given the limitation of a rotated film, the cardiac size,\n mediastinal and hilar contours appear unremarkable. There is calcification of\n the aortic arch. There is no focal air space opacification but there is\n bibasal atelectasis worse on the left. There is no pleural effusion or\n pneumothorax. Pulmonary vasculature is normal and there is no gross osseous\n abnormality.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-24 00:00:00.000",
"description": "O CHEST (SINGLE VIEW) IN O.R.",
"row_id": 1006181,
"text": " 11:30 AM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: VAD PLACEMENT\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: VAD placement.\n\n FINDINGS: A single fluoroscopic image obtained without a radiologist shows\n placement of a catheter that appears to extend to the lower portion of the SVC\n or possibly even into the right atrium.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-03-20 00:00:00.000",
"description": "Report",
"row_id": 1639409,
"text": "nsg admit/progress note\n67 yo male to ER with bright red bleeding pr rectum- hct in ER 10- 2 units prbc and 6 liters ivf. 2 ffp for inr 1.3. To SICU- additional 4 prbc overnoc- hct 2 am 24. Rec 2 packs platelets for count 10- 2 am count up to 60. Plan on continuing to cycle all labs q4 and pr micu orders. 1 lg bm guiac + this am. Sbp remaining greater than 95- see carevue flow sheet for all vital sx. denies chest pain. room air sao2 94-100. removing nasal . Hx of multiple myeloma- curently residing in nursing home in . Pt is DNR/DNI and pr his oncologist Dr to require considering CMO. MICU team spoke with pt and family members about this. Current plan is to continue to give blood products and pressors if needed, but if unresponsive to blood products will consider comfort care. Pt states that he would want this, but that the final dececison would be with his son and daughter. hx of multi gi bleeds. NKDA, foley to gravity, tlc groin line placed in ER. Remains A+O, c/o back pain- which he states is not new. Mso4 prn along with repositoning/hot packs/lidocaine patch. Lower ext bilat. with scars from burns received in . Other pmh, cord compression, dvt's, peripheral neuropathy, schizophrenia, past suicide attempt, depression.\n"
},
{
"category": "ECG",
"chartdate": "2116-03-23 00:00:00.000",
"description": "Report",
"row_id": 189804,
"text": "Sinus rhythm\nProbably normal ECG but baseline artifact makes assessment difficult\nSince previous tracing of , atrial ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2116-03-20 00:00:00.000",
"description": "Report",
"row_id": 189805,
"text": "Baseline artifact\nSinus rhythm\nAtrial premature complexes\nOtherwise may be normal ECG but baseline artifact makes assessment difficult\nSince previous tracing of , sinus tachycardia absent and ST-T wave\nchanges decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2116-03-19 00:00:00.000",
"description": "Report",
"row_id": 189806,
"text": "Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of ST-T wave changes are new. Sinus tachycardia is new.\n\n"
}
] |
8,992 | 103,262 | The patient was admitted to Dr. , of podiatry. Cultures of the second toe were taken. The patient was started on Kefzol. Wound cultures grew sensitive Staphylococcus aureus. Cardiology was consulted for preoperative clearance. They felt that the patient was a high risk because of his known LAD lesion from the cardiac catheterization done in . They felt he was a poor candidate for any kind of cardiac intervention but recommended a pharmacological stress test and review of his previous cardiac catheterization. The patient had a Persantine thallium study on . There was an inferior defect which was partially reversible. There was no anterior wall defect which suggested that the LAD stenosis was not hemodynamically significant. Therefore no other interventions were necessary and the patient was cleared for vascular surgery. On the patient underwent an uneventful left femoral to below the knee popliteal bypass graft with nonreversed saphenous vein. At the end of the surgery the patient had a warm left foot with dopplerable pedal pulses. Postoperatively the patient received two units of packed red blood cells. The patient's anticoagulation with Coumadin for his atrial fibrillation was restarted. Physical therapy evaluated the patient for full weight-bearing ambulation. The patient was doing very well. At the time of discharge the patient's left leg incision was clean, dry and intact. His left second toe had improved considerably and would not require any intervention during this hospitalization. His pedal pulses were dopplerable bilaterally. The patient was instructed to follow up with Dr. in the office for staple removal in two weeks. | FINDINGS: Duplex evaluation is performed of the left femoral-popliteal bypass graft. There is reconstitution of the most distal superficial femoral artery. COMPARISON: Direct comparison is made to a prior MRI of the lower extremities dated . There is straight line flow to the foot via an anterior tibial artery with a single mild focal stenosis identified within the proximal anterior tibial artery. Widely patent aorto-biiliac bypass graft. Small saccular aneurysm identified in the distal aorta in the region of the proximal anastomosis of the graft. This graft appears within normal limits except for the aforementioned small aneurysm adjacent to the proximal anastomotic site. The remainder of the ventricle shows mild global hypokinesis. IMPRESSION: Widely patent left femoral-popliteal bypass graft with evidence of stenosis. The neck of this aneurysm has maximal linear dimensions in the craniocaudal direction of 2.1 cm and in the AP direction of 1.2 cm. A 4 cm segmental occlusion of the mid left anterior tibial artery is present with distal reconstitution and good caliber dorsalis pedis artery and posterior tibial artery below the ankle joint. FINAL REPORT INDICATION: Nonhealing left foot ulcer. IMPRESSION: Bilateral aortoiliac disease. There is reconstitution of a short segment of the above the knee popliteal artery with good flow identified in the below the knee popliteal artery. PELVIS: An aorto- biiliac graft is identified with distal anastomotic sites at the external iliac arteries. Long segmental occlusions of both superficial femoral arteries from their origins as described above. There is flattening of the diaphragms consistent with COPD. Resting perfusion images demonstrate this defect to be partially reversible. Resting perfusion images were obtained with thallium. It is reconstituted more distally and has straight line flow to the foot where it gives off a good caliber dorsalis pedis artery. Atrial fibrillation with a moderate ventricular response and occasionalventricular premature beats. 11:44 AM MRA LEG W&W/OC BILAT; MRA PELVIS Clip # MR RECONSTRUCTION IMAGING Reason: Evaluate for disease of LLE arteries. There is straight line run off to the foot via a posterior tibial artery. The superficial femoral artery is occluded for a long segment from its origin to just above the adductor hiatus. Right foot: There is a good caliber dorsalis pedis artery, no posterior tibial vessel. There is osteopenia. Atrial fibrillation with slow ventricular response- premature ventricular contractions or aberrant ventricular conductionRight bundle branch blockVoltage criteria for left ventricular hypertrophyInferior ST-T changes are nonspecificSince last ECG, no significant change Patient with a history of aortobifem graft. There is a long segment occlusion of the superficial femoral artery and the more proximal above the knee popliteal artery. IMPRESSION: Ischemia of the basilar portion of the inferior wall. 8:08 AM ART DUP EXT LO UNI;F/U; CLINICAL RESEARCH Clip # Reason: graft surveillance FINAL ADDENDUM ADDENDUM: The impression should be changed to: IMPRESSION: Widely patent left femoral-popliteal bypass graft without evidence of stenosis. Patient has history of AAA repair with aortobifemoral bypass graft. The IJ cv line is in proximal SVC. Straight line flow to the right foot via the right anterior tibial artery with a good quality dorsalis pedis. To evaluate for osteomyelitis. please check position, r/o PTX FINAL REPORT CHEST, SINGLE AP FILM. Both the posterior tibial artery and the peroneal arteries have multifocal areas of narrowing and both are visualized to just above the ankle joint. Atrial fibrillation. The aneurysm itself has maximum axial dimensions of 1.5 cm in the AP direction and 1.2 cm in the transverse direction. Stress images demonstrate a severe perfusion defect at the basilar portion of the inferior wall. REASON FOR THIS EXAMINATION: Evaluate for disease of LLE arteries. RIGHT: Graft segment to the common femoral artery is widely patent. 1:00 PM ART EXT (REST ONLY) Clip # Reason: Evaluate blood flow to feet. PA and lateral chest radiograph dated is compared with the PA and lateral radiograph dated . Mild global hypokinesis with EF 47%. Approved: WED 9:56 AM West RADLINE ; A radiology consult service. Peak systolic velocities in cm per second are as follows: 98, 78, 135, 137 in the native proximal vessel, proximal anastomosis, distal anastomosis and native distal vessel respectively. There is cardiomegaly with mild upper zone redistribution. MR LOWER EXTREMITIES WITHOUT AND WITH CONTRAST: AORTA: No focal stenosis. Ejection fraction calculated from gated wall motion images obtained after Persantine administration shows a left ventricular ejection fraction of approximately 47%. FINAL REPORT PLEASE SEE COMBINED REPORT UNDER CLIP # To evaluate for ptx. /nkg , M.D. | 11 | [
{
"category": "Radiology",
"chartdate": "2105-12-14 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 773255,
"text": " 8:08 AM\n ART DUP EXT LO UNI;F/U; CLINICAL RESEARCH Clip # \n Reason: graft surveillance\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n The impression should be changed to:\n\n IMPRESSION: Widely patent left femoral-popliteal bypass graft without\n evidence of stenosis.\n\n\n 8:08 AM\n ART DUP EXT LO UNI;F/U; CLINICAL RESEARCH Clip # \n Reason: graft surveillance\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with non-healing ulcer of L second toe now s/p LLE bypass\n \n REASON FOR THIS EXAMINATION:\n graft surveillance\n ______________________________________________________________________________\n FINAL REPORT\n REASON: Patient with nonhealing ulcer status post lower extremity bypass.\n Perform follow up surveillance.\n\n FINDINGS: Duplex evaluation is performed of the left femoral-popliteal bypass\n graft. Peak systolic velocities in cm per second are as follows: 98, 78,\n 135, 137 in the native proximal vessel, proximal anastomosis, distal\n anastomosis and native distal vessel respectively. Throughout the body of the\n graft velocities range from 94 to 148.\n\n IMPRESSION: Widely patent left femoral-popliteal bypass graft with evidence\n of stenosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 772983,
"text": " 3:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p line placement. please check position, r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with\n REASON FOR THIS EXAMINATION:\n s/p line placement. please check position, r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: CV line placement. To evaluate for ptx.\n\n The IJ cv line is in proximal SVC. No pneumothorax. There is cardiomegaly\n with mild upper zone redistribution. No definite pulmonary consolidation or\n pleural effusions in this single view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-08 00:00:00.000",
"description": "B MRA LEG W/O C BILAT",
"row_id": 772717,
"text": " 6:15 AM\n MRA LEG W/O C BILAT; REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: MRI FOLLOW-UP OF LEG ANGIO FOR CALF EXTENSION\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Nonhealing ulcer of the left second toe. Patient with a history\n of aortobifem graft.\n\n COMPARISON: Direct comparison is made to a prior MRI of the lower extremities\n dated .\n\n TECHNIQUE: Three station MR angiogram was performed with a 3D FAME sequence\n performed after a timing run and utilizing a fluoro trigger technique.\n Approximately 40 cc of Gadolinium was utilized. Axial 2D time of flight\n images were obtained through the region of the ankles and subsequently from\n the level of the knee joint to the ankles. Multiplanar reconstructions were\n generated and evaluated on a work station.\n\n MR LOWER EXTREMITIES WITHOUT AND WITH CONTRAST:\n\n AORTA: No focal stenosis. Small saccular aneurysm identified in the distal\n aorta in the region of the proximal anastomosis of the graft. The neck of this\n aneurysm has maximal linear dimensions in the craniocaudal direction of 2.1 cm\n and in the AP direction of 1.2 cm. The aneurysm itself has maximum axial\n dimensions of 1.5 cm in the AP direction and 1.2 cm in the transverse\n direction.\n\n PELVIS: An aorto- biiliac graft is identified with distal anastomotic sites at\n the external iliac arteries. This graft appears within normal limits except\n for the aforementioned small aneurysm adjacent to the proximal anastomotic\n site.\n\n RIGHT:\n Graft segment to the common femoral artery is widely patent. The superficial\n femoral artery is occluded for a long segment from its origin to just above\n the adductor hiatus. There is reconstitution of the most distal superficial\n femoral artery. No focal stenoses are present within the popliteal artery.\n There is straight line flow to the foot via an anterior tibial artery with a\n single mild focal stenosis identified within the proximal anterior tibial\n artery. Both the posterior tibial artery and the peroneal arteries have\n multifocal areas of narrowing and both are visualized to just above the ankle\n joint.\n\n Right foot: There is a good caliber dorsalis pedis artery, no posterior tibial\n vessel.\n\n LEFT:\n Graft to CFA is widely patent. There is a long segment occlusion of the\n superficial femoral artery and the more proximal above the knee popliteal\n artery. There is reconstitution of a short segment of the above the knee\n popliteal artery with good flow identified in the below the knee popliteal\n artery. There is straight line run off to the foot via a posterior tibial\n artery. The peroneal artery also has straight line flow to the ankle. A 4 cm\n (Over)\n\n 6:15 AM\n MRA LEG W/O C BILAT; REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: MRI FOLLOW-UP OF LEG ANGIO FOR CALF EXTENSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n segment of occlusion is present within the proximal 1/3rd of the anterior\n tibial artery. It is reconstituted more distally and has straight line flow\n to the foot where it gives off a good caliber dorsalis pedis artery. There is\n also a good caliber left posterior tibial vessel extending below the ankle\n joint.\n\n Direct comparison with the prior MRI examination dated shows no\n significant interval change.\n\n MULTIPLANAR RECONSTRUCTIONS: These were essential in delineating the anatomy\n and pathology as described above.\n\n IMPRESSION:\n\n 1. Widely patent aorto-biiliac bypass graft.\n 2. Long segmental occlusions of both superficial femoral arteries from their\n origins as described above.\n 3. Straight line flow to the right foot via the right anterior tibial artery\n with a good quality dorsalis pedis.\n 4. On the left there is a straight line flow to the foot via posterior tibial\n artery. A 4 cm segmental occlusion of the mid left anterior tibial artery is\n present with distal reconstitution and good caliber dorsalis pedis artery and\n posterior tibial artery below the ankle joint.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-07 00:00:00.000",
"description": "B MRA LEG W&W/OC BILAT",
"row_id": 772648,
"text": " 11:44 AM\n MRA LEG W&W/OC BILAT; MRA PELVIS Clip # \n MR RECONSTRUCTION IMAGING\n Reason: Evaluate for disease of LLE arteries.\n Contrast: MAGNEVIST Amt: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with non-healing LLE toe ulcer. MRA performed here at\n demonstrated poor flow to LLE, bypass surgery deferred because patient\n was in poor state of health. Now being considered for revascularization.\n Patient has history of AAA repair with aortobifemoral bypass graft.\n Conventional contrast angiogram contra-indicated in this patient because of\n compromised renal function with solitary kidney.\n REASON FOR THIS EXAMINATION:\n Evaluate for disease of LLE arteries.\n ______________________________________________________________________________\n FINAL REPORT\n PLEASE SEE COMBINED REPORT UNDER CLIP #\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-08 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 772722,
"text": "PERSANTINE MIBI Clip # \n Reason: OBSERVATION FOR SUSPECTED CARDIOVASCULAR DISEASE.\n ______________________________________________________________________________\n FINAL REPORT\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Persantine was infused intravenously for approximately 4 minutes at a dose of\n approximately 0.142 mg/kg/min. There were no anginal symptoms or ST changes.\n\n HISTORY: Eighty-nine year old man who presents for preoperative evaluation\n prior to peripheral vascular surgery.\n\n INTERPRETATION: One to three minutes after the cessation of infusion,\n MIBI was administered IV.\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n Stress images demonstrate a severe perfusion defect at the basilar portion of\n the inferior wall.\n\n Resting perfusion images demonstrate this defect to be partially reversible.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Persantine administration shows a left ventricular ejection fraction of\n approximately 47%. Due to the lack of counts at the basilar portion of the\n inferior wall, that portion of the ventricle is unable to be evaluated for wall\n motion. The remainder of the ventricle shows mild global hypokinesis.\n\n IMPRESSION: Ischemia of the basilar portion of the inferior wall. Mild global\n hypokinesis with EF 47%. /nkg\n\n\n , M.D.\n , M.D. Approved: WED 9:56 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-04 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 772437,
"text": " 1:00 PM\n ART EXT (REST ONLY) Clip # \n Reason: Evaluate blood flow to feet.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with non-healing ulcer of L second toe.\n REASON FOR THIS EXAMINATION:\n Evaluate blood flow to feet.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nonhealing left foot ulcer.\n\n FINDINGS: Monophasic wave forms at all levels involving both lower\n extremities. The ABI measurements are inaccurate due to vessel\n noncompressibility. Volume recordings demonstrate wave form widening at all\n levels and extremely low amplitude at the popliteal levels and distally,\n bilaterally.\n\n IMPRESSION: Bilateral aortoiliac disease. There is likely an element of\n tibial disease bilaterally as well.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-03 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 772384,
"text": " 7:06 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: OSTEOMYOLITIS LEFT SECOND TOE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Osteomyelitis left second toe, preoperative exam.\n\n PA and lateral chest radiograph dated is compared with the PA and\n lateral radiograph dated .\n\n There is moderate cardiomegaly. There is flattening of the diaphragms\n consistent with COPD. No areas of consolidation are identified. The lungs\n are clear. There are no pleural effusions. No pneumothorax identified.\n Osseous structures unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-12-03 00:00:00.000",
"description": "L FOOT AP,LAT & OBL LEFT",
"row_id": 772385,
"text": " 7:06 PM\n FOOT AP,LAT & OBL LEFT Clip # \n Reason: eval for osteo 2nd toe\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with ulcer\n REASON FOR THIS EXAMINATION:\n eval for osteo 2nd toe\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FOOT, 3 VIEWS:\n\n History of ulcer second digit. To evaluate for osteomyelitis.\n\n No fracture. There is osteopenia. No definite evidence for osteomyelitis and\n no radiopaque foreign bodies. There are hammer toes digits two to five\n inclusive.\n\n"
},
{
"category": "ECG",
"chartdate": "2105-12-10 00:00:00.000",
"description": "Report",
"row_id": 162550,
"text": "Atrial fibrillation with slow ventricular response\n- premature ventricular contractions or aberrant ventricular conduction\nRight bundle branch block\nVoltage criteria for left ventricular hypertrophy\nInferior ST-T changes are nonspecific\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-12-03 00:00:00.000",
"description": "Report",
"row_id": 162551,
"text": "Atrial fibrillation with a moderate ventricular response and occasional\nventricular premature beats. Right bundle-branch block. Compared to the\nprevious tracing of , no diagnostic interval change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2105-12-04 00:00:00.000",
"description": "Report",
"row_id": 162552,
"text": "Atrial fibrillation. Right bundle-branch block pattern. Compared to the\nprevious tracing of , no diagnostic change.\nTRACING #2\n\n"
}
] |
24,657 | 186,160 | 1. Upper gastrointestinal bleed - The patient has undergone a bleeding scan, mesenteric angiogram, colonoscopy and esophagogastroduodenoscopy. The patient was in the Medical Intensive Care Unit for two days for which he was admitted for hypotension and hematocrit drop from 33.6 to 26.5. The patient was transfused and remained hemodynamically stable. The patient tolerated colonoscopy and esophagogastroduodenoscopy well without complications. Nonsteroidal anti-inflammatory drugs were held. There was no evidence of rebleeding. The patient was continued on Protonix and was subsequently transferred to the general Medicine floor. Diet was advanced without difficulty. The patient was reevaluated by the gastroenterology team after colonoscopy and has continued to do well. 2. Hematology/Oncology - Known nonHodgkin's lymphoma and Stage IV nonsmall cell lung cancer with bony metastases. The patient's pain was controlled with Oxycodone and Tylenol. Nonsteroidal anti-inflammatory drugs were avoided. Last dose of Zometa was on . The patient is to follow-up as an outpatient with Hematology/ Clinic. | HAD COLONOSCOPY DONE. PASSED LG. COLONOSCOPY IN AM. A superior mesenteric arteriogram was then performed. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. nsg progress note 7a-7pNeuro: A+O X3. no n/v.RESP: LS cta. Lungs clear t/o.GI: Abd softly distended, hyper BS. 1% Lidocaine. Pt came to EW, where his hct 33. TO BE TRANSFUSED FOR HCT <28. VIT. post procedure hct 28.9.. pt recieved 1uprbc's in IR and currently has 1uprbc's infusing (total 4 units prbc's). IV SITE ECCHYMOTIC. ON Q4/HR HCT.NEURO - PT. He received 1.3L NS. HCT STABLE AT 1300 33.1.ID- TEMP MAX 98.8. AMTS. SBP 130-160 VIA ALINE. also to US LUE. LAST OVER/ FOR HCT 28.6 @ . CONT PREPPING WITH GOLYTELY. SOFT, NTND WITH +BS NOTED. U/A YEST. pt transferred to micu. A inferior mesenteric arteriogram was then performed. PHOS 2.3 RECIEVED 3 PKTS NEUTRAPHOS. OF EXTREM. OOB TO COMMADE WITH 2 ASSIST. recommended pt f/u with optometrist if recurs.CV: VSS, afebrile.HR 80-90's no ectopy. PT. PT. PT. PT. PT. PT. LS CLEAR T/O. OVER/ TO 99.3. D OINTMENT APPLIED WITH SOME RELIEF SORENESS.ACCESS - 2 RLE PIVS; PATENT, SITES WNL. Sinus rhythmLateral ST elevation - possible early repolarizationSince last ECG, no significant change Superior mesenteric arteriogram demonstrated a normal branching pattern. SUPPOVE CARE. RECENT BLEED HOWEVER SO INJECTED WITH EPI. CONCLUSION: Focal thrombosis or thrombophlebitis of the antecubital cephalic vein left. POST HCT AFTER 1U PRBCS 32.8. CONT. R-RADIAL ART. Review Of Systems:Nuero: A+O x 3. Manual Bp correlated. CIRCUMF. PERIPHERAL PULSES PALPABLE. pt agreed to restart prep in am. GIVEN 4L GO/LYTELY FOR COLONOSCOPY YEST. Currently in IR. A/P: pt with hcts cont to drop despite tx. YEST. sats 99-100% RA.FE: repat lytes wnl excetp Ca 7.9, and phos 2.2. will need to be addressed upon return to unit. ABP 130'S-160'S/50'S-70'S. Repeat hct post tx is 27.9. team has ordered another unit prbc's. Hcts changed . LR hung d/t dye load in angio. AXOX3. on protonix. ab soft, bs +. cont to follow hct q 4 hrs. up to 1teens when on commode. R femoral angio site benign. Transfer note complete. MONITOR SERIAL HCTS. cont to support as doing. plan for colonoscopy today. RESP 14-20. CV: HR 90's. UO 200 IN EW and 180cc's on arrival to micu. Team notified. ABD. pt with + pulses, + csm to all extremities. HCTS Q HOURS- 1700,2100,0100,0400 SBP 140-160. The right groin was prepped and draped in the usual sterile fashion. Hemostatis is achieved with manual compression. Called out to floor. There is echogenic thrombus within the cephalic vein, limited to the antecubital fossa. in EW INR 1.2. no stool since admit. Complaint subsided. COOPERATIVE WITH CARE.RESP- BS CLEAR. Sinus rhythmNormal ECGSince last ECG, no significant change iv rn in and placed 2nd 18g piv. GI in to see pt and explained dx and folow up care. 0800 hct 35.1 and no s/s of bleeding.GU: pt with lg. IS PRESENTLY ON COMMODE PASSING STOOL.HEME- HCT STABLE AT 33. pt consented for and brought to IR for procedure to stop lgib. INR pending. will cont to follow hct's, tx prn. BLEEDING SCAN+ FOR LOWER GI BLEED. 96-98% ON RA. now drinking Go-lytely again in prep for colonoscopy. MG 1.9 TX WITH 2GMS MAG. FOCUS; NURSING PROGRESS NOTEREVEIW OF SYSTEMSNEURO- ALERT AND ORIENTED X3 AND COOPERATIVE WITH CARE.RESP- BS CLEAR. Bp somewhat elevated this am up to 180/80's. The SOS catheter was then disengaged from the inferior mesenteric artery and repositioned into the origin of the superior mesenteric artery. RIGHT ARM REMAINS EDEMATOUS. Arm measurements taken upper 32.5, lower 30.5 appears per pt to have decreased in girth.DISPO: Full code. The more proximal cephalic vein is patent, as are the brachial veins. PT had recently been started on Allieve, Advil and Oxycodone for bony pain. BP 130's-140's/50's-60's. ARM HAS . MEASURMENTS AS PER FLOWSHEET.HEM- HCT AT 0900 34.4 UP FROM 27.9. DENIES PAIN.RESP - RR TEENS WITH O2SATS. EGD PERFORMED WITH + DUODENAL ULCER; THOUGH NO ACTIVE BLEEDING PRESENT. HCT INITIALLY 33. plan is for pt to start Go-lytely prep this am for colonoscopy this afternooon. easily reoriented. ? repeat hct 26. pt tx 2uprbc's in EW, and brought to bleeding scan which showed + bleeding in lower colon. DENIES SOB.C/V - HR 70'S-90'S, NSR WITH NO ECTOPY NOTED. Pt thought it might be r/t anxiety. MAE. BLOODY STOOL WITH SUBSEQUENT HCT DROP TO 26. BEING MEASURED BY CM. HAS RECEIVED TOTAL 7U PRBCS SINCE ADMIT. (Over) 3:35 AM MESENTERIC Clip # Reason: please eval for possibility of bleeding vessel amenable for Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 203 FINAL REPORT (Cont) CONTRAST: 203 cc Optiray 320, 60% was used. RESP: lS decreased bases, sats high 90's ra, RR 16-20. Next PTT 1800. FULL CODE. repeat hct 29.4. alien placed. ON ALLEVE/ADVIL/PERCOCET @ HOME. He is a Draftsman for the city of .Access: 2 18g piv's.A/P: pt with LGIB hemodynamically stable. RESP 15-18 WITH SATS 96-98% ON RA.CARDIOVASCULAR- HR 90'S NSR WITHOUT ECTOPI. 3:35 AM MESENTERIC Clip # Reason: please eval for possibility of bleeding vessel amenable for Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED Contrast: OPTIRAY Amt: 203 ********************************* CPT Codes ******************************** * EA 1ST ORDER ABD/PEL/LOWER EXT EA 1ST ORDER ABD/PEL/LOWER EXT * * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM * * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER * * NON-IONIC 200 CC SUPPLY * **************************************************************************** MEDICAL CONDITION: 60 year old man with 10 pt hct drop receiving 2units PRBC with now resolved hemodynamic instability REASON FOR THIS EXAMINATION: please eval for possibility of bleeding vessel amenable for embolization in pt w/ positive bleeding scan in sogmoid FINAL REPORT HISTORY: Status post 10 point hematocrit drop and positive bleeding scan. | 12 | [
{
"category": "Radiology",
"chartdate": "2196-11-10 00:00:00.000",
"description": "EA 1ST ORDER ABD/PEL/LOWER EXT A-GRAM",
"row_id": 810644,
"text": " 3:35 AM\n MESENTERIC Clip # \n Reason: please eval for possibility of bleeding vessel amenable for\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 203\n ********************************* CPT Codes ********************************\n * EA 1ST ORDER ABD/PEL/LOWER EXT EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * NON-IONIC 200 CC SUPPLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with 10 pt hct drop receiving 2units PRBC with now resolved\n hemodynamic instability\n REASON FOR THIS EXAMINATION:\n please eval for possibility of bleeding vessel amenable for embolization in pt\n w/ positive bleeding scan in sogmoid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post 10 point hematocrit drop and positive bleeding scan.\n\n Radiologists: Dr. and Dr. performed the procedure,\n with the staff radiologist present and supervising throughout the procedure.\n\n PROCEDURE/TECHNIQUE: Risks and benefits were explained to the patient and\n informed written consent was obtained. The patient was placed supine on the\n angiographic table. The right groin was prepped and draped in the usual\n sterile fashion. Under fluoroscopic guidance access was obtained to the right\n common femoral artery with a 19-gauge single-walled puncture needle. A\n wire was then advanced into the abdominal aorta. The puncture needle\n was then exchanged for a 5-French angiographic sheath. A 5-Frechn C2 glide-\n catheter was then advanced into the distal abdominal aorta. Then, a SOS omni\n catheter was exchanged for the C2 glide catheter. The catheter was then\n placed in the superior mesenteric artery. A superior mesenteric arteriogram\n was then performed.\n\n Superior mesenteric arteriogram demonstrated a normal branching pattern. No\n area of contrast extravasation was noted. The catheter was then withdrawn\n into the aorta and was used to access the inferior mesenteric artery. A\n inferior mesenteric arteriogram was then performed.\n\n Two runs of inferior mesenteric arteriograms were performed in different\n projections. There is no contrast extravasation or evidence for vascular\n malformation. The SOS catheter was then disengaged from the inferior\n mesenteric artery and repositioned into the origin of the superior mesenteric\n artery. Arteriogram with injection of contrast material into SMA demonstrated\n no evidence of active bleeding or vascular abnormalities.\n\n The patient was transfered to a stretcher and the angiographic sheath was then\n removed and pressure was applied. Hemostatis is achieved with manual\n compression.\n (Over)\n\n 3:35 AM\n MESENTERIC Clip # \n Reason: please eval for possibility of bleeding vessel amenable for\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 203\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CONTRAST: 203 cc Optiray 320, 60% was used.\n\n MEDICATIONS: IV conscious sedation, consisting of incremental doses of Versed\n and Fentanyl. 1% Lidocaine.\n\n The patient tolerated the procedure well without complication.\n\n IMPRESSION: Evaluation of the SMA an and the does not demonstrate a GI\n bleed. Negative study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2196-11-11 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 810768,
"text": " 7:50 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: SWOLLEN LEFT ARM, R/O CLOT/DVT IN PROX VEINS\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with swelling of LUE after 18G IV in antecubital vein\n REASON FOR THIS EXAMINATION:\n r/o clot/DVT in proximal vv\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Swelling of left upper extremity after IV placement.\n\n RIGHT UPPER EXTREMITY ULTRASOUND: The left internal jugular vein demonstrates\n normal color flow, as do the left subclavian, axillary, brachial and basilic\n veins. There is echogenic thrombus within the cephalic vein, limited to the\n antecubital fossa. The more proximal cephalic vein is patent, as are the\n brachial veins.\n\n CONCLUSION: Focal thrombosis or thrombophlebitis of the antecubital cephalic\n vein left.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-11 00:00:00.000",
"description": "Report",
"row_id": 1582835,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVEIW OF SYSTEMS\nNEURO- ALERT AND ORIENTED X3 AND COOPERATIVE WITH CARE.\nRESP- BS CLEAR. RESP 15-18 WITH SATS 96-98% ON RA.\nCARDIOVASCULAR- HR 90'S NSR WITHOUT ECTOPI. SBP 140-160. CA 7.6 RECEIVED 3 AMPS CALCIUM GLUCONATE. PHOS 2.3 RECIEVED 3 PKTS NEUTRAPHOS. RIGHT ARM REMAINS EDEMATOUS. MEASUREMENTS OF LEFT LOWER ARM AND LEFT UPPER ARM REMAIN STABLE. 31.5CM LOWER ARM AND 36.5 CM LOWER ARM. PRELIMINARY RESULTS OF U/S OF LEFT ARM SHOWS NO CLOTS IN MAJOR VESSELS. ARM ELEVATED ABOVE HEART ON BATH SHEET.\nGI- ABD SOFT WITH POS BS. PASSING LARGE AMOUNT BLACK BROWN GUIAC POS STOOL THIS AM FROM GOLYTELY PREP. HAD COLONOSCOPY DONE. RECEIVED TOTAL OF 5MG VERSED AND 200MCGS OF FENTANYL FOR THE PROCEDURE. NO SOURCE FOR RECENT BLEED FOUND ON COLONOSCOPY. HAD LOTS OF GAS PAIN AFTER PROCEDURE. UP TO COMMODE PASSED GAS AND FELT MUCH BETTER. DIET CHANGED TO FULL LIQUID DIET. EATING ICECREAM AT PRESENT.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE 300/HR OR GREATER.\nSKIN- SKIN ABRASION AROUND OLD LEFT ANTECUB IV. IV SITE ECCHYMOTIC. TAPE BURNS ON SIDE VERY PAINFUL. LEFT ARM MORE SWOLLEN THAN RIGHT. MEASURMENTS AS PER FLOWSHEET.\nHEM- HCT AT 0900 34.4 UP FROM 27.9. HCT STABLE AT 1300 33.1.\nID- TEMP MAX 98.8. NO OTHER ISSUES.\n WIFE AND DAUGHTER IN TO VISIT.\nDISPO- REMAINS IN THE MICU A FULL CODE.\nPLAN- ADVANCE DIET TO FULL LIQUIDS.\n HCTS Q HOURS- 1700,2100,0100,0400\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-12 00:00:00.000",
"description": "Report",
"row_id": 1582836,
"text": "MICU-B NPN 1900-0700\nPLEASE SEE FHP FOR FURTHER DETAIL AND HX. PT. WITH SM CELL CA/LYMPHOMA WITH METS TO BONE (SHOULDERS AND RIBS). ON ALLEVE/ADVIL/PERCOCET @ HOME. STARTED TO GI BLEED. HCT INITIALLY 33. PT. PASSED LG. AMTS. BLOODY STOOL WITH SUBSEQUENT HCT DROP TO 26. BLEEDING SCAN+ FOR LOWER GI BLEED. PT. TO IR WITH NO SOURCE IDENTIFIED. EGD PERFORMED WITH + DUODENAL ULCER; THOUGH NO ACTIVE BLEEDING PRESENT. ? RECENT BLEED HOWEVER SO INJECTED WITH EPI. PT. GIVEN 4L GO/LYTELY FOR COLONOSCOPY YEST. NO SOURCE BLEEDING IDENTIFIED. PT. HAS RECEIVED TOTAL 7U PRBCS SINCE ADMIT. LAST OVER/ FOR HCT 28.6 @ . PT. TO BE TRANSFUSED FOR HCT <28. POST HCT AFTER 1U PRBCS 32.8. ON Q4/HR HCT.\n\nNEURO - PT. AXOX3. PLEASANT. MOVING INDEPENDENTLY IN BED. YEST. OOB TO COMMADE WITH 2 ASSIST. DENIES PAIN.\n\nRESP - RR TEENS WITH O2SATS. 96-98% ON RA. LS CLEAR T/O. DENIES SOB.\n\nC/V - HR 70'S-90'S, NSR WITH NO ECTOPY NOTED. ABP 130'S-160'S/50'S-70'S. PERIPHERAL PULSES PALPABLE. NO EDEMA NOTED TO EXTREM. U/A YEST. OF LUE FOLLOWING INFILTRATED PIV SITE DURING INFUSION PRBCS. WITH SUBEQUENT EDEMA AND PAIN TO EXTREM. U/S SHOWED NO CLOT IN ANY MAJOR VESSEL. CIRCUMF. OF EXTREM. BEING MEASURED BY CM. ARM HAS . IN SIZE.\n\nGI/GU - DIET ADVANCE TO FULL LIQUIDS WELL/TOL. ABD. SOFT, NTND WITH +BS NOTED. NO STOOL OVER/. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. YELLOW, URINE WITH SEDIMENT.\n\nID - LOW GRADE TEMP. OVER/ TO 99.3. WBC 8.6 THIS AM.\n\nSKIN - SKIN TEAR TO OLD INFILTRATED PIV SITE TO LUE FROM TAPE. VIT. D OINTMENT APPLIED WITH SOME RELIEF SORENESS.\n\nACCESS - 2 RLE PIVS; PATENT, SITES WNL. R-RADIAL ART. LINE IN PLACE; PATENT WITH SHARP WAVEFORM, +DRAW, +FLUSH, SITE WNL.\n\nSOCIAL - WIFE CALLED OVER/ AND SPOKE WITH PT. NO VISITORS OVER/. HAS 2 DAUGHTERS AS WELL.\n\nDISPO - PT. FULL CODE. CONT. SUPPOVE CARE. MONITOR SERIAL HCTS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-10 00:00:00.000",
"description": "Report",
"row_id": 1582832,
"text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X3. COOPERATIVE WITH CARE.\nRESP- BS CLEAR. RESP 14-20. SATS 98-100%.\nCARDIAC- HR 80- NO ECTOPI. SBP 130-160 VIA ALINE. MG 1.9 TX WITH 2GMS MAG. CA 7.5 TX WITH 2 AMPS CALCIUM GLUCONATE.\nGI- ABD SOFT WITH POS BS. ENDOSCOPE DONE THIS AM SHOWING A DUODENAL ULCER THAT WAS INJECTED WITH EPI. THE FINDINGS IN THE DUODENUM WERE CONSISTENT WITH NSAIDS.HE RECEIVED A TOTAL OF 4MG VERSED AND 50MCGS OF FENTANYL FOR THE PROCEDURE. HE IS PRESENTLY BEING PREPPED WITH 4 L OF GOLYTELY FOR A COLONOSCOPY TOMMORROW. HE HAS BEEN NPO EXCEPT FOR GOLYTELY AND MEDS.\nGU- FOLEY PATENT DRAINGING CLEAR YELLOW URINE AROUND 80CC/HR.\nHEME- HCT THIS AM AFTER UNIT OF BLOOD HAD FINISHED WAS 30.9 UP FROM 28.3. 4 HOURS LATER IT WAS 33.6. NEXT HCT DUE AT 1700. TO CONT WITH Q 4 HOUR HCTS TONIGHT.\nID- TEMP MAX 98.9. NO ISSUES.\n WIFE AND DAUGHTER IN VISITING MOST OF DAY.\nDISPO- REMAINS IN MICU. CODE STATUS WAS READRESSED AND CLARIFIED BY MICU TEAM. HE IS A FULL CODE.\nPLAN- CONT Q 4 HOUR HCTS. CONT PREPPING WITH GOLYTELY. COLONOSCOPY IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-10 00:00:00.000",
"description": "Report",
"row_id": 1582833,
"text": "FOCUS; ADDENDUM\nGI- PASSED ON SMALL LOOSE BLACK DARK MAAROON STOOL TODAY. IS PRESENTLY ON COMMODE PASSING STOOL.\nHEME- HCT STABLE AT 33.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-11 00:00:00.000",
"description": "Report",
"row_id": 1582834,
"text": "NPN days:\n Neuro: pt alert and oriented x 3, although this am pt was unclear if it was 5:30 am or PM. easily reoriented. no other s/s disorientation.\n CV: HR 90's. up to 1teens when on commode. BP 130's-140's/50's-60's.\n GI: pt with large amt maroon stool with clots in evening. refused further GO-Lytely prep. wanted to sleep. team aware. pt agreed to restart prep in am. now drinking Go-lytely again in prep for colonoscopy. ab soft, bs +. no further stool. on protonix. hct 29.9 in evening. team later decided to tx 1 uprbc's.. upon routine check, iv noted to be leaking large amt of Tx into the bed. area around iv red r/t tape. IV dc'd.. pt with painful tape blisters burns underneath tape despite careful removal. L arm also noted to be much larger than R.. team notified of all the above. no intervention initially. However, the size of the L arm continued to be concerning, so intern has ordered US to be done. pt with + pulses, + csm to all extremities. Repeat hct post tx is 27.9. team has ordered another unit prbc's.\n GU: uo 100-200 cc's/hr.\n RESP: lS decreased bases, sats high 90's ra, RR 16-20.\n Access: I was unable to place 2nd piv once first iv infiltrated. iv rn in and placed 2nd 18g piv.\n A/P: pt with hcts cont to drop despite tx. plan for colonoscopy today. also to US LUE. cont to support as doing.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-10 00:00:00.000",
"description": "Report",
"row_id": 1582830,
"text": "PMICU NURSING ADMIT NOTE:\n Pt is a 60 yr old male with PMH of NHL and NSCLCA with bony mets to ribs, hip and back. PT had recently been started on Allieve, Advil and Oxycodone for bony pain. He most recently experienced 2 days of diarrhea. Pt came to EW, where his hct 33. He received 1.3L NS. Pt then had large amt blood out per rectum on commode. repeat hct 26. pt tx 2uprbc's in EW, and brought to bleeding scan which showed + bleeding in lower colon. pt transferred to micu. repeat hct 29.4. alien placed. pt consented for and brought to IR for procedure to stop lgib.\n Review Of Systems:\nNuero: A+O x 3. MAE. Reports no back or rib pain on admit.\nCV: HR 90's NSR, bp 130-140/60's.\nGI: repeat hct as noted. INR pending. in EW INR 1.2. no stool since admit. no n/v.\nRESP: LS cta. sats 99-100% RA.\nFE: repat lytes wnl excetp Ca 7.9, and phos 2.2. will need to be addressed upon return to unit. UO 200 IN EW and 180cc's on arrival to micu. FB 1.6L +.\nGU: foley intact, urine light yellow, clear.\nSocial: pt lives with his wife . is still working. He is a Draftsman for the city of .\nAccess: 2 18g piv's.\nA/P: pt with LGIB hemodynamically stable. Currently in IR. await return. will cont to follow hct's, tx prn. will follow lytes on return.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-10 00:00:00.000",
"description": "Report",
"row_id": 1582831,
"text": "NURSING ADDENDUM:\n PT RETURNED FROM IR at 5:15 am. No source of bleeding identified. pt remained hemodynamically stable throughout procedure, recieved 3mg versed and 100 mcg fentanyl for procedure. LR hung d/t dye load in angio. uo brisk. R femoral angio site benign. Sheath pulleld in IR and hemostasis achieved at 5am. Pt needs to keep leg staight and lay flat as per IR orders until 11am. post procedure hct 28.9.. pt recieved 1uprbc's in IR and currently has 1uprbc's infusing (total 4 units prbc's). plan is for pt to start Go-lytely prep this am for colonoscopy this afternooon.\n A/p: No source of LGIB found via angiography. cont to follow hct q 4 hrs. start golytely prep this am.. pt currently deferring in favor of a short nap as he has been up all night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2196-11-12 00:00:00.000",
"description": "Report",
"row_id": 1582837,
"text": "nsg progress note 7a-7p\nNeuro: A+O X3. Denies pain. OOB to chair most of the day. Pt c/o vague vision impairment in left eye stated \" a part of your face is obstructed\". Complaint subsided. recommended pt f/u with optometrist if recurs.\n\nCV: VSS, afebrile.HR 80-90's no ectopy. Bp somewhat elevated this am up to 180/80's. Manual Bp correlated. Pt thought it might be r/t anxiety. Pt does not have a hx of HTN. Team notified. Bp this afternoon more BP 150-160. Team to monitor before starting on antihypertensive meds. pt called out to floor and may be followed there.\n\nRESP: on ra sats 98%, took pt off o2 monitor since no SOB and no oxygen required. Lungs clear t/o.\n\nGI: Abd softly distended, hyper BS. + flatus, no stool today. Started on soft solids, tolerated well. Had several cans \"BOOST\" and adequate po's. GI in to see pt and explained dx and folow up care. Pt much more comfortable. Printed out educated sheets for pt and wife. Hcts changed . Next PTT 1800. 0800 hct 35.1 and no s/s of bleeding.\n\nGU: pt with lg. urine outputs, clear yellow, via foley.\n\nSKIN: left upper extremity with skin tear, OTA, A+ applied. Arm measurements taken upper 32.5, lower 30.5 appears per pt to have decreased in girth.\n\nDISPO: Full code. Called out to floor. Transfer note complete. Wife in to visit all day today and updated on plan of care.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2196-11-13 00:00:00.000",
"description": "Report",
"row_id": 115739,
"text": "Sinus rhythm\nLateral ST elevation - possible early repolarization\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2196-11-09 00:00:00.000",
"description": "Report",
"row_id": 115740,
"text": "Sinus rhythm\nNormal ECG\nSince last ECG, no significant change\n\n"
}
] |
66,664 | 179,966 | ICU course: Pt defibrillated in field after LOC and VFib vs VTach arrest. Once arrived in ED, noted to have AFib (unclear whether chronic or new onset) with RVR unresponsive to betablockers, so was begun on diltiazem for rate control. Given long-standing ETOH consumption, tachycardia perhaps complicated by ETOH withdrawal, however, CIWA score unimpressive. Pt did not need diazepam overnight, but in AM on HD1, pt noted to have continued tachycardia (150s) and diaphoresis, in addition to tremulousness. Diltiazem was increased to 60mg QID, and one dose of diazepam 10mg was given; pt's heart rate responded appropriately. CHADS2 score of 0-1 (congestive heart failure given ECHO showing 35%EF in ED). Cardiology was consulted, and Metoprolol 75mgTID was begun for rate control (discontinued Diltiazem) and heparin drip was begun per discussions. Patient was then successfully cardioverted on after appropriate sedation and TEE showing no clot formation. EF at this time was estimated at 30-35%. Per cardiology, EF may be transiently related to defibrillation, or even ETOH, but query area of LV wall motion abnormality and pt scheduled to have cardiac MRI on . . Course on the Floor: Once stable, pt was then transferred to cardiology service for continued tele monitoring and management of EtOH w/drawal while awating cardiac MRI on . MRI showed dilated cardiomyopathy with moderately increased left ventricular cavity size, global hypokinesis and moderately depressed left ventricular systolic function (LVEF 34%). Pt alos received heparin to coumadin bridge given new afib. EP was consulted to evaluate for possible ablation however, no arrhythmia could be ellicited other than afib. Pt did not want an ICD at this time. Further workup and managment are planned as outpt. . With respect to the pt's alcoholism, the pt was seen by social work but is not interested in quiting drink. He was informed that the cause of his arrest could very well be EtOH related and that he should not drink again. Per social work note: "Pt does not feel ETOH is a problem for him. He notes he has been drinking more frequently lately (past 1-2 years) and he acknowledges he would like to "slow down." But he is clear that he does not wish to stop drinking. He reports that he drinks drinks per night of whiskey. He reports that he would like to only drink 3-4 per night and that would be acceptable to him. He reports that he works full time at . He reports that his drinking does not interfere with work as he never drinks before work. Pt reports typically coming home from work and drinking until going to sleep. Pt reports that he has drank for many years. He notes he has tried to "cut-back" in the past and has also had periods of drinking more than he is now. Pt reports his wife and family are concerned about his drinking...Pt reports that he had a DUI in CT in for which he is now on probation. He meets with his parole officer 1x/month. As part of his probation he is supposed to attend an alcohol treatment program. He reports that he was supposed to go for the first time yesterday for intake. He does not know the name of the program but reports he has the address and phone # and believes it is in . Pt is not interested in further treatment resources at this time. Provided pt with local AA meeting list." . Pt was discharged in stable condition on Coumadin and amiodarone with cardiac outpt follow-up and told not to drink EtOH as this may cause another life-threatening and possible deadly arrhythmia. Outpt follow-up will be w/pcp and cardiologist (Dr. . | There is a trivial/physiologic pericardial effusion.IMPRESSION: No intracardiac thrombus seen. The right ventricular end-diastolic volume index was normal. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The right ventricular stroke volume and pulmonic flow demonstrated no significant pulmonic or tricuspid regurgitation. There is noaortic valve stenosis. Wall motion abnormality.Height: (in) 70Weight (lb): 190BSA (m2): 2.04 m2BP (mm Hg): 136/89HR (bpm): 109Status: InpatientDate/Time: at 18:34Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. No ASD by 2D orcolor Doppler.LEFT VENTRICLE: Severely depressed LVEF.RIGHT VENTRICLE: Borderline normal RV systolic function.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). The myocardium appeared to have homogenous signal intensity without evidence of myocardial fatty infiltration. The left ventricular end-diastolic dimension index was normal. Mild right atrial enlargement. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Normal right ventricular cavity size and systolic function. The ascending, transverse anddescending thoracic aorta are normal in diameter and free of atheroscleroticplaque to 46 cm from the incisors. The mitral valveappears structurally normal with trivial mitral regurgitation. Novegetation/mass on pulmonic valve.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The main pulmonary artery diameter index was normal. The main pulmonary artery diameter index was normal. Suboptimal technicalquality, a focal LV wall motion abnormality cannot be fully excluded.Beat-to-beat variability on LVEF due to irregular rhythm/premature beats.RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Thrombus.Height: (in) 70Weight (lb): 172BSA (m2): 1.96 m2BP (mm Hg): 151/83HR (bpm): 61Status: InpatientDate/Time: at 14:02Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or theRA/RAA. The aortic valve was tri-leaflet with normal valve area. The coronary sinus diameter was normal. Mild mitral regurgitation. Normal left ventricular wall thickness andcavity size. Quantitative Flow There was no significant intra-cardiac shunt. Aortic flow demonstrated no significant aortic regurgitation. IMPRESSION: No acute pulmonary process. Myocardial Fibrosis There was a small area of focal hyperenhancement at the inferior insertion of the right ventricle consistent with the presence of myocardial scarring/fibrosis. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Mildly dilated aortic sinus.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Probable tiny left renal cyst. The indexed diameters of the ascending and descending thoracic aorta were normal. The indexed diameters of the ascending and descending thoracic aorta were normal. FINDINGS: The lungs are clear without consolidation or edema. The calculated mitral valve regurgitant fraction was consistent with mild mitral regurgitation. Late gadolinium contrast-enhanced CMR images demonstrated a small focal area of hyperenhancement at the inferior insertion of the right ventricle consistent with myocardial fibrosis. The pericardial thickness was normal. FINDINGS: There is no acute hemorrhage, edema, mass effect, or infarct. Right ventricular chamber size and free wallmotion are normal. There is no biliary dilatation and the common duct measures 0.3 cm. IMPRESSION: No acute intracranial process. The cardiac silhouette is within normal limits for size. No CMR evidence of right ventricular fatty infiltration/dysplasia. Compared to the previous tracing thereis no significant change. The left atrial AP dimension was normal. The calculated right ventricular ejection fraction was normal at 47%, with normal free wall motion. The rhythm appears to be atrial fibrillation.Emergency study performed by the cardiology fellow on call.Conclusions:The left atrium is normal in size. The remaining segmentsare hypokinetic. There were no pericardial or pleural effusions. No AR.MITRAL VALVE: No mass or vegetation on mitral valve.TRICUSPID VALVE: Normal tricuspid valve leaflets. No effusion or pneumothorax is noted. Overallleft ventricular systolic function is severely depressed (LVEF= 25-30 %).Right ventricular function is borderline normal. The pulmonaryartery systolic pressure could not be determined. No focal liver lesion identified. The ascending aorta is mildly dilated. No focal liver lesion is identified. The ventricles and sulci are normal in size and morphology. arrest vs seizures REASON FOR THIS EXAMINATION: Eval acute process No contraindications for IV contrast WET READ: MLHh WED 9:03 PM No acute process. Restingtachycardia (HR>100bpm). No aortic regurgitation is seen. No aortic regurgitation is seen. There is no pericardialeffusion.If clinically indicated, a follow-up study by laboratory personnel issuggested to better define regional systolic function. Findings: Structure and Function There was normal epicardial fat distribution. There is no hydronephrosis. Atrial fibrillation with LBBB. The pancreas and midline structures are only minimally visualized due to overlying bowel. The anteroseptal and inferolateral wall thicknesses were normal. A small hypoechoic structure in the mid portion of the left kidney probably represents a simple cyst measuring 0.8 x 0.6 x 0.7 cm. There were no aneurysms seen in the RV free wall or right ventricular outflow tract. No atrial septal defect is seen by 2D or color Doppler. Ventricular fibrillation. The origins of the left main and right coronary arteries were identified in their customary positions. The paranasal sinuses and mastoid air cells are clear. The RVEF was low normal at 47%. Atrial fibrillation. There was abnormal septal motion consistent with interventricular conduction delay. Septal motion is abnormal (?due to IVCD). There is considerable beat-to-beatvariability of the left ventricular ejection fraction due to an irregularrhythm/atrial fibrillation. The portal vein is patent with hepatopetal flow. The visualized osseous structures are unremarkable. Pre cardioversion. S/p AED shock. 2) Function: Breath-hold cine SSFP images were acquired in the left ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8- mm slices with 2-mm gaps), sagittal and coronal orientations of the left ventricular outflow tract, and aortic valve short axis orientations. No mass orvegetation is seen on the mitral valve. No masses or vegetations areseen on the aortic valve. | 10 | [
{
"category": "Radiology",
"chartdate": "2168-06-23 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1141302,
"text": " 1:51 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: Signs of cirrhosis or other liver disease\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with elevated transaminases and hx of ETOH abuse\n REASON FOR THIS EXAMINATION:\n Signs of cirrhosis or other liver disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old man with elevated transaminases and history of ETOH\n abuse.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: The liver is diffusely echogenic consistent with fatty\n infiltration. No focal liver lesion is identified. There is no biliary\n dilatation and the common duct measures 0.3 cm. The portal vein is patent\n with hepatopetal flow. No gallstones are identified. The pancreas and\n midline structures are only minimally visualized due to overlying bowel. The\n spleen is unremarkable and measures 8.5 cm. There is no hydronephrosis. The\n right kidney measures 10.8 cm and the left kidney measures 9.3 cm. A small\n hypoechoic structure in the mid portion of the left kidney probably represents\n a simple cyst measuring 0.8 x 0.6 x 0.7 cm.\n\n IMPRESSION:\n 1. Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study. No focal liver lesion\n identified.\n 2. Probable tiny left renal cyst.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1141172,
"text": " 7:57 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with ? arrest vs seizures\n REASON FOR THIS EXAMINATION:\n Eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLHh WED 9:03 PM\n No acute process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old male with suspected cardiac arrest, less likely\n syncope.\n\n No prior examinations for comparison.\n\n TECHNIQUE: Contiguous non-contrast axial images were obtained through the\n brain.\n\n FINDINGS: There is no acute hemorrhage, edema, mass effect, or infarct. The\n ventricles and sulci are normal in size and morphology. The paranasal sinuses\n and mastoid air cells are clear.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-27 00:00:00.000",
"description": "MR CARDIAC MORPH/FX P/P CONTRAST",
"row_id": 1141850,
"text": " 12:14 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: question structural disease that predisposes patient to VT\n Admitting Diagnosis: SYNCOPE\n Contrast: MAGNEVIST Amt: 35\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with significant EtOH hx who had ?VT, who had an arrest in the\n field requiring cpr and shock.\n REASON FOR THIS EXAMINATION:\n question structural disease that predisposes patient to VT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n Patient Name: \n\n MR#: Status: Inpatient\n Study Date: \n Indication: 38-year-old man with history of alcohol abuse, cardiomyopathy and\n recent cardiac arrest referred for evaluation of myocardial fibrosis.\n Requesting Physician: . \n Height (in): 70\n Weight (lbs): 196\n Body Surface Area (m2): 2.09\n\n Hemodynamic Measurements\n Measurement Result\n Systemic Blood Pressure (mmHg) 145/84\n Heart Rate (bpm) 69\n\n Rhythm: sinus\n\n\n Measurement Result Male Normal\n Range\n LV End-Diastolic Dimension (mm) *64 <62\n LV End-Diastolic Dimension Index (mm/m2) 31 <32\n LV End-Systolic Dimension (mm) 51\n LV End-Diastolic Volume (ml) *242 <196\n LV End-Diastolic Volume Index (ml/m2) **116 <95\n LV End-Systolic Volume (ml) 159\n LV Stroke Volume (ml) 83\n LV Ejection Fraction (%) **34 >54\n LV Anteroseptal Wall Thickness (mm) 10 <12\n LV Inferolateral Wall Thickness (mm) 10 <11\n LV Mass (g) 191\n LV Mass Index (g/m2) *91 <80\n\n RV End-Diastolic Volume (ml) 158\n RV End-Diastolic Volume Index (ml/m2) 75 <114\n RV End-Systolic Volume (ml) 83\n RV Stroke Volume (ml) 75\n (Over)\n\n 12:14 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: question structural disease that predisposes patient to VT\n Admitting Diagnosis: SYNCOPE\n Contrast: MAGNEVIST Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n RV Ejection Fraction (%) 47 >46\n\n QFlow Net Aortic Forward Stroke Volume (QS net, ml) 73\n QFlow Net Pulmonary Artery Forward Stroke Volume\n (Qp net, ml) 75\n QP/QS 1.03 0.8 - 1.2\n QFlow Aortic Cardiac Output (l/min) 5.2\n QFlow Aortic Cardiac Index (l/min/m2) 2.5 >2.0\n QFlow Aortic Valve Regurgitant Volume (ml) 2\n QFlow Aortic Valve Regurgitant Fraction (%) 3 <5\n Mitral Valve Regurgitant Volume (ml) 8\n Mitral Valve Regurgitant Fraction (%) *10 <5\n Effective Forward LVEF (%) **30 >54\n Pulmonic Valve Regurgitant Volume (ml) 3\n Pulmonic Valve Regurgitant Fraction (%) 4 <5\n Tricuspid Valve Regurgitant Volume (ml) 0\n Tricuspid Valve Regurgitant Fraction (%) 0 <5\n\n Aortic Valve Area (2-D) (cm2) 4.2 >3.0\n Aortic Valve Area Index (cm2/m2) 2.0\n\n Ascending Aorta diameter (mm) 28 <39\n Ascending Aorta diameter Index (mm/m2) 13 <20\n Transverse Aorta diameter (mm) 24 <31\n Descending Aorta diameter (mm) 21 <28\n Descending Aorta Index (mm/m2) 10 <14\n Main Pulmonary Artery diameter (mm) 22 <29\n Main Pulmonary Artery diameter Index (mm/m2) 11 <15\n Left Atrium (Parasternal Long Axis) (mm) 33 <40\n Left Atrium Length (4-Chamber) (mm) 48 <52\n Right Atrium (4-Chamber) (mm) *54 <50\n Pericardial Thickness (mm) 2 <4\n Coronary Sinus diameter (mm) 6 <15\n\n * = Mildly abnormal, ** =moderately abnormal, *** = severely abnormal\n\n CMR Technical Information:\n CMR Technologists: , RT\n Nursing support: , RN\n\n eGFR: 75ml/min1.73m2 based on creatinine 1.1 mg/dl on \n Total Gd-DTPA (Magnevist ) contrast: 35 ml (0.2mmol/kg)\n Injection site: right antecubital vein\n\n Complications: None.\n (Over)\n\n 12:14 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: question structural disease that predisposes patient to VT\n Admitting Diagnosis: SYNCOPE\n Contrast: MAGNEVIST Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1) Structure: Axial dual-inversion T1 and T2-weighted (T2 STIR) images of the\n myocardium were obtained with and without (T1) spectral fat saturation pre-\n pulses in 5-mm contiguous slices.\n 2) Function: Breath-hold cine SSFP images were acquired in the left\n ventricular 2-chamber, 4-chamber, horizontal long axis, short axis slices (8-\n mm slices with 2-mm gaps), sagittal and coronal orientations of the left\n ventricular outflow tract, and aortic valve short axis orientations.\n 3) Flow: Phase-contrast cine images were obtained transverse to the aorta\n (axial plane) and main pulmonary artery (oblique plane).\n 4) Myocardial Viability/Fibrosis: Late gadolinium enhancement (LGE) images\n were obtained using a Phase Sensitive Inversion Recovery (PSIR) and a\n segmented inversion-recovery TFE acquisition with spectral fat saturation pre-\n pulses. Navigator gated high resolution axial LGE images were obtained using a\n segmented inversion-recovery TFE acquisition with spectral fat saturation pre-\n pulses (4-mm slices) 15 minutes after injection of a total of 0.2 mmol/kg\n gadopentetate dimeglumine (35 ml Magnevist solution). PSIR 3D short-axis, and\n PSIR 2D 4-chamber, and 2-chamber long-axis images (10-mm slices with 5-mm\n gaps) were obtained 25 minutes after injection of a total of 35 ml Magnevist\n solution.\n\n\n Findings:\n Structure and Function\n There was normal epicardial fat distribution. The myocardium appeared to have\n homogenous signal intensity without evidence of myocardial fatty infiltration.\n The pericardial thickness was normal. There were no pericardial or pleural\n effusions. The origins of the left main and right coronary arteries were\n identified in their customary positions. The indexed diameters of the\n ascending and descending thoracic aorta were normal. The main pulmonary\n artery diameter index was normal. The left atrial AP dimension was normal.\n The right atrial length in the 4-chamber view was mildly increased with normal\n left atrial length. The coronary sinus diameter was normal.\n The left ventricular end-diastolic dimension index was normal. The end-\n diastolic volume index was moderately increased. The calculated left\n ventricular ejection fraction was moderately depressed at 34% with moderate\n global hypokinesis. There was abnormal septal motion consistent with\n interventricular conduction delay. The anteroseptal and inferolateral wall\n thicknesses were normal. The left ventricular mass index was mildly increased.\n The right ventricular end-diastolic volume index was normal. The calculated\n right ventricular ejection fraction was normal at 47%, with normal free wall\n motion. There was no focal thinning or fatty infiltration seen in the RV free\n wall. There were no aneurysms seen in the RV free wall or right ventricular\n outflow tract.\n The aortic valve was tri-leaflet with normal valve area. A systolic signal\n (Over)\n\n 12:14 PM\n MR /FX P/P CONTRAST; MR FLOW MAP, ADD-ONClip # \n Reason: question structural disease that predisposes patient to VT\n Admitting Diagnosis: SYNCOPE\n Contrast: MAGNEVIST Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n void was seen in the left atrium consistent with mitral regurgitation.\n\n Quantitative Flow\n There was no significant intra-cardiac shunt. Aortic flow demonstrated no\n significant aortic regurgitation. The calculated mitral valve regurgitant\n fraction was consistent with mild mitral regurgitation. The resultant\n effective forward LVEF was moderately depressed at 30%. The right ventricular\n stroke volume and pulmonic flow demonstrated no significant pulmonic or\n tricuspid regurgitation.\n\n Myocardial Fibrosis\n There was a small area of focal hyperenhancement at the inferior insertion of\n the right ventricle consistent with the presence of myocardial\n scarring/fibrosis.\n\n\n Impression:\n 1. Dilated cardiomyopathy with moderately increased left ventricular cavity\n size, global hypokinesis and moderately depressed left ventricular systolic\n function (LVEF 34%). Late gadolinium contrast-enhanced CMR images\n demonstrated a small focal area of hyperenhancement at the inferior insertion\n of the right ventricle consistent with myocardial fibrosis.\n 2. Normal right ventricular cavity size and systolic function. The RVEF was\n low normal at 47%. No CMR evidence of right ventricular fatty\n infiltration/dysplasia.\n 3. Mild mitral regurgitation.\n 4. The indexed diameters of the ascending and descending thoracic aorta were\n normal. The main pulmonary artery diameter index was normal.\n 5. Mild right atrial enlargement.\n\n The images were reviewed by Drs. , -Zohlman,\n , , and .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1141171,
"text": " 8:13 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with ? VF arrest\n REASON FOR THIS EXAMINATION:\n Eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT HOURS.\n\n HISTORY: Cardiac arrest. Ventricular fibrillation.\n\n COMPARISON: None.\n\n FINDINGS: The lungs are clear without consolidation or edema. The\n mediastinum is unremarkable. The cardiac silhouette is within normal limits\n for size. No effusion or pneumothorax is noted. The visualized osseous\n structures are unremarkable.\n\n IMPRESSION: No acute pulmonary process.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2168-06-24 00:00:00.000",
"description": "Report",
"row_id": 89650,
"text": "PATIENT/TEST INFORMATION:\nIndication: Status post cardiac arrest with CPR for cardiopulmonary arrest. Alcohol abuse. Atrial fibrillation. Pre cardioversion. ? Thrombus.\nHeight: (in) 70\nWeight (lb): 172\nBSA (m2): 1.96 m2\nBP (mm Hg): 151/83\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 14:02\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. No AR.\n\nMITRAL VALVE: No mass or vegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV\nglycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No\nTEE related complications. The rhythm appears to be atrial fibrillation.\nCardiology fellow involved with the patient's care was notified by telephone.\nMD caring for the patient was notified of the echocardiographic results by\ne-mail.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\nleft ventricular systolic function is severely depressed (LVEF= 25-30 %).\nRight ventricular function is borderline normal. The ascending, transverse and\ndescending thoracic aorta are normal in diameter and free of atherosclerotic\nplaque to 46 cm from the incisors. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. No masses or vegetations are\nseen on the aortic valve. No aortic regurgitation is seen. No mass or\nvegetation is seen on the mitral valve. No vegetation/mass is seen on the\npulmonic valve. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: No intracardiac thrombus seen. Severe left ventricular systolic\ndysfunction while in rapid atrial fibrillation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2168-06-22 00:00:00.000",
"description": "Report",
"row_id": 89651,
"text": "PATIENT/TEST INFORMATION:\nIndication: Loss of consciousness. S/p AED shock. Atrial fibrillation with LBBB. ? Wall motion abnormality.\nHeight: (in) 70\nWeight (lb): 190\nBSA (m2): 2.04 m2\nBP (mm Hg): 136/89\nHR (bpm): 109\nStatus: Inpatient\nDate/Time: at 18:34\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nBeat-to-beat variability on LVEF due to irregular rhythm/premature beats.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm). The rhythm appears to be atrial fibrillation.\nEmergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. Normal left ventricular wall thickness and\ncavity size. Septal motion is abnormal (?due to IVCD). The remaining segments\nare hypokinetic. Due to suboptimal technical quality, regional assessment\ncould not be fully made. Overall left ventricular systolic function is\nmoderately depressed (LVEF= 35 %). There is considerable beat-to-beat\nvariability of the left ventricular ejection fraction due to an irregular\nrhythm/atrial fibrillation. Right ventricular chamber size and free wall\nmotion are normal. The ascending aorta is mildly dilated. The aortic valve\nleaflets (?#) appear mildly thickened with good leaflet excursion. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIf clinically indicated, a follow-up study by laboratory personnel is\nsuggested to better define regional systolic function.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2168-06-25 00:00:00.000",
"description": "Report",
"row_id": 237492,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing there\nis no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-06-24 00:00:00.000",
"description": "Report",
"row_id": 237493,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof the rhythm has changed and the rate is slower.\n\n"
},
{
"category": "ECG",
"chartdate": "2168-06-22 00:00:00.000",
"description": "Report",
"row_id": 237494,
"text": "Atrial fibrillation with rapid ventricular response. Left bundle-branch block.\nSince the previous tracing of same date ventricular rate is faster.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2168-06-22 00:00:00.000",
"description": "Report",
"row_id": 237495,
"text": "Probable atrial fibrillation with a rapid ventricular response. Left\nbundle-branch block. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
65,270 | 132,260 | The patient was admitted to the CCU after his catheterization procedure with Impella in place. In the evening, he was noted to develop a LBBB, which was consistent with myocardial damage from his massive anterior wall STEMI. Later in the evening, his Impella device was felt to have moved and to no longer be properly positioned. The position of the Impella was readjusted by the interventional cardiology fellow under echocardiographic guidance. Throughout the night, the patient's clinical status deteriorated and he became increasingly acidotic. It was felt that he could have ischemic bowel; however, the patient was too clinically unstable to undergo a CT scan. The patient's family was called into the hospital, and the gravity of his situation was explained to them. They felt that he would not want to live in his current state and decided that they would withdraw care. Pressors were weaned down and the patient expired. | Assessment and Plan 78 y/o M with h/o recent duodenal bleed admitted with anterior STEMI. Myocardial infarction, acute (AMI, STEMI, NSTEMI) Assessment: Intubated pt. Anterior wallmyocardial infarction with ST-T wave configuration suggesting acute process.Clinical correlation is suggested. Sinus tachycardia with A-V conduction delay. Probable sinus tachycardia with A-V conduction delay. # Hyperlipidemia: Statin as above. After RHC demonstrated severely elevated left-sided filling pressures, Impella placed and IABP pulled. After RHC demonstrated severely elevated left-sided filling pressures, Impella placed and IABP pulled. After rhc demonstrated severely elevated left-sided filling pressures, impella placed and iabp pulled. After rhc demonstrated severely elevated left-sided filling pressures, impella placed and iabp pulled. After RHC demonstrated severely elevated left-sided filling pressures, Impella placed and IABP pulled. After RHC demonstrated severely elevated left-sided filling pressures, Impella placed and IABP pulled. On angiography, he was noted to have thrombus in mid-RCA, as well as acute thrombotic occlusion of LAD. Shocked x2 in the ED and was given amiodarone. Impella device repositioned (by interventional fellow) after echo showed improper postioning. Impella device repositioned (by interventional fellow) after echo showed improper postioning. Response: Cont to titrate Neo and Dopa. Titrating NEO and Dopamine for pressure support. ------ Protected Section------ ------ Protected Section Error Entered By: , MD on: 19:58 ------ Chief Complaint: STEMI/VF ARREST HPI: 78M with recent duodenal ulcer bleed presented to OSH with CP and anterior ST-segment depression. TITLE: Cardiology fellow CCU admit note 78M with recent duodenal ulcer bleed presented to OSH with CP and anterior ST-segment depression. Interventional cards fellow called for repositioning. S/p BMS to LAD and RCA, also s/p Impella placement. Sedated on Versed and Fentanyl gtts. Received epi by EMS. Myocardial infarction. Emergency study. 78M with recent duodenal ulcer bleed presented to OSH with CP and anterior ST-segment depression. GI on consult due to recent GI bleed. PA line and Aline in Rt groin. - transfuse PRN to maintain hematocrit > 30 - consult GI; will need a scope to possibly treat any source of bleeding - trend Hct - IV PPI . Neo and dopamine for bp support. Neo and dopamine for bp support. Neo and dopamine for BP support. Intraventricularconduction delay suggests atypical left bundle-branch block. ECG at OSH showed ST elevations in V1-V4, ST depressions in II, III, aVF. There is a trivial/physiologic pericardial effusion. Myocardial Infarction, Acute - STEMI Assessment: Cardiogenic shock with sever metabolic acidosis. Myocardial Infarction, Acute - STEMI Assessment: Cardiogenic shock with sever metabolic acidosis. TITLE: Cardiology fellow CCU admit note 86M with 3VD s/p bypass and patent LIMA->LAD, SVG->OM and SVG->RCA, severe AS (0.8-1 cm2 in ) presents with chest pain, ECG changes concerning for diffuse ischemia. TITLE: Cardiology fellow CCU admit note 86M with 3VD s/p bypass and patent LIMA->LAD, SVG->OM and SVG->RCA, severe AS (0.8-1 cm2 in ) presents with chest pain, ECG changes concerning for diffuse ischemia. on Neo and Dopamine gtts for BP support. Since the previous tracing of same dateintraventricular conduction delay is now present.TRACING #2 PATIENT/TEST INFORMATION:Indication: Echocardiographic guidance for Impella placement.Height: (in) 70Weight (lb): 200BSA (m2): 2.09 m2BP (mm Hg): 112/60HR (bpm): 131Status: InpatientDate/Time: at 21:00Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Severely depressed LVEF.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Emergency study. Suboptimal image quality - ventilator. Reportedly, pt was in a.fib on transfer to the cath lab. Ventricular deptal defect. Initially treated LAD lesion, then placed IABP, then treated RCA lesion with POBA alone, followed by stenting because of thrombotic occlusion. Initially treated LAD lesion, then placed IABP, then treated RCA lesion with POBA alone, followed by stenting because of thrombotic occlusion. Initially treated lad lesion, then placed iabp, then treated rca lesion with poba alone, followed by stenting because of thrombotic occlusion. Initially treated lad lesion, then placed iabp, then treated rca lesion with poba alone, followed by stenting because of thrombotic occlusion. Initially treated LAD lesion, then placed IABP, then treated RCA lesion with POBA alone, followed by stenting because of thrombotic occlusion. Plan: Pressors & impella device stopped. Plan: Pressors & impella device stopped. Then, the RCA lesion was treated, initially with POBA alone, followed by stenting because of thrombotic occlusion. The device isthen seen being pulled toward the left ventricular outflow tract into a moreproximal position. PROPHYLAXIS: -DVT ppx with heparin gtt -Holding bowel regimen in setting of recent GI bleed CODE: Presumed full COMM: (wife) ; (son) DISPO: CCU for now ICU Care Nutrition: Glycemic Control: Lines: Sheath - 11:45 AM 16 Gauge - 11:45 AM 18 Gauge - 11:45 AM Arterial Line - 11:48 AM PA Catheter - 11:49 AM Prophylaxis: DVT: (Systemic anticoagulation: Heparin gtt) Stress ulcer: PPI VAP: HOB elevation, Mouth care Comments: Communication: Comments: Code status: Full code Disposition: ICU PULSES: Right: DP unable to find PT dopplerable Left: DP unable to find PT dopplerable NEURO: Intubated, Sedated. | 16 | [
{
"category": "Echo",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Report",
"row_id": 67282,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Ventricular deptal defect. Free wall rupture. Mitral regurgitation.\nHeight: (in) 70\nWeight (lb): 200\nBSA (m2): 2.09 m2\nBP (mm Hg): 50/28\nHR (bpm): 140\nStatus: Inpatient\nDate/Time: at 09:48\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: LA not well visualized.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized.\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction. No LV\nmass/thrombus. No VSD.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: No MVP. Mild mitral annular calcification. Moderate (2+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - ventilator. Suboptimal image quality -\npatient unable to cooperate. Emergency study. Emergency study performed by the\ncardiology fellow on call. Results were personally reviewed with the MD caring\nfor the patient.\n\nConclusions:\nThere is moderate regional left ventricular systolic dysfunction with\nanteroseptal and inferoseptal hypokinesis extending to the apex with near\nakinesis at the base (LVEF 30-35%). No masses or thrombi are seen in the left\nventricle. There is no ventricular septal defect. The aortic valve is not well\nseen. There is no mitral valve prolapse and at least moderate [2+] mitral\nregurgitation. There is a trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Report",
"row_id": 67780,
"text": "PATIENT/TEST INFORMATION:\nIndication: Echocardiographic guidance for Impella placement.\nHeight: (in) 70\nWeight (lb): 200\nBSA (m2): 2.09 m2\nBP (mm Hg): 112/60\nHR (bpm): 131\nStatus: Inpatient\nDate/Time: at 21:00\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Emergency study. Emergency study performed by the cardiology\nfellow on call. Echocardiographic results were reviewed by telephone with the\nMD caring for the patient.\n\nConclusions:\nAn intracardiac device (Impella) is seen in the left ventricle. The device is\nthen seen being pulled toward the left ventricular outflow tract into a more\nproximal position. The LVEF is severely depressed. Compared to the prior study\nfrom today, the LVEF has decreased and an Impella device is now seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Report",
"row_id": 144536,
"text": "Probable sinus tachycardia with A-V conduction delay. Intraventricular\nconduction delay suggests atypical left bundle-branch block. Probable anterior\nwall myocardial infarction of indeterminate age but may be acute. Clinical\ncorrelation is suggested. Since the previous tracing of same date\nintraventricular conduction delay is now present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Report",
"row_id": 144537,
"text": "Sinus tachycardia with A-V conduction delay. Rightward axis. Anterior wall\nmyocardial infarction with ST-T wave configuration suggesting acute process.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 730563,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730739,
"text": "CCU Nursing Progress Note.\n 78M with recent duodenal ulcer bleed presented to osh with diffuse back\n pain, upper and lower cp and abd pain with nausea and anterior\n st-segment depression. Transferred via to for primary\n pci. Enroute from helicopter to cath lab- pt went into vf\n stopped in\n ed\n multiple shocks and amio bolus and pt went into af w/ pulse\n stat\n transfer to cath lab. On angiography, had thrombus in mid-rca after 95%\n stenosis, as well as acute thrombotic occlusion of lad. Initially\n treated lad lesion, then placed iabp, then treated rca lesion with poba\n alone, followed by stenting because of thrombotic occlusion. Initial\n hct here 18.6, also with left groin hematoma, transfused aggressively\n with 5 units prbcs and rec\nd 5+l of ivf. After rhc demonstrated\n severely elevated left-sided filling pressures, impella placed and iabp\n pulled. Neo and dopamine for bp support. To ccu for further management.\n Myocardial Infarction, Acute - STEMI\n Assessment:\n Cardiogenic shock with sever metabolic acidosis.\n Action:\n Aggressively rxed with impella device, pressors x2-dopa & neosyn, ivf,\n multiple ventilator chgs, & sodium bicarb (bolus & gtt). Impella device\n repositioned (by interventional fellow) after echo showed improper\n postioning. CCU fellow & attending in-overall condition & prognosis\n discussed with team. Family called & told severity of\n condition-encouraged to come in. Maintaining pressure with pressors &\n bicarb till family present.\n Response:\n Family mtg with team-situation discussed. Family (wife & son) after\n discussion made pt .\n Plan:\n Pressors & impella device stopped.\n"
},
{
"category": "General",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Generic Note",
"row_id": 730548,
"text": "TITLE: Cardiology fellow CCU admit note\n 78M with recent duodenal ulcer bleed presented to OSH with CP and\n anterior ST-segment depression. Transferred for primary PCI. On\n angiography, had thrombus in mid-RCA after 95% stenosis, as well as\n acute thrombotic occlusion of LAD. Initially treated LAD lesion, then\n placed IABP, then treated RCA lesion with POBA alone, followed by\n stenting because of thrombotic occlusion. Initial Hct here 18.6, so\n transfused aggressively. After RHC demonstrated severely elevated\n left-sided filling pressures, Impella placed and IABP pulled. Would\n shoot for goal Hct >30, consult GI, continue aspirin, clopidogrel,\n intensive statin therapy, Neo and dopamine for BP support. Currently in\n sinus rhythm. Would get repeat echocardiogram in the morning.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730800,
"text": "Pt expired at 0730, pronounced by Dr. . Family at his side.\n Wedding ring removed and given to wife. Pt had no other belongings.\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 730724,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: suction out dark brown secretions from oral cavity\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated, Adjust Min. ventilation to control\n pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Hemodynimic\n instability, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2115-03-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 730786,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 83.5 None\n Ideal tidal volume: mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient expired disconnected from mechanical ventilation, MD assessed\n patient.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730776,
"text": "CCU Nursing Progress Note.\n 78M with recent duodenal ulcer bleed presented to osh with diffuse back\n pain, upper and lower cp and abd pain with nausea and anterior\n st-segment depression. Transferred via to for primary\n pci. Enroute from helicopter to cath lab- pt went into vf\n stopped in\n ed\n multiple shocks and amio bolus and pt went into af w/ pulse\n stat\n transfer to cath lab. On angiography, had thrombus in mid-rca after 95%\n stenosis, as well as acute thrombotic occlusion of lad. Initially\n treated lad lesion, then placed iabp, then treated rca lesion with poba\n alone, followed by stenting because of thrombotic occlusion. Initial\n hct here 18.6, also with left groin hematoma, transfused aggressively\n with 5 units prbcs and rec\nd 5+l of ivf. After rhc demonstrated\n severely elevated left-sided filling pressures, impella placed and iabp\n pulled. Neo and dopamine for bp support. To ccu for further management.\n Myocardial Infarction, Acute - STEMI\n Assessment:\n Cardiogenic shock with sever metabolic acidosis.\n Action:\n Aggressively rxed with impella device, pressors x2-dopa & neosyn, ivf,\n multiple ventilator chgs, & sodium bicarb (bolus & gtt). Impella device\n repositioned (by interventional fellow) after echo showed improper\n postioning. CCU fellow & attending in-overall condition & prognosis\n discussed with team. Family called & told severity of\n condition-encouraged to come in. Maintaining pressure with pressors &\n bicarb till family present.\n Response:\n Family mtg with team-situation discussed. Family (wife & son) after\n discussion made pt .\n Plan:\n Pressors & impella device stopped. Family present in room.\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730651,
"text": "78M with recent duodenal ulcer bleed presented to OSH with diffuse back\n pain, upper and lower CP and abd pain with nausea and anterior\n ST-segment depression. Transferred via to for primary\n PCI. Enroute from helicopter to cath lab- pt went into VF\n stopped in\n ED\n multiple shocks and amio bolus and pt went into AF w/ pulse\n stat\n transfer to cath lab. On angiography, had thrombus in mid-RCA after 95%\n stenosis, as well as acute thrombotic occlusion of LAD. Initially\n treated LAD lesion, then placed IABP, then treated RCA lesion with POBA\n alone, followed by stenting because of thrombotic occlusion. Initial\n Hct here 18.6, also with Lt groin hematoma, transfused aggressively\n with 5 units PRBCs and rec\nd 5+L of IVF. After RHC demonstrated\n severely elevated left-sided filling pressures, Impella placed and IABP\n pulled. Neo and dopamine for BP support. Currently in sinus rhythm with\n frequent runs of PVCs. Another 150mg IV amio bolus given, ASA 325mg,\n Plavix 600mg and 1G Cefazolin given in cath lab. Total of 9mg Versed\n and 400mcg Fentanyl given in cath for sedation. To CCU for further\n management.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Intubated pt. on Neo and Dopamine gtts for BP support.\n Impella device in Lt groin. PA line and Aline in Rt groin. Extremities\n cool. Pt obeying simple commands on arrival to CCU\n nodding head no\n when asked if he was having pain. Pt moved all extremities. Bilat leg\n immobilizers on.\n Action:\n Unable to dopple LT DP pulse\n able to dopple all other\n pulses. Feet dusky bilat. Cold to touch.\n Titrating NEO and Dopamine for pressure support.\n Impella with good waveform at P8 with flow 2.3 purge\n pressurs 400smmHg\n titrating Dextrose 20% heparinized gtt for purge\n pressure goal within 300-700s per protocol.\n Heparin gtt 600 units/hr\n PTT wnl 66.\n On arrival to CCU (pt rec\nd 5 units PRBCs in cath lab for\n HCT 18) 12pm HCT 39.5 and repeat HCT at 4pm was 36.\n Family in to visit in afternoon\n attending and nursing\n talking with family, updating them. Numbers and some history obtained.\n OGT clamped\n placement confirmed by CXR\n unable to\n aspirate any secretions or arrival. Pt NPO.\n Sedated on Versed and Fentanyl gtts.\n GI on consult due to recent GI bleed.\n Response:\n Con\nt to titrate Neo and Dopa.\n Shortly after CXR and then turn, lost wave waveform on\n impella device\n no change in flow or other alarms\n status screen\n shows pump position unknown. Impella changed to P2 wth flow dropping\n to 1.7L/min purge pressures increased to 597. BP increased with impella\n turned down.\n Bedside ECHO by cards fellow\n consulting with CCU attending\n on phone and Impella call center re: questionable position of impella.\n Interventional cards fellow called for repositioning.\n Blood tinged secretions via ETT. PO2 decreasing (difficult\n to obtain sats\n poor pleths due to cool extremities)\n FIO2 increased\n up to 100%. Pt becoming more acidotic. CCU team and RESP aware.\n Plan:\n ECHO in am.\n Repeat labs and cardiac calcs this evening.\n Serial HCTs.\n Tylenol, pan culture, abx this evening.\n Titrate pressors. Sedation for comfort.\n Con\nt vent changes. Increase peep. Con\nt 100% fio2 for now.\n"
},
{
"category": "Physician ",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 730653,
"text": "Chief Complaint: STEMI/VF ARREST\n HPI:\n 78M with recent duodenal ulcer bleed presented to OSH with CP and\n anterior ST-segment depression. Transferred to for PCI. Arrived\n to in VF arrest. Received epi by EMS. Shocked x2 in the ED and was\n given amiodarone. Reportedly, pt was in a.fib on transfer to the cath\n lab.\n .\n On angiography, he was noted to have thrombus in mid-RCA, as well as\n acute thrombotic occlusion of LAD. In the cath lab, the LAD lesion was\n initially treated and an IABP was placed. Then, the RCA lesion was\n treated, initially with POBA alone, followed by stenting because of\n thrombotic occlusion. Initial Hct here 18.6, so transfused a total of 5\n units of PRBCs. After RHC demonstrated severely elevated left-sided\n filling pressures, Impella placed and IABP pulled.\n .\n On arrival to the CCU, the patient's VS were T= 98.1 BP= 116/52 HR= 150\n RR= 14 O2 sat= 93% on ventilator. He was intubated and sedated and was\n not able to provide any further historical information.\n Allergies:\n Last dose of Antibiotics:\n Metronidazole - 10:00 PM\n Infusions:\n Heparin Sodium - 600 units/hour\n Midazolam (Versed) - 2.5 mg/hour\n Fentanyl - 50 mcg/hour\n Dopamine - 5 mcg/Kg/min\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 12:45 PM\n Midazolam (Versed) - 06:38 PM\n Other medications:\n HOME MEDICATIONS (confirmed with Rite-Aid Pharmacy):\n - omeprazole 20 mg \n - paroxicam 20 mg once daily (was instructed to no longer take)\n - tramadol 50 mg \n - viagra 100 mg PRN\n - gabapentin 300 mg once a day (?twice a day)\n - pravachol 20 mg daily\n Past medical history:\n Family history:\n Social History:\n - peripheral neuropathy\n - hyperlidipemia\n - chronic low back pain\n - Unable to obtain, as pt is intubated.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: - Unable to obtain, as pt is intubated.\n Review of systems:\n Flowsheet Data as of 10:53 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.1\nC (100.6\n HR: 128 (106 - 150) bpm\n BP: 102/58(69) {71/39(51) - 137/85(104)} mmHg\n RR: 21 (7 - 25) insp/min\n SpO2: 67%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 73 Inch\n CVP: 11 (7 - 19)mmHg\n PAP: (37 mmHg) / (22 mmHg)\n PCWP: 24 (24 - 24) mmHg\n CO/CI (Fick): (4.5 L/min) / (2.1 L/min/m2)\n Mixed Venous O2% Sat: 45 - 70\n Total In:\n 9,327 mL\n PO:\n TF:\n IVF:\n 9,327 mL\n Blood products:\n Total out:\n 0 mL\n 655 mL\n Urine:\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 8,672 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 942 (942 - 942) mL\n PS : 5 cmH2O\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 100%\n PIP: 31 cmH2O\n Plateau: 20 cmH2O\n Compliance: 100 cmH2O/mL\n SpO2: 67%\n ABG: 7.05/54/56/18/-16\n Ve: 10.8 L/min\n PaO2 / FiO2: 56\n Physical Examination\n VS: T= 98.1 BP= 116/52 HR= 150 RR= 14 O2 sat= 93% on ventilator\n GENERAL: 78 y/o M intubated and sedated. Does not respond to painful\n stimuli.\n HEENT: NC/AT. PERRL. ET tube in place.\n CARDIAC: Faint HS. RRR; No m/r/g appreciaed.\n LUNGS: Respirated lung sounds. Lungs CTA B anteriorly.\n ABDOMEN: Soft, ND. No HSM or tenderness. BS present.\n EXTREMITIES: No pitting edema noted in the bilateral lower extremities.\n Cold extremities.\n PULSES:\n Right: DP unable to find PT dopplerable\n Left: DP unable to find PT dopplerable\n NEURO: Intubated, Sedated. PERRL. Does not respond to painful stimuli.\n Babinski equivocal bilaterally.\n Labs / Radiology\n 299 K/uL\n 13.6\n 214 mg/dL\n 1.0 mg/dL\n 19 mg/dL\n 18 mEq/L\n 112 mEq/L\n 4.2 mEq/L\n 141 mEq/L\n 37\n 19.7 K/uL\n [image002.jpg]\n \n 2:33 A3/21/ 01:00 PM\n \n 10:20 P3/21/ 01:05 PM\n \n 1:20 P3/21/ 02:42 PM\n \n 11:50 P3/21/ 04:29 PM\n \n 1:20 A3/21/ 05:38 PM\n \n 7:20 P3/21/ 06:39 PM\n 1//11/006\n 1:23 P3/21/ 07:01 PM\n \n 1:20 P3/21/ 07:04 PM\n \n 11:20 P3/21/ 09:00 PM\n \n 4:20 P3/21/ 09:18 PM\n Hct\n 41\n 36.0\n 37\n 37\n TC02\n 19\n 18\n 18\n 17\n 14\n 16\n Other labs: PT / PTT / INR:13.5/66.0/1.2, CK / CKMB /\n Troponin-T://, Lactic Acid:6.2 mmol/L, Ca++:6.8 mg/dL, Mg++:1.7\n mg/dL, PO4:3.8 mg/dL\n ECG: ?A.fib; poor baseline; Noteable for ST elevations in V1-V4, ST\n depressions in II, III, aVF.\n Assessment and Plan\n 78 y/o M with h/o recent duodenal bleed admitted with anterior STEMI.\n S/p BMS to LAD and RCA, also s/p Impella placement.\n .\n # STEMI: Pt presented with STEMI. Admission labs significant for CK\n , MB >500, Trop-T >25. ECG at OSH showed ST elevations in V1-V4,\n ST depressions in II, III, aVF. He went to the cath lab, where he\n underwent BMS to the LAD and RCA. He also had an Impella placed.\n - transfuse PRN to maintain hematocrit > 30\n - continue aspirin\n - continue plavix\n - starting simvastatin 80 mg daily\n - repeat echo in AM\n - continue tele\n .\n # Recent GI Bleed: The patient presented with a hematocrit of 18. He is\n now s/p aggressive resuscitation with 5 units of PRBCs.\n - transfuse PRN to maintain hematocrit > 30\n - consult GI; will need a scope to possibly treat any source of\n bleeding\n - trend Hct\n - IV PPI \n .\n # Hyperlipidemia: Statin as above.\n .\n # Chronic Pain:\n - will need to address pain regimen when pt is no longer sedated\n .\n .\n FEN: NPO as diet for now; Nutrition C/S for TF recs in AM\n ACCESS: Right femoral line.\n PROPHYLAXIS:\n -DVT ppx with heparin gtt\n -Holding bowel regimen in setting of recent GI bleed\n CODE: Presumed full\n COMM: (wife) ; (son) \n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Sheath - 11:45 AM\n 16 Gauge - 11:45 AM\n 18 Gauge - 11:45 AM\n Arterial Line - 11:48 AM\n PA Catheter - 11:49 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "General",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Generic Note",
"row_id": 730584,
"text": "TITLE: Cardiology fellow CCU admit note\n 86M with 3VD s/p bypass and patent LIMA->LAD, SVG->OM and SVG->RCA,\n severe AS (0.8-1 cm2 in ) presents with chest pain, ECG changes\n concerning for diffuse ischemia. Presumably, CP is due to severe AS, as\n he had patent grafts a month ago. For now, would hold warfarin, start\n heparin, try to limit chest pain by IVF administration, no nitrates or\n opiates. If requires ventilatory support, would strongly urge NIPPV, as\n sedation would likely drop his blood pressure. Likely for cath\n tomorrow, so NPO after MN.\n"
},
{
"category": "General",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Generic Note",
"row_id": 730646,
"text": "TITLE: Cardiology fellow CCU admit note\n 86M with 3VD s/p bypass and patent LIMA->LAD, SVG->OM and SVG->RCA,\n severe AS (0.8-1 cm2 in ) presents with chest pain, ECG changes\n concerning for diffuse ischemia. Presumably, CP is due to severe AS, as\n he had patent grafts a month ago. For now, would hold warfarin, start\n heparin, try to limit chest pain by IVF administration, no nitrates or\n opiates. If requires ventilatory support, would strongly urge NIPPV, as\n sedation would likely drop his blood pressure. Likely for cath\n tomorrow, so NPO after MN.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD on:\n 19:58 ------\n"
},
{
"category": "Nursing",
"chartdate": "2115-03-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 730647,
"text": "78M with recent duodenal ulcer bleed presented to OSH with CP and\n anterior ST-segment depression. Transferred for primary PCI. On\n angiography, had thrombus in mid-RCA after 95% stenosis, as well as\n acute thrombotic occlusion of LAD. Initially treated LAD lesion, then\n placed IABP, then treated RCA lesion with POBA alone, followed by\n stenting because of thrombotic occlusion. Initial Hct here 18.6, so\n transfused aggressively. After RHC demonstrated severely elevated\n left-sided filling pressures, Impella placed and IABP pulled. Would\n shoot for goal Hct >30, consult GI, continue aspirin, clopidogrel,\n intensive statin therapy, Neo and dopamine for BP support. Currently in\n sinus rhythm. Would get repeat echocardiogram in the morning.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Titrating NEO and Dopamine for\n Response:\n After turn at 5pm, lost wave waveform on impella device\n change in flow or other alarms\n status screen shows pump position\n unknown.\n Bedside ECHO by cards fellow\n consulting with CCU attending\n on phone and Impella call center re: questionable position of impella.\n Plan:\n ECHO in am.\n Repeat labs 2030hrs and cardiac calcs.\n Tylenol, pan culture, abx this evening.\n"
}
] |
5,475 | 103,968 | MODSPIT X1; MINIMAL ASPIRATES. MAINTAINS TEMP IN SERVOCONTROLLED ISOLETTE. Abdomen benign; voiding andhaving trace stool x1. Infant has remained in RA with sats >96%.BS clear= with mild retractions. REMAINS ON CAFFEINEA:STABLEP:CONTINUE TO MONITOR#3F/E/NO:TF AT 150CC/KG. A: Stable inNCO2. Abd is soft and full; voiding well and hadsmall transitional stool (g-). sljaundiced.#4-O; temp stable in servo isolette, active and , AFOF,no spells. IVF OF D10W WITH 2MEQ NACL AND 1MEQ KCL AT35CC/K/D INFUSING WITHOUT INCIDENCE VIA PERIPHERAL IV.CONTINUE CURRENT FEEDING PLAN. AG20cm, soft, active bowel sounds, voiding qs and stoolingsoft brown. Remains on Caffeine.#3Infant remains on TF=140cc/k. RR 30's-50's with mild ICretractions. NPN 0700-1900#2 O: Infant remains in RA. P: Contto monitor.#4 O: Maintaining temp in heated isolette set in servo mode.Awake and with cares; somewhat fighsty waking betweencares. P: Cont tosupport and update.#6 O: Infant remains under single phototherapy with eyeshields in place. NeonatologyDoing well low flow NC RA. MILD ICRETRACTIONS. CALMS WITH NESTINGAND CONTAINMENT. P: cont with planas tolerated.#4: Temp stable in servo warmer, fontanelles are soft andflat. IVF of D10ww/2Na/1Kcl infusing through PIV w/o incident. TF at 100 cc/k/d. Voiding, stooling normally. Will monitor need for return to CPAP.Wt 1285 down 65. Films of the chest and abdomen are both within normal limits. NPN#2-O: remains in RA sats 99-100 , well perfused, clearand equal , RR 30's-50's, no retractions, no spells nodesats, on caffeine qd as ordered.#3-O: on tf 150cc/k/d, IV infiltrated, dc'd and feedsincreased as ordered. Infanttaking 34cc's of BM20 q 4h via gavage. PIV infusing wellat 100cc/k. AGstable. NESTED ONSHEEPSKIN W/BOUNDARIES. P: Cont to support development.#5 O: No contact as yet this shift. LS clear and =. Mild IC/SC retractions, color isruddy pink. Lytes notable for Na 145 and k 8.1 with hemolyzed specimen. Placed on 200cc NC 21% at 0530.Cont to montor resp status closely on NC. Lytes in good range.Jaundiced with bili in 8 range. Otherwise normal head ultrasound. Abdomen benign. FONTANEL SFOT AND FLAT; SUTURES SMOOTHA:AGAP:CONTIUE TO SUPPORT AND MONITOR#5PARENTINGO:MOM X1 FOR UPDATE. TF 120/k/d; IVF changed to D10Wwith 2Na, 1KCl at 100/k/d and enteral feeds of PE20 at20/k/d. MD SPIT X1, MIN ASPIRATES. P:Cont to monitor.#3 O: TF= 80cc/kg/d. Abx d/c'd forneg cultures. NURSNG PROGRESS NOTE2 - BSC/=, MILD IC RETRACTIONS NOTED. PT VOIDING, TRANSITIONALSTOOL, GUIAC -.A: SPIT X1 - NG FEED TIME EXTENDED TO 1 HR. CXR done, wnl. P- Cont toassess for Resp needs.#3-O/A- TF=120cc/kg/d. MAINTAINS TEMP IN SERVOCONTROLLED ISOLETTE. Nested insheepskin. NESTED INSHEEPSKIN. Infant remainson NCO2. Voiding 3.9 cc/kg/hr and stooling normally. KUB done, wnl. FOLLOW WT.4 - DEV - TEMP STABLE IN SERVO MODE ISOLETTE. Last CBC benign;bl cx pending. Temp stable inheated isolette. IVF OF D10W WITH 2MEQ NACL AND1MEQ KCL INFUSING WITHOUT INCIDENCE AT 65CC/K/D. NPN DAYSALT IN RESP:LUNGS CLEAR, RR 30'S WITH MILD INTERCOASTALRETRACTIONS. Bili this am 11.2/0.3/10.9. WT=1.220(-25)P: CONT TO MONITOR. Stable with O2. HAD A NORMAL HEAD U/S THIS MORNING. REMAINS ONCAFFEINE. TODAY'S BILI IS 5.9 0.2 5.7. A: Stable in RA thus far. Lg mec stoolx1. Temp stable nested in servo isolette. NODESATS, NO A/BS, RECEIVING CAFFEINE.A; STABLE AT RAP: CONT TO MONITOR3 - FEN - TF=150CC/K OF BM20. 1.6ccbilious NNP. SHE IS BLD TYPE A POSITIVE, AND COOMBS NEG. Mild IC/SCretractions. BP 80/42 54 THIS MORNING. 0.1CC DQ. Remainson caffeine. Nostool thus far. NPN 0700-1900#1 O: Infant remains on amp and gent for 48h r/o. To draw 24h lytes andbili.#4 O: Maintaining temp on servo controlled warmer. SHE REMAINS ON CAFFINE. ASP0-2CC. SHE RECEIVED 48HRS OF AMPI AND GENT, AND WERE THEN D/C'ED DUE TO BLD CX NEG. RR 40'S WITH MILD INTERCOASTAL RETRACTIONS. A: AGA. P: Cont tomonitor and administer antibx per order.#2 O: Infant remains in RA. PT ANDACTIVE. 0.4-1.8CC. Tempstable. PT . Resolveswith BBO2 or increased O2. ABDROUND,, +BS, NO LOOPS. A: Toleratingstart of feeds. SATS=99-100%RA. SHE IS ON BM24CAL, 150CC/K/D, 34CC Q4HRS VIA GAVAGE OVER 1HR AND 10MINS. Neonatology attending note9 d.o.Resp: in RA, on caffeine, no spell, clear.CV: no murmurWt=1235 gm + 15, TF= 150 cc/kg/d with EBM 22, tolerated well, Abdomen soft.bili=5.9A: 31 GA, jaundice, AOP.P: advance calorie density, start Fe, consider transfering to if bed available. MAINTAINS TMEP IN SERVOCONTROLLED ISOLETTE. P: Continue tomonitor.#3 FEN O: Tf remain at 80cc/k/d, baby remains npo. Lytes & Dsticks wnl. A/P: Cont tomonitor temp. Infant made NPO at 0030 and IVF changed to D10Ww/1meq NaCl. P: Obtain bili with 0400care. Remains on amp and gent for 48hr R/O. 1 seedy stool G-.A: tol feeds. O: Temp stable nested in servo isolette. TEMPERATURE LOW X1 REQUIRINGINCREASE IN CONTROL POINT. CONTINUE CURRENTFEEDING PLAN. CHANGED TO DOUBLE BANK LIGHT PHOTOTHERAPY ANDTEMP DOWN TO 98.4. Abdominalexam benign, IVF of d10 , infusing through piv well. REMAINS ON CAFFEINEA:STABLEP:CONTINUE TO MONITOR FOR SPELLS#3F/E/NO:TF AT 140CC/KG. O: Under single phototherapy. D/S 97 THISAFTERNOON. STOOL GUIAC NEG. REMAINS ONCAFFEINE. Abdomen benign.Will begin feeds as tolerated. NPO at present on IVF at TF=80 cc/k/d. Voiding well, med-lg mecstools. VSS-seeflowsheet. ASP.0.8-2.2CC.VOIDING AND STOOLING WELL. 0.6-1.2CC. CONTINUEDEVELOPMENTAL CARES. WILLREMAIN UNDER DOUBLE PHOTOTHERAPY FOR NOW, AND RECHECK BILION SUNDAY.ALT IN NUTRITION R/ :TF 140CC/K/D. MILDRETRACTIONS. P: Continueantibiotics as orderd.#2 Resp O: Baby remains in room air, rr 40-70's, lungsslightly diminished, o2 sats 94-100%, Baby does have someIC/SC retractions. Minaspirates. Transferred to NICU uneventfully.PEwt 1350g (25-50th %ile) OFC 27cm (10-25th %ile) LN 38.5cm (10-25th %ile)hr 142 rr 46 T 96.9 BP 44/34 (39) SaO2 93% in 0.21 FiO2HEENT AFSF; non-dysmorphic; palate intact; moderate nasal flaring; mouth/neck normalCHEST mild retractions; grunting respirations resolved; fair bs bilat; few scattered cracklesCVS well-perfused; RRR; PPP; S1S2 normal; no murmurABD soft, non-distended; no organomegaly; no masses; bs active; anus patentGU normal preterm female genitaliaCNS active, responsive to stim; tone AGA; moving all limbs symmetrically; suck/gag/grasp/Moro normalINTEG normalMSK normal spine/limbs/hips/claviclesImpression31-1/7 week GA female with1. IVF OF D10W WITH 2MEQ NACL AND 1MEQ KCL INFUSINGWITHOUT INCIDENCE VIA PERIPHERAL IV AT 85CC/K/D. CONTINUE TO SUPPORT ANDUPDATE. RR 40-60'S WITH MILD INTERCOASTALRETRACTIONS. NeonatologyDoing well. 1 spit. Dstick 93. Dstick 93. Advancing feeds as tolerated. IVF D10 W/LYTES VIA PIV AT 4CC/HR.ABDOMEN SOFT, ROUND WITH GOOD B.S. Bili in range.Repeat CBCX shows improvement in WBC> Clincially stable on abx for 48 h r/o.COntinue to monitor resp status and feeding tolerance. | 43 | [
{
"category": "Radiology",
"chartdate": "2197-04-12 00:00:00.000",
"description": "P BABYGRAM (CHEST & ABDOMEN) PORT",
"row_id": 760352,
"text": " 10:27 AM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: EVALUATE CHEST EXPANSION AND ABDOMEN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with STARTED ON CAFFINE FOR APNEA & BRADYS, NOTED TO HAVE COFFEE GROUND\n ASPIRATES\n REASON FOR THIS EXAMINATION:\n EVALUATE CHEST EXPANSION AND ABDOMEN\n ______________________________________________________________________________\n FINAL REPORT\n 1\n\n INDICATIONS:\n\n CHEST AND ABDOMEN: This is a child with apnea and bradycardia. No prior\n studies are available for comparison.\n\n There is a nasogastric tube within the stomach. Films of the chest and\n abdomen are both within normal limits.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-04-19 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 760883,
"text": " 7:31 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT,R/O IVH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity\n REASON FOR THIS EXAMINATION:\n r/o IVH\n ______________________________________________________________________________\n FINAL REPORT\n HEAD ULTRASOUND:\n\n HISTORY: 31 week premature infant first ultrasound.\n\n FINDINGS: Examination of the cranium through the anterior fontanelle and the\n left mastoid foramen demonstrated no evidence of intracranial hemorrhage or\n structural abnormality. Two tiny choroid plexus cysts are noted, each\n measuring approximately 3 mm, one on the right and one on the left. These are\n unlikely to be of any clinical significance.\n\n IMPRESSION: Bilateral tiny choroid plexus cysts unlikely to be of clinical\n importance. Otherwise normal head ultrasound.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-13 00:00:00.000",
"description": "Report",
"row_id": 1756004,
"text": "Neonatology\nDoing well low flow NC RA. Comfortable apeparing. No murmur\n\nWt 1235 down 50. Feeds at 20 cc/k/d being tolerated so far. Abdomen benign. Lytes in good range.\n\nJaundiced with bili in 8 range. Under photorx.\n\nContinue to monitor bili, feeding tolerance\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-13 00:00:00.000",
"description": "Report",
"row_id": 1756005,
"text": "NPN 7a-7p\n\n\n#2: Conts in NCO2, 200cc/21% all day. RR 30-50s, breath\nsounds are clear and equal. Mild IC/SC retractions, color is\nruddy pink. On caffiene, no spells or desats. A: Stable in\nNCO2. P: cont to monitor.\n#3: TF increased today to 140cc/kg/d. Currently working up\non feeds by 10cc/kg/d . Feeds are currently at 30c/kg/d\nof BM/PE20. Abdomen is benign, voiding, no stool yet. AG\nstable. No spits, min aspirates. D/S 90. IVF of D10w\nw/2Na/1Kcl infusing through PIV w/o incident. LAst feed\nincrease was at 1200. A: Tolerating feeds. P: cont with plan\nas tolerated.\n#4: Temp stable in servo warmer, fontanelles are soft and\nflat. and active with cares, sleeping well. Infant\nbrings hands to face, likes pacifier. A: AGA. P: cont to\nsupport.\n#5: Mom and Dad both in, updated at bedside. A: loving\nparents. P: Cont to support.\n#6 :Conts on double phototx, eye shields on at all times.\n8hr bili sent - pending. A/P: cont with plan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-13 00:00:00.000",
"description": "Report",
"row_id": 1756006,
"text": "NICU Fellow Exam Note\nPhysical Exam:\nActive, vigorous premature infant, no distress.\nSkin warm and jaundiced.\nFontanelles soft and flat.\nChest clear.\nCardiac regular without murmur.\nAbdomen soft with active bowel sounds.\nExtremities warm.\nAppropriate tone and activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1756020,
"text": "NPN DAYS\n\n\nALT IN RESP:RR 40-50'S WITH MILD INTERCOASTAL RETRACTIONS.\nMAINTAINS O2 SATS IN HIGH 90'S TO 100% IN RA. NO EPISODES OF\nAPNEA OR BRADYCARDIA OR DESATS. REMAINS ON CAFFEINE.\nCONTINUE TO MONITOR FRO SPELLS.\n\nHYPERBILIRUBINEMIA:DECREASED TO SINGLE PHOTOTHERAPY THIS\nMORNING DUE TO BILI DECREASED TO 6.5 0.3 THIS MORNING. EYE\nSHIELDS ON AT ALL TIMES. WILL CHECK BILI AGAIN IN THE\nMORNING.\n\nALT IN NUTRITION R/ :TF 150CC/K/D. FEEDS CURRENTLY AT\n115CC/K/D OF BM20, 26CC Q4HRS VIA GAVAGE OVER 40MINS. ABD\nEXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 19-20. ASP.\n0.6-0.8CC. VOIDINF WELL. INCREASING FEEDS 15CC/K/D AT\n12AM AND 12PM. IVF OF D10W WITH 2MEQ NACL AND 1MEQ KCL AT\n35CC/K/D INFUSING WITHOUT INCIDENCE VIA PERIPHERAL IV.\nCONTINUE CURRENT FEEDING PLAN. ASSESS FOR ANY FEEDING\nINTOLERANCE.\n\nALT IN GROWTH AND DEVELOPMENT D/ : AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN SERVO\nCONTROLLED ISOLETTE. NESTED IN SHEEPSKIN. CONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING: IN TO VISIT AT 12PM. THEY TOOK TEMP\nAND CHANGED DIAPER. MOM KANGAROOED FOR 1HR. TOL WELL.\nUPDATED AT BEDSIDE. CONTINUE TO SUPPORT AND UPDATE. \nWILL VISIT WINCESTER THIS WEEK TO DECIDE ABOUT TRANSFER.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1756021,
"text": "NPN\n\n\n#2-O: remains in RA sats 99-100 , well perfused, clear\nand equal , RR 30's-50's, no retractions, no spells no\ndesats, on caffeine qd as ordered.\n\n#3-O: on tf 150cc/k/d, IV infiltrated, dc'd and feeds\nincreased as ordered. Tol BM20 34cc q 4 PG over 40\". AG\n20cm, soft, active bowel sounds, voiding qs and stooling\nsoft brown. wt up 20 gms to 1.245.\n\n#6-O: under single phototherapy, bili pending this am. sl\njaundiced.\n\n#4-O; temp stable in servo isolette, active and , AFOF,\nno spells. acts app. for . age.\n\n#5-O; mom called x 1.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-17 00:00:00.000",
"description": "Report",
"row_id": 1756022,
"text": "NPN 0700-1900\n\n\n#2 O: Infant remains in RA. RR 30's-50's with mild IC\nretractions. LS clear and =. O2 sats 99-100%. No spells.\nRemains on caffeine. A: Stable in RA. P: Cont to monitor.\n\n#3 O: TF= 150cc/kg/d (Increased to this at 0800). Infant\ntaking 34cc's of BM20 q 4h via gavage. Sm spit x1; feeding\nincreased to infuse 50 minutes. Abdomen benign; voiding and\nhaving trace stool x1. DS 86. A: Tolerating feeds. P: Cont\nto monitor.\n\n#4 O: Maintaining temp in heated isolette set in servo mode.\nAwake and with cares; somewhat fighsty waking between\ncares. Nested in sheepskin; sucks on pacifier when offered.\nA: AGA. P: Cont to support development.\n\n#5 O: No contact as yet this shift. A: Involved. P: Cont to\nsupport and update.\n\n#6 O: Infant remains under single phototherapy with eye\nshields in place. Bili this am 6.7/0.2/6.5. No immediate\nplans to recheck. A: Hyperbili. P: Cont to follow bili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-14 00:00:00.000",
"description": "Report",
"row_id": 1756007,
"text": "NPN\n\n\n#2\nInfant was in N/C 200cc flow;21% until ~2400 when infant was\ntrialed in RA. Infant has remained in RA with sats >96%.\nBS clear= with mild retractions. Color is pink and ruddy.\nNo spells noted thus far. Remains on Caffeine.\n\n#3\nInfant remains on TF=140cc/k. Wt is down 15gms-1220.\nInfant is advancing on feeds and is presently on 40cc/k of\nBM/PE20 q4 hours. Infant has had small non-bilious\naspirates. Abd is soft and full; voiding well and had\nsmall transitional stool (g-). No spits. PIV infusing well\nat 100cc/k. Ds=79. Lytes drawn and are pending.\n\n#4\nInfant remains in a heated isolette nestled in sheepskin\nwith boundaries. Infant is with cares; irritable at\ntimes; does console self with the pacifier. Temp has been\nstable.\n\n#5\nMom up last evening. Mom took temp and held infant while\ngavage feed was infusing. Appears pleased with progress\nthus far. Mom is being D/C'ed today-- family meeting\nscheduled for 1300.\n\n#6\nInfant remains under double phototherapy with eyes covered.\nColor remains jaundiced. Bili level drawn and is pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-14 00:00:00.000",
"description": "Report",
"row_id": 1756008,
"text": "Neonatology Attending\nDOL 4\n\nHas been in room air since 2400, with no cardiorespriatory events.\n\nNo murmur. BP 70/45 (53).\n\nWt 1220 (-15) on TFI 140 cc/kg/day, including feeds 40 cc/kg/day BM/PE20. Voiding, stooling normally. D-stick 79 Na 142/K 4.6/Cl 111/CO2 20.\n\nOff antibiotics.\n\nBilirubin 8.0/0.3 under double phototherapy\n\nA&P\nPremature infant with reisudal feeding immaturity, hyperbilirubinemia. Continue on double phototherapy and recheck bilirubin in 48 hours. Continue to await maturation of oral feeding skills.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-12 00:00:00.000",
"description": "Report",
"row_id": 1755998,
"text": "NPN addendum\n\n\n2. Infant had total of 5 desats to 60-70's with apnea, 3 at\nrest. NNP aware. Placed on 200cc NC 21% at 0530.\nCont to montor resp status closely on NC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-12 00:00:00.000",
"description": "Report",
"row_id": 1755999,
"text": "Neonatology\nOn NCO2 at 200 cc low fio2 for desats during course of night.\nGenerally comfortable appearing. Caffeine started last night. CBC unremarkable. Will monitor need for return to CPAP.\n\nWt 1285 down 65. TF at 100 cc/k/d. NPO last night because of spells. Lytes notable for Na 145 and k 8.1 with hemolyzed specimen. KUB to be checked. If KUB ok will reconsider starting feeds later today.\n\nContinues on abx for 48 h r/o.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-12 00:00:00.000",
"description": "Report",
"row_id": 1756000,
"text": "Nursing Progress Note\nIn addition, Mom's currently on the following MED's:\nCatapres (patch), Hydralazine, Nifedapine, Labetalol, KCl.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1756017,
"text": "1900-0700 NPN\n\n\n#2RESPIRATORY\nO:REMAINS IN RA WITH SATS >96%. BS CLEAR. MILD IC\nRETRACTIONS. RESP RATE 40-60. NO SPELLS. REMAINS ON CAFFEINE\nA:STABLE\nP:CONTINUE TO MONITOR\n\n#3F/E/N\nO:TF AT 150CC/KG. BABY ADVANCED TO ENTERAL FEEDS 100CC/KG\nPE20 23CC Q4HR GAVAGE OVER 30\". REMAINDER OF FLUID D10\nW/LYTES VIA PIV AT 50CC/KG. ABDOMEN SOFT WITH GOOD B.S. MOD\nSPIT X1; MINIMAL ASPIRATES. WT UP 5 GM (STILL BELOW BW).\nVOIDING AND STOOLING WELL. DS 104\nA:MOD SPIT X1 OTHERWISE TOLERATING WELL\nP:CONTINUE TO ADVANCE 15CC/KG AS ORDERED, MONITOR\nTOLERANCE TO FEEDS, WILL INCRASE FEEDING TIME SECONDARY TO\nSPIT AND MONITOR\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH STABLE TEMPERATURE.\nACTIVE/FEISTY WITH CARES; SLEEPING WELL BETWEEN. NESTED ON\nSHEEPSKIN W/BOUNDARIES. LIKES PACIFIER. CALMS WITH NESTING\nAND CONTAINMENT. FONTANEL SFOT AND FLAT; SUTURES SMOOTH\nA:AGA\nP:CONTIUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO:MOM X1 FOR UPDATE. INFORMED MOM THAT \nHOSPITAL ALSO HAS A LEVEL 2 NURSERY FOR RETROTRANSFER THAT\nSHE WANT TO LOOK AT AS IT IS CLOSER TO HER HOUSE \n.\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#6HYPERBILI\nO:REMAINS UNDER DOUBLE PHOTOTHERAPY. BILI THIS AM 6.1\nA:DECREAESING BILI\nP:CONTINUE PHOTOTHERAPY AS ORDERED\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1756018,
"text": "Neonatology Attending\nAddendum - Physical Examination\n\nHEENT AFSF\nCHEST no retractions; good bs bilat; no crackles\nCVS well-perfused; RRR; PPP; S1S2 normal; no murmur\nABD soft, non-distended; bs active; no hernia\nCNS active, responsive to stim; tone AGA\nINTEG normal\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-16 00:00:00.000",
"description": "Report",
"row_id": 1756019,
"text": "Neonatology Attending\nDOL 6\n\n remains in room air, with no apnea/bradycardia on caffeine. No murmur, BP 74/48 (57). Wt 1225 (+5) on TFI 150 cc/kg/day, including 100 cc/kg/day BM/PE20. Voiding 3.9 cc/kg/hr and stooling normally. Under double phototherapy with bili 6.5/0.3 today (decreased from 8).\n\nA&P\nPremature infant with residual feeding immaturity, hyperbilirubinemia. We will repeat the bilirubin in 24 hours, after transitioning to single phototherapy. Continue to advance feeds as tolerated. For cranial ultrasound this week. No other changes in management as detailed above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1756028,
"text": "Neonatology attending note\n9 d.o.\nResp: in RA, on caffeine, no spell, clear.\nCV: no murmur\nWt=1235 gm + 15, TF= 150 cc/kg/d with EBM 22, tolerated well, Abdomen soft.\nbili=5.9\nA: 31 GA, jaundice, AOP.\nP: advance calorie density, start Fe, consider transfering to if bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1756029,
"text": "NICU NURSING TRANSFER NOTE\n WAS BORN ON TO A 33 YR OLD MOM, G2P2 AT 33 1/7WEEKS . MOM HAD A C/S BABY HAD OF 7,8. SHE REQUIRED BBO2 AT DELIVERY. SHE RECEIVED 48HRS OF AMPI AND GENT, AND WERE THEN D/C'ED DUE TO BLD CX NEG. SHE WAS PLACED ON NASAL CANNULA 02 ON DAY 2 OF LIFE FOR DESATS AND STARTED ON CAFFEINE. SHE CAME OUT OF O2 AT 12AM FRIDAY MORNING. SHE HAS REMAINED IN RA SINCE, MAINTAINING O2 SATS IN HIGH 90'S TO 100% IN RA. RR 40'S WITH MILD INTERCOASTAL RETRACTIONS. NO EPISODES OF APNEA OR BRADYCARDIA OR DESATS SINCE THE FIRST FEW DAYS OF BIRTH. SHE REMAINS ON CAFFINE. NO MURMUR, HR 140-160'S. BP 80/42 54 THIS MORNING. MOM IS ON CLONIDINE FOR HER BP, AND SHE IS BF, THEREFORE WE CHECK BABY'S BP Q SHIFT. SHE HAS NOT HAD ANY HYPOTENSION. HAD A MAX BILI OF 11 AND WAS ON DOUBLE PHOTOTHERAPY. ON SUNDAY IT WAS DECREASED TO SINGLE PHOTOTHERAPY. TODAY'S BILI IS 5.9 0.2 5.7. SHE REMAINS UNDER SINGLE PHOTOTHERAPY, AND PLANS ARE TO RECHECK BILI ON FRIDAY. SHE IS BLD TYPE A POSITIVE, AND COOMBS NEG. MOM IS A POSITIVE. HAD A NORMAL HEAD U/S THIS MORNING. HER BIRTH WGT WAS 1350. TODAY'S WGT IS 1235, UP 15. SHE IS ON BM24CAL, 150CC/K/D, 34CC Q4HRS VIA GAVAGE OVER 1HR AND 10MINS. SHE HAS OCCASIONAL SPITS. NONE SO FAR THIS MORNING. GIRTH 19-20. ASP0-2CC. VOIDING AND STOOLING WELL. STOOL LAST NIGHT GUAIC NEG. NO LOOPS. D/S LAST NIGHT 83. VISIT QOD AND KANGAROO FOR 1HR. THEY HAVE A 2YR OLD DAUGHTER WHO WAS BORN HERE AT 30WEEKS . FAMILY IS INTACT AND LOVING, AND INVOLVED. THEY ARE AGREEABLE TO TRANSFER TO HOSPITAL SPECIAL CARE NURSERY CAN BE CLOSER TO HOME AND EASIER TO VISIT. CONTINUE ROUTINE CARE. SHE IS TO START FESO4 TODAY. 0.1CC DQ. VIT E 5IU QD, AND SHE CONTINUES ON PG CAFFEINE 8MG QD AT 8PM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-12 00:00:00.000",
"description": "Report",
"row_id": 1756001,
"text": "Nursing Progress Note\n\n\n#1-O/A- Infant shows no signs of infection. Abx d/c'd for\nneg cultures. P- Cont to assess for signs of sepsis.\n#2-O/A- Received infant on NCO2 200cc, 21%. Infant remains\non NCO2. Only desats after cares so far today. Resolves\nwith BBO2 or increased O2. CXR done, wnl. P- Cont to\nassess for Resp needs.\n#3-O/A- TF=120cc/kg/d. Plans to restart feeds of PE 20 @\n20cc/kg/d. IVF is D10w1Na @100cc/kg/d. Abd exam benign.\nVoiding, no stool so far this shift. Small brown tinged asp\nthis am. KUB done, wnl. P- Cont to assess for FEN needs.\n#4-O/A- cont to be awake and active with cluster\ncares q4hrs. Sleeps well between cares. Temp stable in\nheated isolette. P- Cont to assess for G&D needs.\n#5-O/A- No parental contact so far this shift. P- Cont to\nenc parental calls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-12 00:00:00.000",
"description": "Report",
"row_id": 1756002,
"text": "NICU Fellow Exam Note\nPhysical Exam:\nActive premature infant, vigorous, in no distress.\nFontanelles soft and flat.\nChest well aerated and clear.\nCardiac regular without murmur.\nAbdomen soft, hypoactive but present bowel sounds.\nExtremities warm.\nAppropriate tone and activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-13 00:00:00.000",
"description": "Report",
"row_id": 1756003,
"text": "NPN 1900-0730\n\n1 Pot for sepsis\n6 hyperbili\n\n2. Remains in NC 200cc, 21%. Sats >95%. Lungs clear, RR\n30-40 with IC/SC retractions. No A&B's, no desats. Remains\non caffeine. Stable with O2. Cont to monitor resp status.\n\n3. Wt down 50gm to 1235gm. TF 120/k/d; IVF changed to D10W\nwith 2Na, 1KCl at 100/k/d and enteral feeds of PE20 at\n20/k/d. Abd benign, voiding, no stool thus far. 1.6cc\nbilious NNP. aware and plan to cont w/\nfeeds. No emesis. Dstick 78, lytes WNL-see flowsheet.\nCont to monitor closely for further s/sx of feeding\nintolerance.\n\n4. Temp stable nested in servo isolette. Awake and\nirritable with cares, resting well inbetween. Suckling on\npacifier at times. MAE. Cont to promote dev.\n\n5. Mom in to visit and able to change diapher and take temp\nindependently. Mom updated on plan of care. Cont to\nsupport and update parents.\n\n6. Bili this am 11.2/0.3/10.9. Color ruddy, jaundiced. No\nstool thus far. Started on double photo therapy with eye\nshields on. Plan to check bili ~1100.\n\nREVISIONS TO PATHWAY:\n\n 1 Pot for sepsis; d/c'd\n 6 hyperbili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1756014,
"text": "Neonatology Attending Progress Note\nAddendum - PE\nBaby is with mild jaundice on phototherapy.\nAF soft and flat.\nLungs clear and equal.\nCVS - S1 S2 normal, no murmur noted\nAbd - soft with normal bowel sounds\nGU - normal female\nNeuro - very active with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1756015,
"text": "Neonatology Attending Progress Note\n\nNow day of life 5 for this 31 week gestation infant.\n\nRespiratory status - in RA for over 24 hours.\nRR 30-60s.\nOn caffeine.\nNo apnea and bradycardia noted in past 24 hours.\nHR 140-170s\nBP 70/57 61\n\nWt. no change 1220gm on 140cc/kg/d TF - advancing on feedings gradually on 70cc/kg/d of PE or MM and 70cc/kg/d of IV fluids.\nDS 97\nUO 4.5cc/kg/hr\n\nBili 8.0 yesterday - on double phototherapy.\n\nAssessment/plan:\nSteady progress continues with good response to caffeine.\nWill increase to 150cc/kg/d with continued gradual advancement of feedings.\nFU bili to be sent tomorrow with continued phototherapy.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1756016,
"text": "NPN DAYS\n\n\nALT IN RESP:LUNGS CLEAR, RR 30'S WITH MILD INTERCOASTAL\nRETRACTIONS. MAINTAINS O2 SATS IN HIGH 90'S TO 100% IN RA.\nNO EPISODES OF APNEA OR BRADYCARDIA OR DESATS. REMAINS ON\nCAFFEINE. CONTINUE TO SMONITOR FOR SPELLS.\n\nHYPERBILIRUBINEMIA:REMAINS UNDER DOUBLE PHOTOTHERAPY WITH\nEYE SHIELDS ON AT ALL TIMES. WILL RECHECK BILI IN THE\nMORNING.\n\nALT IN NUTRITION R/ :TF INCREASED TO 150CC/K/D TODAY.\nFEEDS CURRENTLY AT 85CC/K/D OF BM/PE20, 19CC Q4HRS VIA\nGAVAGE OVER 30MINS. INCREASING FEEDS 15CC/K/D AT 12AM\nAND 12PM. ABD EXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 19-20.\nASP. 0.4-1.8CC. VOIDING WELL. IVF OF D10W WITH 2MEQ NACL AND\n1MEQ KCL INFUSING WITHOUT INCIDENCE AT 65CC/K/D. CONTINUE\nCURRENT FEEDING PLAN. MONITOR FOR ANY FEEDING INTOLERANCE.\n\nALT IN GROWTH AND DEVELOPMENT D/ : AND ACTIVE WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TEMP IN SERVO\nCONTROLLED ISOLETTE. SUCKS ON PACIFER INTERMIT. NESTED IN\nSHEEPSKIN. CONTINUE DEVELOPMENTAL CARES. HEAD U/S ON\nWEDNESDAY.\n\nALT IN PARENTING: NO CONTACT FROM THUS FAR THIS\nSHIFT. CONTINUE TO SUPPORT AND UPDATE. THEY WILL PROBABLY BE\nINTO VISIT SUNDAY.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-11 00:00:00.000",
"description": "Report",
"row_id": 1755994,
"text": "NPN 0700-1900\n\n\n#1 O: Infant remains on amp and gent for 48h r/o. Temp\nstable. Infant active and with cares. Last CBC benign;\nbl cx pending. A: No obvious ss/ of sepsis. P: Cont to\nmonitor and administer antibx per order.\n\n#2 O: Infant remains in RA. RR 40's-60's. Mild IC/SC\nretractions. LS are clear and =. Infant with some upper\nairway congestion; suctioned for lg yellow-clear secretions\nfrom nares. O2 sats 97-99%. Infant had one spontaneous desat\nto 80's needing blowby; other occasional drifts in o2 sats\nto high 80's which are QSR'd. A: Stable in RA thus far. P:\nCont to monitor.\n\n#3 O: TF= 80cc/kg/d. Infant started on gavage feeds of PE20\nat 30cc/kg or 7.0cc's q 4h. Receiving D10 at 50cc/kg.\nAbdomen benign; voiding 3.1cc/kg/h in last 8h. Lg mec stool\nx1. DS 77. Abdomen flat and round with + BS. A: Tolerating\nstart of feeds. P: Cont to monitor. To draw 24h lytes and\nbili.\n\n#4 O: Maintaining temp on servo controlled warmer. Awake and\n with cares; sleeping well between. Nested in\nsheepskin. A: AGA. P: Cont to support development.\n\n#5 O: Dad in throughout day; visiting with infant's sibling.\nMom briefly visiting at bedside. Asking appropriate\nquestions. Trying to plan family meeting Fri. (Mom to be\nd/c'd this day). A: Involved. P: Cont to support and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-11 00:00:00.000",
"description": "Report",
"row_id": 1755995,
"text": "NICU Fellow Exam Note\nPhysical Exam:\nPremature infant, in RA, in no distress.\nActive with exam.\nSkin warm and pink.\nFontanelles soft and flat.\nChest well aerated, clear.\nCardiac regular without murmur.\nAbdomen soft with active bowel sounds.\nAppropriate tone and activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-11 00:00:00.000",
"description": "Report",
"row_id": 1755996,
"text": "Addendum to above NPN\nInfant has had couple SR'd drifts in o2 sats to 80's this shift. Infant had desat to 60%; no brady but with apnea and needing BBo2. Infant to be started on caffeine tonight. Loading dose to be given when up from pharmacy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1756023,
"text": "NURSNG PROGRESS NOTE\n\n\n2 - BSC/=, MILD IC RETRACTIONS NOTED. SATS=99-100%RA. NO\nDESATS, NO A/BS, RECEIVING CAFFEINE.\nA; STABLE AT RA\nP: CONT TO MONITOR\n\n3 - FEN - TF=150CC/K OF BM20. MD SPIT X1, MIN ASPIRATES. ABD\nROUND,, +BS, NO LOOPS. AG=20-21CM. PT VOIDING, TRANSITIONAL\nSTOOL, GUIAC -.\nA: SPIT X1 - NG FEED TIME EXTENDED TO 1 HR. WT=1.220(-25)\nP: CONT TO MONITOR. FOLLOW WT.\n\n4 - DEV - TEMP STABLE IN SERVO MODE ISOLETTE. PT AND\nACTIVE. NESTED. AFOF. MAEW.\nA: GROWING PREEMIE\nP: CONT TO SUPPORT DEV NEEDS\n\n5 -PARENT - MOM CALLING X1 - UPDATED, ASKING APPROP\nQUESTIONS.\nA: INVOLVED FAMILY\nP; CONT TO SUPPORT AND INFORM.\n\n6 - BILI = PT UNDER SINGLE PHOTOTHERAPY, EYE SHIELDS IN\nPLACE. PT . VOIDING, STOOLING.\nA; PHOTOTHERAPY\nP; CONT TO MONITOR\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1756024,
"text": "Neonatology attending note\n8 do.\nResp: in RA, on caffeine, no spell.\nCV: no murmur.\nFEN: wt= 1220 gm -25. tolerated feeding EBM 20 cal/oz., abdomen soft.\nJaundice.\nA: 31 , AOP, jaundice.\nP: advance calories density.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1756025,
"text": "fellow exam\nvitals stable in room air, anterior fontanelle flat, neck supple, bilateral equal and clear air entry, no murmur, abdomen soft and non distended with bowel sounds present, femorals felt. mild jaundice\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-18 00:00:00.000",
"description": "Report",
"row_id": 1756026,
"text": "NPN DAYS\n\n\n ALT IN RESP:REMAINS IN RA, MAINTAINS O2 SATS IN HIGH 90'S\nTO 100% IN RA. RR 40-60'S WITH MILD INTERCOASTAL\nRETRACTIONS. NO EPISODES OF APNEA OR BRADYCARDIA OR DESATS.\nREMAISN ON CAFFEINE. CONTINUE TO MONITOR FOR SPELLS.\n\nHYPERBILIRUBINEMIA:REMAINS UNDER SINGLE PHOTOTHERAPY WITH\nEYE SHIELDS ON AT ALL TIMES. WILL OBTAIN BILI IN THE\nMORNING.\n\nALT IN NUTRITION R/ :TOL FULL VOLUME FEEDS WELL ON\n150CC/K/D OF BM22, 34CC Q4HRS VIA GAVAGE OVER 70MINS. ABD\nEXAM BENIGN, NO LOOPS, NO SPITS. GIRTH 19. ASP.0.8-2.2CC.\nVOIDING AND STOOLING WELL. STOOL GUIAC NEG. CONTINUE CURRENT\nFEEDING PLAN. MONITOR FOR ANY FEEDING INTOLERANCE. INCREASE\nCALORIES AGAIN TOMORROW.\n\nALT IN GROWTH AND DEVELOPMENT D/ : AND ACTIV WITH\nCARES. SLEEPS WELL BTW FEEDS. MAINTAINS TMEP IN SERVO\nCONTROLLED ISOLETTE. NESTED IN SHEEPSKIN. CONTINUE\nDEVELOPMENTAL CARES.\n\nALT IN PARENTING:MOM IN TO VISIT THIS AFTERNOON WITH HER\nSISTER. MOM UPDATED AT BEDSIDE. MOM KANGAROOED FOR 1HR. TOL\nWELL. VISITED HOSPITAL SPECIAL CARE\nNURSERY THIS AFTERNOON. THEY WOULD LIKE TO TRANSFER THERE.\nTRANSFER WILL BE DONE TOMORROW. CONTINUE TO SUPPORT AND\nUPDATE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-19 00:00:00.000",
"description": "Report",
"row_id": 1756027,
"text": "NPN 1900-0700\n\n\n2. O: Ls clear. RR 40-60's. O2 sats> 94% RA. No spells.\nCaffeine given as ordered. Mild intercostal retractions. A:\nNo spells. P: Cont to monitor resp status.\n\n3. O: WT 1235 gms, up 15. TF 150cc/kg of BM22 via ngt. Min\naspirates. 1 spit. AG 19-19.5 cm. Voiding. 1 seedy stool G-.\nA: tol feeds. P: Cont to monitor wt, abd, and tol of feeds.\n\n4. O: Temp stable nested in servo isolette. and\nactive with cares. Int sucking on pacifier. A/P: Cont to\nmonitor temp. Cont to cluster care.\n\n5. O: No contact from thus far this shift.\n\n6. O: Under single phototherapy. Tf 150cc/kg. Voiding and\nstooling. A: hyperbilirubinemia. P: Obtain bili with 0400\ncare. Cont to monitor bili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-12 00:00:00.000",
"description": "Report",
"row_id": 1755997,
"text": "NPN 1900-0730\n\n\n1. Remains on amp and gent for 48hr R/O. VSS-see\nflowsheet. Dstick 93. Blood cultures pending. No apparent\ns/sx of sepsis. Cont to monitor and treat as per team.\n\n2. Lungs clear and equal in RA. Sats 97-99%, RR 30-50 with\nSC retractions. Nasal stuffiness noted, attempted to\nsuction nares with 6fr catheter and unable to pass \nNNP aware. Desat x2 to 60-70% and apneic after\ncrying episode with cares. Both times required BBO2 and\nstim. Caffeine initiated. Cont to monitor resp status\nclosely.\n\n3. Wt down 65gm to 1285gm. TF increased to 100/k/d. 7cc\nyellow aspirate with flecks of coffee ground and blood;\nmod-large spits from -0030-NNP aware. Abd\nsoft, round, +BS, no loops, pink. Voiding well, med-lg mec\nstools. Infant made NPO at 0030 and IVF changed to D10W\nw/1meq NaCl. Dstick 93. Not tolerating feeds, now NPO.\nCont to monitor FEN closely.\n\n4. Temp stable nested under warmer. Able to wean set temp.\nAwake and irritable with cares, resting well inbetween.\nSuckling on pacifier at times. MAE. Cont to promote dev.\n\n5. Parents in to visit briefly last night and updated on\nplan of care. Cont to support and update parents.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-14 00:00:00.000",
"description": "Report",
"row_id": 1756011,
"text": "NPN DAYS\n\n\nRESP:REMAINS IN RA, MAINTAINS O2 SATS IN HIGH 90'S TO 100%.\nLUNGS CLEAR, RR 40-60'S, WITH MILD INTERCOASTAL RETRACTIONS.\nNO EPISODES OF APNEA OR BRADYCARDIA OR DESATS. REMAINS ON\nCAFFEINE. CONTINUE TO MONITOR FOR SPELLS.\n\nHYPERBILIRUBINEMIA:REMAINS UNDER DOUBLE PHOTOTHERAPY WITH\nEYE SHILEDS ON AT ALL TIMES. BILI THIS MORNING 8.0 0.3. WILL\nREMAIN UNDER DOUBLE PHOTOTHERAPY FOR NOW, AND RECHECK BILI\nON SUNDAY.\n\nALT IN NUTRITION R/ :TF 140CC/K/D. FEEDS CURRENTLY AT\n55CC/K/D OF BM/PE20, 12CC Q4HRS VIA GAVAGE OVER 20MINS.\nINCREASING FEEDS 15CC/K/D AT 12AM AND 12PM. ABD EXAM\nBENIGN, NO LOOPS, NO SPITS. GIRTH 19. ASP. 0.6-1.2CC. UOP\n4CC/K/HR FOR THE PAST 12HRS. NO STOOL TODAY. D/S 97 THIS\nAFTERNOON. IVF OF D10W WITH 2MEQ NACL AND 1MEQ KCL INFUSING\nWITHOUT INCIDENCE VIA PERIPHERAL IV AT 85CC/K/D. CONTINUE\nCURRENT FEEDING PLAN. MONITOR FOR ANY FEEDING INTOLERANCE.\n\nALT IN GROWTH AND DEVELOPMENT D/ : NAD ACTIVEW ITH\nCARES. SLEEPS WELL BTW FEEDS. IRRITABLE AT TIMES BUT CALMS\nWITH PACIFER. MAINTAINS TEMP IN SERVO CONTROLLED ISOLETTE.\nTEMP UP TO 100.2 AT 12PM. SHE WAS UNDER DOUBLE SPOTLIGHT\nPHOTOTHERAPY. CHANGED TO DOUBLE BANK LIGHT PHOTOTHERAPY AND\nTEMP DOWN TO 98.4. BABY IS NESTED IN SHEPPSKIN. CONTINUE\nDEVELOPMENTAL CARES. SHE WILL HAVE A HEAD U/S NEXT\nWEDNESDAY.\n\nALT IN PARENTING:PARENTS UP TO VISIT AT 12PM. DAD TOOK TEMP\nAND CHANGED DIAPER. DAD KANGAROOED FOR ABOUT 30MINS AND MOM\nHELD BABY FOR ABOUT 30MINS. FAMILY MEETING HELD AT 1PM. ALL\nQUESTIONS ANSWERED. PARENTS WILL TAKE A TOUR OF WINCESTER\nSPECIAL CARE NURSERY AND LET US KNOW IF THEY WOULD LIKE TO\nTRANSFER THERE NEXT WEEK. CONTINUE TO SUPPORT AND UPDATE.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-14 00:00:00.000",
"description": "Report",
"row_id": 1756012,
"text": "NICU Fellow Exam Note\nPhysical Exam\nActive premature infant, no distress.\nFontanelles soft and flat.\nChest well aerated and clear.\nCardiac regular without murmur.\nAbdomen soft with active bowel sounds.\nAppropriate tone and activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-15 00:00:00.000",
"description": "Report",
"row_id": 1756013,
"text": "1900-0700 NPN\n\n\n#2RESPIRATORY\nO:REMAINS IN RA WITH SATS 99-100%. BS CLEAR. MILD\nRETRACTIONS. NO SPELLS. REMAINS ON CAFFEINE\nA:STABLE\nP:CONTINUE TO MONITOR FOR SPELLS\n\n#3F/E/N\nO:TF AT 140CC/KG. INCREASED ENTERAL FEEDS TO 70CC/KG+16CC\nQ4HR GAVAGE OVER 30\". IVF D10 W/LYTES VIA PIV AT 4CC/HR.\nABDOMEN SOFT, ROUND WITH GOOD B.S. NO SPITS AND <1CC\nASPIRATES. WT UNCHANGED AT 1220GM. VOIDING WELL 4.5CC/KG\nX12HR; NO STOOLS\nA:STABLE, TOLERATING FEEDS WELL\nP:CONTINUE TO INCREASE FEEDS 15CC/KG AS TOLERATED,\nMONITOR TOLERANCE TO FEEDS\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE. TEMPERATURE LOW X1 REQUIRING\nINCREASE IN CONTROL POINT. ACTIVE/MAE WIHT CARES.\nIRRITABLE/STRESSY AT TIMES; CALMS WITH CONTAINMENT/PACIFIER.\nSLEEPING WELL BETWEEN. NESTED ON SHEEPSKIN W/BOUNDARIES.\nA:AGA\nP:CONTINUE TO MONITOR AND SUPPORT\n\n#5PARENTING\nO:MOM X1 FOR UPDATE.\nA:INVOLVED, INVESTED\nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE. PARENTS\nLOOKING AT / FOR RETROTRANSFER OVER THE\nNEXT FEW DAYS--NO DECISION MADE YET THOUGH\n\n#6HYPERBILI\nO:REMAINS UNDER DOUBLE PHOTOTHERAPY WITH BILIMASK IN PLACE.\nCOLOR PINK/RUDDY.\nA:HYPERBILI\nP:CONTINUE PHOTOTHERAPY, CHECK BILI SUNDAY AM\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-10 00:00:00.000",
"description": "Report",
"row_id": 1755989,
"text": "Admission Note\n31-1/7 week GA female admitted for management of prematurity\n\nMaternal Hx - 33 year old G4P1->2 woman with past medical history notable for chronic hyperreninemic hypertension since age 17, on hydraliazine, labetalol, nifedipine, catapres and potassium supplements. Obstetric history remarkable for previous 30 week infant by cesarean section in after pregnancy complicated by severe hypertension. Prenatal screens: A pos, antibody neg, RPR non-reactive, rubella immune, GBS unknown.\n\nPregnancy Hx - based on 6- and 9-week ultrasounds, for EGA 31-1/7 weeks. Pregnancy complicated by acute-on-chronic hypertension. Betamethasone course completed , following which she developed insulin-dependent gestational diabetes mellitus. Repeat cesarean section performed for worsening PIH under epidural and spinal anesthetic. No maternal intrapartum fever or fetal tachycardia. No intrapartum antibiotics administered. ROM at delivery, yielding clear amniotic fluid.\n\nNeonatal course - Infant emerged with good tone and weak cry. Tactile stim, oral and nasal bulb suctioning provided and dried. Free flow oxygen administered for mild central cyanosis and intermittent grunting. Apgars 7 at one minute and 8 at five minutes. Transferred to NICU uneventfully.\n\nPE\nwt 1350g (25-50th %ile) OFC 27cm (10-25th %ile) LN 38.5cm (10-25th %ile)\nhr 142 rr 46 T 96.9 BP 44/34 (39) SaO2 93% in 0.21 FiO2\nHEENT AFSF; non-dysmorphic; palate intact; moderate nasal flaring; mouth/neck normal\nCHEST mild retractions; grunting respirations resolved; fair bs bilat; few scattered crackles\nCVS well-perfused; RRR; PPP; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal preterm female genitalia\nCNS active, responsive to stim; tone AGA; moving all limbs symmetrically; suck/gag/grasp/Moro normal\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nImpression\n31-1/7 week GA female with\n1. Mild respiratory distress, improving over the first hour and likely secondary to transitional respirations and retained fetal lung fluid.\n2. Sepsis risk, low-grade and based only on GBS unknown status with preterm delivery but without labor. No intrapartum antibiotic prophylaxis.\n3. Risk for hypoglycemia, based on maternal IDGDM.\n\n\nPlan\nInfant has been admitted to NICu for further management. Maintain oxygen saturations 89-93%. No specific respiratory interventions indicated currently, but will consider further investigations if respiratory distress worsens.\n\nCardiac examination is currently unremarkable. Maintain mean BP > 36 mmHg and follow clinically for PDA.\n\nNPO until cardiorespiratory stability is confirmed. Peripheral IV maintenance D10W at 80 cc/kg/day in the interim. Initial d-stick prior to IV placement was borderline at 47; we will continue to follow glucose on IV dextrose carefully in light of maternal GDM.\n\nA CBC and blood culture have been drawn. Given the absence of labor or other significant sepsis risk factors, we will defer ant\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-10 00:00:00.000",
"description": "Report",
"row_id": 1755990,
"text": "Admission Note\n(Continued)\nibiotic therapy unless WBC is abnormal, blood culture positive or respiratory symptoms persist over the next 2 hours.\n\nAppropriate screening for ROP and IVH per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-11 00:00:00.000",
"description": "Report",
"row_id": 1755991,
"text": "1 Pot for sepsis\n2 Resp\n3 FEN\n4 DEV\n5 Parenting\n\nREVISIONS TO PATHWAY:\n\n 1 Pot for sepsis; added\n Start date: \n 2 Resp; added\n Start date: \n 3 FEN; added\n Start date: \n 4 DEV; added\n Start date: \n 5 Parenting; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-11 00:00:00.000",
"description": "Report",
"row_id": 1755992,
"text": "NICU NPN 1900-0700\n\n\n#1 O: Baby started on Amp and gent. cbc with diff re-sent,\n(see flowsheet), diff pending. A: stable. P: Continue\nantibiotics as orderd.\n\n#2 Resp O: Baby remains in room air, rr 40-70's, lungs\nslightly diminished, o2 sats 94-100%, Baby does have some\nIC/SC retractions. Nares suctioned for large amounts of\nwhite secretions. Hr 130-160's, color pink, bp's have been\nstable throughout the night. A: stable. P: Continue to\nmonitor.\n\n#3 FEN O: Tf remain at 80cc/k/d, baby remains npo. Abdominal\nexam benign, IVF of d10 , infusing through piv well. D\nsticks stable during the night(Initially on admit, was 46).\nVaiding and stooling. A: stable. P: Continue to monitor.\n\n#4 DEV O: temsp are stable, nested on sheepskin, on servo\nwarmer. Baby is , irritable with cares, sleeps well in\nbetween cares, fontanells are soft and flat. A: aga P:\nContinue to support development.\n\n#5 Parenting O: Parents in to visit, updated at the bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-11 00:00:00.000",
"description": "Report",
"row_id": 1755993,
"text": "Neonatology\nDoing well. RA. few desats. Not requiring escalation of rx at this point. Comfortable appearing. No evidence of PDA.\n\nWt 1350 . NPO at present on IVF at TF=80 cc/k/d. Abdomen benign.\nWill begin feeds as tolerated. Lytes in good range.\n\nNot sig jaundiced. Bili in range.\n\nRepeat CBCX shows improvement in WBC> Clincially stable on abx for 48 h r/o.\n\nCOntinue to monitor resp status and feeding tolerance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-14 00:00:00.000",
"description": "Report",
"row_id": 1756009,
"text": "Social Work\nMother known to me from her prenatal adm to 6s. She lives in w/ husb and their 21 mo old dtr, born @ 30 and who also remained in the NICU x 6 . Parents reports that they spent each day w/ their first dtr in the NICU. They both now recognize their limitations and needing to balance the time w/ their 21 mo old, requesting that there be a possible transfer to .\n\nFamily mtng this afternoon w/ RN, sw and fellow present w/ parents. Mo and fa have several solid family supports, many of who are currently caring for their dtr. Mo's parents, mo and fa-in-law and her sister are all available to assist w/ childcare. Husb has benefit of paid paternity leave, and vacation time.\n\nBoth mother and father appear to be coping well w/ their second baby girl being in the NICU. They report how much easier it is to know what to expect, and that they are not as fearful. Mo initially had concerns around her breastmilk coming in, now pumping and going smoothly. Couple would it logistically easier if baby were transferred, and will tour WH next wk.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-04-14 00:00:00.000",
"description": "Report",
"row_id": 1756010,
"text": "Clinical Nutrition:\nO:\nFormer 31 weeker, BG now on DOL #4\nMaternal history reviewed.\nBirth wt: 1350g (10-25th%ile)\nBirth LN: 38.5cm (10-25th%ile)\nBirth HC: 27cm (10-25th%ile)\nCurrent wt: 1220g (-15g); down ~10% from birth wt.\nLabs: noted this am\nDsticks: 78-90 over the previous 24hrs\nAccess: PIV\nTF: 140 cc/kg/day\nNutrition: BM20\nGI: small/non-bilious spits noted, passed meconium stool\n\nA/goals:\nStarted feeds on DOL #1 noted to have occ. non-bilious spits. Voiding & stooling. Lytes & Dsticks wnl. Advancing feeds as tolerated. TF goal= 150 cc/kg/day. Growth goals: ~15-20 g/kg/day, ~0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN. Begin Iron & vit E once @ 24Kcals/oz feeds. Would consider starting PN/IL if feeds are not advanced per plan or if continues w/ spits over the next 24hrs. Will cont. to follow w/team & participate in nutrition plans.\n"
}
] |
|
26,421 | 192,868 | 1. Hypoxia. The patient was admitted to the MICU for question of left lower lobe pneumonia versus congestive obstructive pulmonary disease exacerbation. Patient's O2 sats remained stable for the patient, and he was quickly titrated down from his face mask to his nasal cannula of 3 liters. As the patient was at his baseline oxygen requirements, it was not felt to be a congestive obstructive pulmonary disease exacerbation. Patient has been started on higher dose of prednisone in the MICU, but when he was transferred to the floor, the patient was placed back on his taper of 40 mg po q day. The patient was maintained on Levaquin 500 mg po q day to complete a seven day course for a question of a left lower lobe infiltrate due to the patient's poor ability to comply with x-rays. This could not be further evaluated. Patient's myopathic disease likely contributes to his difficulty breathing and inability to clear hypercarbia. The patient was transferred out of the MICU on hospital day one and did very well. He was at his baseline and ready to return to the , . 2. Myopathy: I discussed the case with Dr. , the patient's neurologist, who said the patient's myopathy was of unclear etiology, and had nonspecific biopsy results. No further workup was planned as the patient has not had good results from steroid use. Steroids were being tapered. This plan was continued as inpatient. The patient will continue his outpatient steroid taper at Star of . 3. Swallowing: The patient was questioned to have aspiration stating that he was coughing up food particles. Bedside swallow evaluation was performed which did not reveal any signs of aspiration. The slight decrease in clearing of secretions may be related to his myopathy. A video swallow was not performed as there was self-limited utility. 4. Iritis/corneal ulcer: As patient has missed several outpatient appointments with his ophthalmologist, Dr. , the patient was sent to Clinic from the floor. Dr. was unavailable, but he was seen by another ophthalmologist. Examination revealed no evidence for iritis. Corneal transplant doing well. No evidence for corneal ulcer. Artificial tears was recommended qid for keratitis. Follow up with Dr. in one month. | Denies SOB SpO2:91-96% BS:Bronchial BS R base, crackles L base with some coarse rhonchi in upper zones that clear with DB&C. SBP=109-149.GI: +bowel sounds, no stools tonight.GU: U/O=70-100cc/hr with no leak of foley noted.Skin: No open areas noted.Neuro: Pupils=+, MAE. Expectorated x1 large green-tan sputum, sent for cxAfebrile, remains on Levofloxicin poHemodynamically stableA&Ox2, calm, compliant with treatmentExcellent appetite, fluid balance stableA:Swallowing study at bedside, tolerated well, recommendation to continue with current regime, video study not recommended OOB to chair with assist Called out to medical floorR:Stable, close to or at baseline pulmonary function, Continue with coarse of Levo, follow sputum cx results, evaluate for Bipap if desaturations occur overnoc Some leaking around indwelling catheter, ?d/c if this continuesGI:Abd soft, slightly distended, +BS. Sister states patient at baselineCV:HR:86-103 SR-ST, no VEA BP:159-175/79-95, down to 119-130/85 after restarting his po medsGU:BUN/Cr:14/.8, U/O:100-150cc/hr yellow-amber, some sediment, clearing through the day. One transient episode of desaturation to 70% while on R/A and sleepingBS:Diminished throughout, some rhonchi noted this afternoon after neb. HR=87-97 NSR with no ectopy noted. Full code status that was established this am from EW now changed back to DNI in light of patient's chronic, marginal pulmonary function S/MICU Nursing Progress note 7am-7pmSee Carevue for Additional Objective Data#1:Acute on Chronic Respiratory FailureD:FiO2 2L NC all day with RR:12 (while asleep)-24/min. CXR:Bilat pleural effusions, RLL atelectesis, ?LLpneumonia.ABG sent this evening at 18:30:63/81/7.39/51/19Started on q 4 hour nebs and inhaler therapy, will attemp Bipap tonightID:Tmax:99.8R, WBC:5.4, antibx pared down to Levofloxicin po q 24hrNeuro:Awake, oriented x1, confused to events, easily re-oriented. Lethargic at mn. Excellent appetite, taking po's well.Hct:34.5 stableEndo:BS:161 post IV solumedrol in EWDispo:Proxy is patients sister , in to visit him this evening. No apnea or distress noted.Plan: Transfer to floor today. O2 decreased to 2l. S/MICU Nursing Admission/Progress NoteROSResp:Denies SOB. Much more awake at 2am.Resp: Slept well with 2l NC O2 all night. Lung sounds coarse and diminished at bases. Admitted on .35 Venti mask with RR:20-24/min SpO2:91-99% Wears 3L NP eating SpO2:92-95%. Some soft brown stool noted with rectal temp. "B" Systems review:CVS: Afebrile. Sats=96-99%. Skin warm and dry. recognized sister this afternoon, asking her appropriate questions. No cough, no sputum production. Pt is . Speech is clear and appropriate. | 3 | [
{
"category": "Nursing/other",
"chartdate": "2107-02-14 00:00:00.000",
"description": "Report",
"row_id": 1607286,
"text": "S/MICU Nursing Admission/Progress Note\nROS\nResp:Denies SOB. Admitted on .35 Venti mask with RR:20-24/min SpO2:91-99% Wears 3L NP eating SpO2:92-95%. One transient episode of desaturation to 70% while on R/A and sleeping\nBS:Diminished throughout, some rhonchi noted this afternoon after neb. No cough, no sputum production. CXR:Bilat pleural effusions, RLL atelectesis, ?LLpneumonia.\nABG sent this evening at 18:30:63/81/7.39/51/19\nStarted on q 4 hour nebs and inhaler therapy, will attemp Bipap tonight\n\nID:Tmax:99.8R, WBC:5.4, antibx pared down to Levofloxicin po q 24hr\n\nNeuro:Awake, oriented x1, confused to events, easily re-oriented. recognized sister this afternoon, asking her appropriate questions. Sister states patient at baseline\n\nCV:HR:86-103 SR-ST, no VEA BP:159-175/79-95, down to 119-130/85 after restarting his po meds\n\nGU:BUN/Cr:14/.8, U/O:100-150cc/hr yellow-amber, some sediment, clearing through the day. Some leaking around indwelling catheter, ?d/c if this continues\n\nGI:Abd soft, slightly distended, +BS. Some soft brown stool noted with rectal temp. Excellent appetite, taking po's well.\nHct:34.5 stable\n\nEndo:BS:161 post IV solumedrol in EW\n\nDispo:Proxy is patients sister , in to visit him this evening. Full code status that was established this am from EW now changed back to DNI in light of patient's chronic, marginal pulmonary function\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-02-15 00:00:00.000",
"description": "Report",
"row_id": 1607287,
"text": " \"B\" Systems review:\n\nCVS: Afebrile. Skin warm and dry. All pulses palpable. HR=87-97 NSR with no ectopy noted. SBP=109-149.\n\nGI: +bowel sounds, no stools tonight.\n\nGU: U/O=70-100cc/hr with no leak of foley noted.\n\nSkin: No open areas noted.\n\nNeuro: Pupils=+, MAE. Speech is clear and appropriate. Lethargic at mn. O2 decreased to 2l. Much more awake at 2am.\n\nResp: Slept well with 2l NC O2 all night. Lung sounds coarse and diminished at bases. Sats=96-99%. No apnea or distress noted.\n\nPlan: Transfer to floor today. Pt is .\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-02-15 00:00:00.000",
"description": "Report",
"row_id": 1607288,
"text": "S/MICU Nursing Progress note 7am-7pm\nSee Carevue for Additional Objective Data\n#1:Acute on Chronic Respiratory Failure\nD:FiO2 2L NC all day with RR:12 (while asleep)-24/min. Denies SOB SpO2:91-96% BS:Bronchial BS R base, crackles L base with some coarse rhonchi in upper zones that clear with DB&C. Expectorated x1 large green-tan sputum, sent for cx\nAfebrile, remains on Levofloxicin po\nHemodynamically stable\nA&Ox2, calm, compliant with treatment\nExcellent appetite, fluid balance stable\n\nA:Swallowing study at bedside, tolerated well, recommendation to continue with current regime, video study not recommended\n OOB to chair with assist\n Called out to medical floor\n\nR:Stable, close to or at baseline pulmonary function, Continue with coarse of Levo, follow sputum cx results, evaluate for Bipap if desaturations occur overnoc\n"
}
] |
18,715 | 148,639 | The patient was started on heparin as well as Coumadin. His INR was monitored closely as well as his PTT. His PTT stayed relatively stable around 50 and this was on a heparin dose of 800 units per hour. His hematocrit was stable at 37.1. His PTT was ranged from 52 to 57. His INR was 1.2 on the day of discharge. His chemistries were all normal. The patient was evaluated by physical therapy and occupational therapy and they decided that he would be an excellent rehabilitation candidate. We agreed that he was stable for transfer to rehab on and he will chose the rehab of his choice. We will continue the Coumadin. We will also continue the heparin until therapeutic INR is reached. We will also like to keep the PTT between 50 and 70 until this therapeutic INR is reached. We will also continue laxatives for the patient's constipation. | PT STATES THAT THERE IS NO LOSS OF SENSATION TO THE LEFT EXTREMITIES. NO BM THIS SHIFT.GU: PT HAS AN INDWELLING FOLEY CATHETER WHICH IS SECURE AND PATENT. NEURO CHES=CKS AS PER PROTOCOL WITH NO UNTOWARD INCIDENCES.PLAN: CONTINUE TO MONITOR NEURO STATUS AND INSERTION SITE TO RIGHT GROIN. HAS BEEN DIAGNOSED WITH RIGHT SIDED TRANSFERED TO FOR CEA PROCEDURE.INITIALLY PT. BILATERAL CHEST EXPANSION NOTED.GI: ABDOMEN IS SOFT, NON-DISTENDED AND NON-TENDER TO PAPATION. BBS= ESSENTIALLY CLEAR. BBS= ESSENTIALLY CLEAR. BILATERAL CHEST EXPANSION NOTED.GI: ABDOMEN IS SOFT, NON-DISTENDED AND NON-TENDER. TOLERATED TRANSFER WITHOUT DIFFICUTLY.PT. No abnormal extra- axial collections seen. Injection of the left vertebral shows no significant anomaly. PT DOES NOT HAVE ANY DIMINISHED SENSORY PERCEPTION TO THE LEFT SIDE.NEURO TEAM IS AT BEDSIDE EVALUATING FOR CEA. ADEQUATE UOP > OR = TO 60CC/HR.INTEG: 2 #18 PIV TO LEFT HAND REMAIN SECURE AND PATENT.PLAN: CONTINUE TO MONITOR PTT AND MAKE HEPARIN ADJUSTMENTS AS PER PROTOCOL. POSTOPERATIVE DIAGNOSIS: Right internal carotid artery dissection extending intracranially with absence of filling of the MCA territory with significant presence of collateral perfusion from pial collaterals from the right anterior cerebral artery territory which fills from the left A1 segment and from the posterior circulation via the posterior communicating artery. PT ARRIVES AND WAS SAFELY SITUATED WITH NO UNTOWARD INCIDENCE. ADEQUATE UOP AMBER-YELLOW CLEAR URINE > OR = TO 60CC/HR.INTEG: PT HAS NO SKIN BREAKDOWN TO THE BACK OR BUTTOCKS. the area of isodensity is most likely due unaffected brain within the region of infarct. Injection of the innominate artery reveals the presence of slow flow in the right common carotid artery. PT HAD NO BM THIS SHIFT BUT IS PASSING FLATUS.GU: INDWELLING FOLEY CATHETER REMAINS SECURE AND PATENT WITH AMBER, CLEAR-CLOUDY URINE. Injection of the left common carotid artery reveals it to be free of disease or stenosis, however, it is characterized by a highly tortuous double- S-shaped curve in the middle of the cervical segment. SBP > OR = TO 100 WITH NO SYMPTOMATIC HYPER OR HYPOTENSIVE CRISIS. The right and left groin areas were prepped and draped in the usual sterile fashion and a 5-French vascular sheath was inserted into the right common femoral artery and kept on a heparinized saline flush. pt pt grion at site of procedure look good. TECHNIQUE: Non-contrast CT of the brain was performed. CLEAN,DRY AND INTACT GAUZE ON THE AREA. RIGHT GROIN IS HEALING NICELY, WELL APPROXIMATED WITH NO SIGNS OF ACTIVE BLEEDING, DRAINAGE OR REDNESS TO THE AREA. The venous phase is unremarkable and shows excellent opacification of sinuses. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS. NO GAG OR COUGH IMPAIRMENTS. PT HAS NO COMPLAINTS OF DISCOMFORT WITH VOIDING. HAD CEREBRAL ANGIOGRAM DONE WHICH WAS CONCLUSIVE FOR CAROTID DISSECTION. PT HAS RIGHT GROIN INCISION. Injection of the right vertebral artery shows no evidence of injury or anomaly in the cervical course although it is somewhat tortuous. the ventricles are not dilated. There is no acute intracranial hemorrhage. pt BS are clear throughout.GI/GU: pt UO is adequate (> 50 cc/hr) pt UP has become Amber with clotts pt had an tramatic foley cath placment. There is no shift in the normally midline structures. Injection of the right common carotid artery also reveals good filling of the right external carotid artery, however, with no significant collateral flow in the retrograde direction in the ophthalmic artery. INTACT COUGH AND GAG. PERLA.CV: HR 60-70'S, NSR WITH NO SIGNS OF ECTOPY. DENIES THAT HE HAS LOST ANY SENSATION TO EITHER. no s/s of bleeding. MONITOR PT/PTT, AND CRIT, MAKE HEPARIN ADJUSTMENTS AS NEEDED. This in conjunction with the lack of retrograde flow in the ophthalmic artery would suggest that the dissection may involve the entire cervical segment to include intracranial portions of the middle cerebral artery. NO SIGNS OF ACTIVE BLEEDING NOTED. Of note, there is no significant retrograde flow in the right A1 segment and no filling of the right middle cerebral artery segment. FINDINGS: There is a hypodensity within the region of the right basal ganglia. This is likely the mirror image of the right segment which is dissected, which in turn most likely explains the lack of any cortical infarct in this patient and also helps explain the location of the deep basal ganglia infarct which is most likely the segment that received the least blood flow in this situation. There is mild mass effect with compression of the sulci. ABLE TO MOVE HIS RIGHT UPPER AND LOWER EXTREMITY WITH NORMAL STRENGTH BUT IS STILL UNABLE TO MOVE HIS LEFT UPPER OR LOWER EXTREMITY. ANESTHESIA: Monitored anesthesia care. Pt has some lesser sensation in his left extremities. PT HAS STRONG PALPABLE PULSES TO BILATERAL RADIAL AND DORSALIS PEDIS. HEPARIN DRIP CONTINUES. CONTROL PAIN LEVEL AS NEEDED. In this region of hypodensity, a slightly hyperdense to isodense area is seen. NO COMPLAINTS OF CHEST PAIN.RR: PT HAS BEEN ON RA WITH 02 SATS > OR = TO 96%. OBEYS COMMANDS. OBEYS COMMANDS. CONTINUE TO CLOSELY MONITOR PT'S NEURO STATUS. There are no fractures seen. No area of acute hemorrhage is seen. WILL MOVE HIS RIGHT UPPER AND LOWER EXTREMITY WITHOUT DIFFICULTY BUT IS UNABLE TO MOVE HIS LEFT SIDE. STRONG PALPABLE PULSES TO BILATERAL RADIAL AND DORSALIS PEDIS. There is no evidence of dissection and the basilar trunk is patent as are all the major branches including the posterior cerebral artery and superior cerebellar vessels. RR 15-20, SP02 96-100% WITH NO COMPLAINTS OF SOB OR DIFFICULTY BREATHING. There is mild mucosal thickening seen in the sphenoid sinuses. There is also a hypodensity noted along the peripheral aspect of the right parietal lobe. THANK YOU. THANK YOU. Will continue to monitor pt coags and MS. PT HAS HAD NO SEIZURE ACTIVITY NOTED. pt is able to move his right side of his body, but is unable to move his left. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2101-09-24 00:00:00.000",
"description": "Report",
"row_id": 1508173,
"text": "Review of systems:\n\nNeuro: Pt is alert and oreinted x 3. pt has become more lethargic as the day has gone on, pt has slept throughout the day. pt will wake with stimuli and cooperate and comuncate but at times fades out during interaction. pt is able to move his right side of his body, but is unable to move his left. Pt has some lesser sensation in his left extremities. Pt also has left sided facial droop. Pt had a repeat head CT today to check if CVA had progressed, results pending.\n\nCV: pt BP has been WNL. Pt has +4 palpable pulses in all extremities. pt pt grion at site of procedure look good. no s/s of bleeding. Pt hepring gtt was stopped due a PTT of 150. STAT PTT drawn and PTT was WNL, awaiting a third PTT before restarting hep gtt.\n\nResp: Pt sao2 on RA is > 96%. pt BS are clear throughout.\n\nGI/GU: pt UO is adequate (> 50 cc/hr) pt UP has become Amber with clotts pt had an tramatic foley cath placment. will coninue to monitor.\n\nPlan Pt was seen by a neuro team, and tranfered to there team, pt has been called out and is awaiting a bed. Will continue to monitor pt coags and MS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-25 00:00:00.000",
"description": "Report",
"row_id": 1508174,
"text": "NURSING PRGRESS NOTE 7P-7A\nREPORT RECEIVED AT 1900. PT'S ENVIRONMENT SECURED FOR SAFETY. ALL ALARMS ON MONTOR ARE FUNCTIONING.\n\nNEURO: ALERT AND ORIENTED X 3. PT INTERACTIVE AND CONVERSES WITH FAMILY AND FRIENDS AT BEDSIDE. PERLA. PT. OBEYS COMMANDS. ABLE TO MOVE HIS RIGHT UPPER AND LOWER EXTREMITY WITH NORMAL STRENGTH BUT IS STILL UNABLE TO MOVE HIS LEFT UPPER OR LOWER EXTREMITY. PT. DENIES THAT HE HAS LOST ANY SENSATION TO EITHER. PT HAS RESIDUAL FACIAL DROOP TO THE LEFT SIDE. PERLA.\n\nCV: HR 60-70'S, NSR WITH NO SIGNS OF ECTOPY. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS. STRONG PALPABLE PULSES TO BILATERAL RADIAL AND DORSALIS PEDIS. CAP REFILL TO ALL FOUR EXTREMITIES IS < 3 AND BRISK. RIGHT GROIN IS HEALING NICELY, WELL APPROXIMATED WITH NO SIGNS OF ACTIVE BLEEDING, DRAINAGE OR REDNESS TO THE AREA. NO SIGNS OF JVD NOTED. PT. RECEIVED HIS COUMADIN AT 2100 THIS PM. HEPARIN DRIP CONTINUES. BASED ON 2300 PTT- DRIP WAS INCREASED FROM 800UNITS TO 900 UNITS/HR AS PER HEPARIN PROTOCOL.\n\nRR: PT REMAINS ON RA. RR 15-20, SP02 96-100% WITH NO COMPLAINTS OF SOB OR DIFFICULTY BREATHING. BBS= ESSENTIALLY CLEAR. INTACT COUGH AND GAG. BILATERAL CHEST EXPANSION NOTED.\n\nGI: ABDOMEN IS SOFT, NON-DISTENDED AND NON-TENDER. BS X 4 QUADRANTS. PT TOLERATED HIS DINNER AND ICE CREAM WITH NO COMPLAINTS OF N/V/D. PT IS REQUESTING THAT HIS DIET BE CONSISTENT WITH HIS VEGITARIAN REGIMEN. THIS WAS NOTED AND AN ORDER WAS PLACED IN THE COMPUTER. PT HAD NO BM THIS SHIFT BUT IS PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER REMAINS SECURE AND PATENT WITH AMBER, CLEAR-CLOUDY URINE. ADEQUATE UOP > OR = TO 60CC/HR.\n\nINTEG: 2 #18 PIV TO LEFT HAND REMAIN SECURE AND PATENT.\n\nPLAN: CONTINUE TO MONITOR PTT AND MAKE HEPARIN ADJUSTMENTS AS PER PROTOCOL. CONTINUE TO CLOSELY MONITOR PT'S NEURO STATUS. PT WILL BE TRANSFERRING TODAY TO 5. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-23 00:00:00.000",
"description": "Report",
"row_id": 1508171,
"text": "NURSING ADMISSION NOTE\nREPORT RECEIVED AT 1900. PT. ARRIVED TO MICU B AT VIA AMBULANCE. PT. TOLERATED TRANSFER WITHOUT DIFFICUTLY.\n\nPT. ADMITTED FROM FOR INCREASINGLY WORSENING CT. PT. HAS BEEN DIAGNOSED WITH RIGHT SIDED TRANSFERED TO FOR CEA PROCEDURE.\n\nINITIALLY PT. HAD BEEN COMPLAINING OF MIGRAINE HA FOR THE PAST 2-3 WEEKS WHICH HE HAD BEEN TREATING WITH IBUPROFEN WITHOUT RESULTS. ON HE BECAME UNCONSIOUS AND WHEN HE CAME TO DIALED 911 AND PRESENTED TO ER. HE HAS NO MOVEMENT TO THE LEFT SIDE- NEITHER LEFT UPPER EXTREMITY NOR LOWER LEFT EXTEMITY WILL MOVE. PT HAS NOTED LEFT SIDED FACIAL DROOP AS WELL. PT DOES NOT HAVE ANY DIMINISHED SENSORY PERCEPTION TO THE LEFT SIDE.\n\nNEURO TEAM IS AT BEDSIDE EVALUATING FOR CEA. ANESTHESIA TO COME UP FOR BEDSIDE ASSESSMENT AND PREOP.\n\nPLAN: WILL CONTINUE TO MONITOR UNTIL PT IS TX TO SURGERY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-09-24 00:00:00.000",
"description": "Report",
"row_id": 1508172,
"text": "NURSING PROGRESS NOTE 0145-0700\nREPORT RECEIVED FROM INTERVENTIONAL RADIOLOGY AT 0130. PT WAS TRANSFERRED BACK TO MICU B 773 VIA BED ACCOMPANIED BY DR. . PT ARRIVES AND WAS SAFELY SITUATED WITH NO UNTOWARD INCIDENCE. PT'S ENVIRONMENT SECURED FOR SAFETY AND ALL ALARMS ON MONITOR ARE FUNCTIONING.\n\nNEURO: ALERT AND ORIENTED X 3. PT HAS HAD NO SEIZURE ACTIVITY NOTED. PT. HAD CEREBRAL ANGIOGRAM DONE WHICH WAS CONCLUSIVE FOR CAROTID DISSECTION. PERLA. OBEYS COMMANDS. WILL MOVE HIS RIGHT UPPER AND LOWER EXTREMITY WITHOUT DIFFICULTY BUT IS UNABLE TO MOVE HIS LEFT SIDE. PT STATES THAT THERE IS NO LOSS OF SENSATION TO THE LEFT EXTREMITIES. LEFT FACIAL DROOP IS ALSO NOTED. SPEECH IS VERY SLIGHTLY SLURRED. PT HAS BEEN COMPLAINING OF SOME BACK PAIN- NEURO TEAM IS AWARE- BEING MANAGED BY FREQUENT REPOSITIONING AND 2-4MG OF MORPHINE SLOW IVP AS ORDERED.\n\nCV: PT HAS BEEN IN NSR WITH HR IN THE 70'S WITH NO SIGNS OF ECTOPY. SBP > OR = TO 100 WITH NO SYMPTOMATIC HYPER OR HYPOTENSIVE CRISIS. S1 AND S2 AS PER AUSCULTATION. NO MURMUR, RUBS OR GALLOPS AUSCULTATED. PT HAS STRONG PALPABLE PULSES TO BILATERAL RADIAL AND DORSALIS PEDIS. PT WAS WITH 1000UNITS OF HEPARIN AND IS CURRENTLY ON A HEPARIN DRIP AT 1000UNITS/ HR. WILL DRAW PT/PTT AND CRIT AFTER 6 HOURS OF HEPARIN DRIP THERAPY. NO SIGNS OF JVD NOTED. NO COMPLAINTS OF CHEST PAIN.\n\nRR: PT HAS BEEN ON RA WITH 02 SATS > OR = TO 96%. BBS= ESSENTIALLY CLEAR. NO GAG OR COUGH IMPAIRMENTS. BILATERAL CHEST EXPANSION NOTED.\n\nGI: ABDOMEN IS SOFT, NON-DISTENDED AND NON-TENDER TO PAPATION. BS X 4 QUADRANTS. PASSING FLATUS. NO BM THIS SHIFT.\n\nGU: PT HAS AN INDWELLING FOLEY CATHETER WHICH IS SECURE AND PATENT. PT HAS NO COMPLAINTS OF DISCOMFORT WITH VOIDING. ADEQUATE UOP AMBER-YELLOW CLEAR URINE > OR = TO 60CC/HR.\n\nINTEG: PT HAS NO SKIN BREAKDOWN TO THE BACK OR BUTTOCKS. PT HAS RIGHT GROIN INCISION. NO SIGNS OF ACTIVE BLEEDING NOTED. CLEAN,DRY AND INTACT GAUZE ON THE AREA. NEURO CHES=CKS AS PER PROTOCOL WITH NO UNTOWARD INCIDENCES.\n\nPLAN: CONTINUE TO MONITOR NEURO STATUS AND INSERTION SITE TO RIGHT GROIN. MONITOR PT/PTT, AND CRIT, MAKE HEPARIN ADJUSTMENTS AS NEEDED. CONTROL PAIN LEVEL AS NEEDED. PLEASE SEE FLOW SHEET FOR ADDITIONAL INFORMATION AS NEEDED. THANK YOU.\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-23 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 768902,
"text": " 10:02 PM\n CAROT/CEREB Clip # \n Reason: STROKE\n Contrast: OPTIRAY Amt: 190\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Right basal ganglia stroke in the setting of a\n spontaneous right carotid dissection.\n\n POSTOPERATIVE DIAGNOSIS: Right internal carotid artery dissection extending\n intracranially with absence of filling of the MCA territory with significant\n presence of collateral perfusion from pial collaterals from the right anterior\n cerebral artery territory which fills from the left A1 segment and from the\n posterior circulation via the posterior communicating artery.\n\n ANESTHESIA: Monitored anesthesia care.\n\n INDICATION: This patient is a 50 year old man who suffered an acute stroke\n characterized by left hemiplegia. He was transferred to Neurosurgery from an\n outside hospital for consideration of revascularization or recanalization\n procedure. This angiogram is being performed to determine whether the\n dissection may be recanalized or whether there are any other possible\n therapeutic interventions to treat this lesion.\n\n Consent was obtained from the patient and his wife. They were given a full\n and complete explanation of the procedure including the risks, benefits and\n possible complications. They understood and wished to proceed with the\n operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right and left groin areas were\n prepped and draped in the usual sterile fashion and a 5-French vascular sheath\n was inserted into the right common femoral artery and kept on a heparinized\n saline flush. A 5-French catheter was then inserted into the innominate\n artery, followed by the right common carotid artery, followed by the right\n subclavian artery, followed by the right vertebral artery, followed by the\n left common carotid artery, followed by the left subclavian artery, followed\n by the left vertebral artery. With the catheter in each of these positions, a\n series of angiographic runs was performed in neck and head and then the\n catheter was then withdrawn from the patient and the vascular sheath was\n removed with manual compression to achieve hemostasis. Injection of the\n innominate artery reveals the presence of slow flow in the right common\n carotid artery. Injection of the right common carotid artery reveals a\n (Over)\n\n 10:02 PM\n CAROT/CEREB Clip # \n Reason: STROKE\n Contrast: OPTIRAY Amt: 190\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n tapering of the right internal carotid artery to complete halt, consistent\n with an occlusive dissection. Injection of the right common carotid artery\n also reveals good filling of the right external carotid artery, however, with\n no significant collateral flow in the retrograde direction in the ophthalmic\n artery. Injection of the right vertebral artery shows no evidence of injury\n or anomaly in the cervical course although it is somewhat tortuous. There is\n no evidence of dissection and the basilar trunk is patent as are all the major\n branches including the posterior cerebral artery and superior cerebellar\n vessels. Significantly, there is a prominent filling of a dilated right\n posterior communicating artery which is perfusing the majority of the temporal\n lobe on the right side. Injection of the left subclavian artery reveals no\n evidence of origin of the vertebral artery and shows no evidence of stenosis\n or atherosclerosis. Injection of the left vertebral shows no significant\n anomaly. Injection of the left common carotid artery reveals it to be free of\n disease or stenosis, however, it is characterized by a highly tortuous double-\n S-shaped curve in the middle of the cervical segment. This is likely the\n mirror image of the right segment which is dissected, which in turn most\n likely explains the lack of any cortical infarct in this patient and also\n helps explain the location of the deep basal ganglia infarct which is most\n likely the segment that received the least blood flow in this situation. Of\n note, there is no significant retrograde flow in the right A1 segment and no\n filling of the right middle cerebral artery segment. This in conjunction with\n the lack of retrograde flow in the ophthalmic artery would suggest that the\n dissection may involve the entire cervical segment to include intracranial\n portions of the middle cerebral artery. The venous phase is unremarkable and\n shows excellent opacification of sinuses.\n\n IMPRESSION: Right internal carotid artery occlusive dissection with pial\n collaterals from the right anterior cerebral artery branches.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-09-24 00:00:00.000",
"description": "CT EMERGENCY HEAD W/O CONTRAST",
"row_id": 768940,
"text": " 12:34 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: HI PTT, RIGHT MCA STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with right MCA stroke, s/p angio, now with overshooting PTT\n REASON FOR THIS EXAMINATION:\n stroke extension, hemorhage?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50_-year-old man with right MCA stroke, status post angio with\n elevated PTT.\n\n TECHNIQUE: Non-contrast CT of the brain was performed.\n\n COMPARISONS: None.\n\n FINDINGS: There is a hypodensity within the region of the right basal ganglia.\n In this region of hypodensity, a slightly hyperdense to isodense area is seen.\n There is mild mass effect with compression of the sulci. There is also\n associated compression of the right lateral ventricle frontal . There is\n no shift in the normally midline structures. No abnormal extra- axial\n collections seen. There is no acute intracranial hemorrhage. the ventricles\n are not dilated. There is also a hypodensity noted along the peripheral aspect\n of the right parietal lobe. There are no fractures seen. There is mild mucosal\n thickening seen in the sphenoid sinuses. The right internal carotid artery is\n not well visualized.\n\n IMPRESSION:\n 1. Acute right basal ganglia and parietal cortex MCA territory infarct. the\n area of isodensity is most likely due unaffected brain within the region of\n infarct. 2. No area of acute hemorrhage is seen.\n\n"
}
] |
26,995 | 198,388 | Cardiac catheterization showed complex disease and cardiac surgery was consulted. As Mr. had received plavix, he awaited plavix washout and was taken to the operating room on where he underwent a CABG x 4. He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was transferred to the floor on POD #1. He did well postoperatively. He did have atrial fibrillation for which he was given amiodarone and increased lopressor. He converted to a normal sinus rhythm. He otherwise did well postoperatively and was ready for discharge home on POD #4. | Noaortic regurgitation is seen. There are simple atheroma in thedescending thoracic aorta. of the mitral chordae (normal variant). Mildly dilated ascending aorta. Mildly dilated descendingaorta. No TEErelated complications.Conclusions:PRE-BYPASS: The left atrium is moderately dilated. Thedescending thoracic aorta is mildly dilated. SLightly oozy throughout case, last plavix ? Arrived apaced for sinus brady underneath. Ct slowing down, output serosang. The aortic root is markedlydilated at the sinus level. There is asinus of Valsalva aneurysm. Right ij cordis introducer and swan line, right radial a line all zeroed and transduced with adequate waveforms. The coronary arteries arise from the normal expected anatomical location. The ascending aorta is mildly dilated. Respiratory CarePt extubated W/O incident. Other than a slightly unfolded intrathoracic aorta, the cardiac silhouette and hilar contour are within normal limits. Mildly thickened aortic valveleaflets (3). No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. A right chest tube terminates along the medial upper right hemithorax. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. COnt assess cardio/resp status. A right IJ Swan-Ganz catheter tip terminates within the main pulmonary artery. Dilated sinuses of Valsalva. Mitral valve prolapse. Resp CarePt from OR s/p CABG. The LCX shows minimal mixed plaque and gives off an OM branch which bifurcates into two further branches. The coronary circulation is co-dominant. The LAD and LCX arise separately from the left aortic cusp. COMPARISON: Preop chest radiograph . Labile BP +/- ntg. Assessment is as follows:Neuro: Arrived sedated on propofol. Sinus ofValsalva aneurysm. Left ventricular function. Please also refer to the separately dictated report of CT chest. The sinuses of Valsalva are dilated. Sinus rhythm. Moderate thickening ofmitral valve chordae. A nasogastric tube terminates within the proximal stomach with side port above the GE junction. Restraints removed with extubation. Followup and clinical correlation aresuggested. There is extensive mixed plaque in the right coronary artery which gives off the PDA. There is evidence of bilateral effusions posteriorly. Able to phonate post extubation. Sinus bradycardia. discussed w dr. ,propofol resumed for sedationb & safety. Dilatation of the ascending aorta above the aortic valve as described above. moving legs but not to command yetCV: HR 58-60 nsr, bp as above labile +/- ntg see flowsheet. Sternal and mediastinal dressings cdi, left leg ace wrap with steri strips intact underenath JP with serosang drainage from left knee. Sinus bradycardiaLong P-R intervalEarly R wave progressionAnt/septal and lateral T wave changes may be due to myocardial ischemiaClinical correlation is suggestedNo previous tracing available for comparison Trivial mitralregurgitation is seen. There is a bovine arch with 19.0 x 15.5 mm right brachiocephalic artery. lt. groin eccymotic,scant sero sang. CONCLUSION: The findings of CTA are as above. CT CHEST WITH AND WITHOUT CONTRSTS: There is minimal biapical fibrosis and pleural thickening. + placement confirmed by auscultation and xray. Simple atheroma in descending aorta.AORTIC VALVE: Three aortic valve leaflets. Icu packet given.Plan: Wake and wean and extubate when appropriate. in the ME long axis view.TEE examination was limited to the upper and mid-esophageal windows due tohistory of gatric surgery. IMPRESSION: High nasogastric tube placement with side port above the GE junction. (Over) 2:05 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: dilated ascending aorta and aortic root Admitting Diagnosis: CHEST PAIN\CARDIAC CATH FINAL REPORT (Cont) 3. The cardiomediastinal silhouette demonstrates expected post-CABG changes. Assess for s/s bleeding. Weaning propofol. IMPRESSION: Findings consistent with expected post-operative course and no PTX after multiple tube removal. Lg amount bilious drng via ogt which is to LCWSGu: FOley patent, uop clear yellow. Some subsegmental atelectatic changes are seen at the bases bilaterally. A left chest tube terminates in the lateral lung base. 2:05 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: dilated ascending aorta and aortic root Admitting Diagnosis: CHEST PAIN\CARDIAC CATH FINAL ADDENDUM ADDENDUM: CT ANGIOGRAM: The examination was performed on the Aquilion 64 scanner, the images were acquired in a retrospective gated fashion and form the basis of this report. Reconstructions were performed in the axial, sagittal, and coronal planes. A mediastinal drain is present. The aorticvalve leaflets (3) are mildly thickened. PA AND LATERAL CHEST RADIOGRAPHS FINDINGS: Other than minimal biapical pleural scarring, the lungs appear clear. Once appropriate reversals given. Valvular heart disease.Status: InpatientDate/Time: at 11:43Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Sinus of valsalva was found to be dilated > 5.5 cm. There are diffuse ST-T wave changes and persistence ofthe T wave inversions in leads V1-V6 which are more prominent consistentwith evolving anterolateral ischemia. Otherwise expected post- CABG changes. PERRLA. Current ABG: 7.35/41/168/24. No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Markedly dilated aortic sinus. | 14 | [
{
"category": "Radiology",
"chartdate": "2159-11-12 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 983636,
"text": " 8:34 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN\\CARDIAC CATH\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with 3VD for CABG\n REASON FOR THIS EXAMINATION:\n acute pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pre-op CABG.\n\n No priors are available.\n\n PA AND LATERAL CHEST RADIOGRAPHS\n\n FINDINGS: Other than minimal biapical pleural scarring, the lungs appear\n clear. Other than a slightly unfolded intrathoracic aorta, the cardiac\n silhouette and hilar contour are within normal limits. No evidence of\n pneumothorax, pulmonary edema, or pleural effusion. Surgical clips are noted\n in the region of the distal esophagus.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-11-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 983736,
"text": " 2:05 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: dilated ascending aorta and aortic root\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n CT ANGIOGRAM: The examination was performed on the Aquilion 64 scanner, the\n images were acquired in a retrospective gated fashion and form the basis of\n this report. The examination was performed post-administration of sublingual\n Nitroglycerin and intravenous Metoprolol.\n\n The coronary circulation is co-dominant. There is extensive mixed plaque in\n the right coronary artery which gives off the PDA. The LAD and LCX arise\n separately from the left aortic cusp. There is extensive mixed plaque\n throughout the LAD with an area of approximately 70% stenosis in the proximal\n LAD. The LAD gives off a D1 and D2 branches which also have mixed plaque. The\n LCX shows minimal mixed plaque and gives off an OM branch which bifurcates\n into two further branches.\n\n The ejection fraction was 75%, the end-diastolic volume was 134 ml, the end-\n systolic volume was 33 ml, the stroke-volume was 101 ml, the cardiac output\n was 5.4 liters per minute.\n\n CONCLUSION:\n\n The findings of CTA are as above. The immediate significant finding is a 70%\n stenosis of the proximal LAD.\n\n Please also refer to the separately dictated report of CT chest.\n\n\n\n\n\n\n\n 2:05 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: dilated ascending aorta and aortic root\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with 3vd for CABG\n REASON FOR THIS EXAMINATION:\n dilated ascending aorta and aortic root\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old male with three-vessel disease for coronary artery\n bypass graft. Pre-operative assessment.\n\n TECHNIQUE: CT of the chest was performed without intravenous contrast\n followed by CT of the chest post-administration of intravenous contrast.\n\n Reconstructions were performed in the axial, sagittal, and coronal planes.\n Reconstructions were also performed in the 3D imaging lab.\n\n CT CHEST WITH AND WITHOUT CONTRSTS:\n\n There is minimal biapical fibrosis and pleural thickening. There are no\n worrisome lung lesions. There is no pericardial or pleural effusion. There is\n no significant intrathoracic lymphadenopathy.\n\n There is no aortic dissection or pulmonary embolism. The ascending aorta just\n above the aortic valve measures 44 x 38 mm. The ascending aorta at the level\n of the right main pulmonary artery measures 38 x 37 mm. The coronary arteries\n arise from the normal expected anatomical location. There is a bovine arch\n with 19.0 x 15.5 mm right brachiocephalic artery.\n\n The visualized liver and spleen appear unremarkable. There is a subcentimeter\n low-attenuation focus in the left adrenal gland, this is too small to\n characterize. There are multiple surgical clips in the upper abdomen\n surrounding the distal esophagus likely representing operation for a hiatus\n hernia.\n\n MUSCULOSKELETAL: There are multilevel degenerative changes present in the\n spine.\n\n Please note, the findings of the coronary angiogram will be added as an\n addendum once reconstructions have been performed in the 3D imaging lab.\n\n CONCLUSION:\n\n 1. Dilatation of the ascending aorta above the aortic valve as described\n above.\n\n 2. Bovine arch with the brachiocephalic trunk at the origin measureing 19 x\n 15 mm.\n\n (Over)\n\n 2:05 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: dilated ascending aorta and aortic root\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Subcentimeter low-attenuation focus in the left adrenal gland is too small\n to characterize and may be assessed further with an MRI as per clinical need.\n\n Please note the report of coronary CT angiogram will be added as an addendum\n once reconstructions have been performed in the 3D imaging lab.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 984022,
"text": " 3:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film-contact NP # if abnormal\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film-contact NP # if abnormal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man status post CABG.\n\n COMPARISON: Preop chest radiograph .\n\n SUPINE AP CHEST RADIOGRAPH: The endotracheal tube tip terminates 3 cm from\n the carina. A nasogastric tube terminates within the proximal stomach with\n side port above the GE junction. A right IJ Swan-Ganz catheter tip terminates\n within the main pulmonary artery. A left chest tube terminates in the lateral\n lung base. A mediastinal drain is present. A right chest tube terminates\n along the medial upper right hemithorax. The cardiomediastinal silhouette\n demonstrates expected post-CABG changes. There is no pneumothorax. There is\n no appreciable effusion.\n\n IMPRESSION: High nasogastric tube placement with side port above the GE\n junction. Recommend advancing several centimeters. Otherwise expected post-\n CABG changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-11-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 984322,
"text": " 12:53 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumo / please do after 1300 hrs / pt had pacinf wires\n Admitting Diagnosis: CHEST PAIN\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with s/p ct pull\n REASON FOR THIS EXAMINATION:\n r/o pneumo / please do after 1300 hrs / pt had pacinf wires dc'd\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON AT 11:55\n\n INDICATION: Followup post-op films.\n\n COMPARISON: at 16:16.\n\n FINDINGS:\n\n Lines and tubes have been removed and there is no PTX. Some subsegmental\n atelectatic changes are seen at the bases bilaterally. There is evidence of\n bilateral effusions posteriorly. Some basilar airspace disease seen on the\n lateral view, not well localized, may be corresponding to retrocardiac\n densities on the frontal film. Distinction of that finding between\n atelectasis and pneumonia cannot be made radiographically.\n\n IMPRESSION: Findings consistent with expected post-operative course and no\n PTX after multiple tube removal. Basilar atelectatic changes are likely,\n though pneumonia cannot be excluded radiographically.\n\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2159-11-15 00:00:00.000",
"description": "Report",
"row_id": 68119,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve prolapse. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 11:43\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSinus of valsalva was found to be dilated > 5.5 cm. in the ME long axis view.\n\nTEE examination was limited to the upper and mid-esophageal windows due to\nhistory of gatric surgery. Although the patient denoes any history of\ndysphagia /Odynophagia and eats regular diet.\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\nin the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Markedly dilated aortic sinus. Dilated sinuses of Valsalva. Sinus of\nValsalva aneurysm. Mildly dilated ascending aorta. Mildly dilated descending\naorta. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate thickening of\nmitral valve chordae. of the mitral chordae (normal variant). No resting\nLVOT gradient. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nPRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo\ncontrast or thrombus is seen in the body of the left atrium or left atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. Overall\nleft ventricular systolic function is normal (LVEF>55%). Right ventricular\nchamber size and free wall motion are normal. The aortic root is markedly\ndilated at the sinus level. The sinuses of Valsalva are dilated. There is a\nsinus of Valsalva aneurysm. The ascending aorta is mildly dilated. The\ndescending thoracic aorta is mildly dilated. There are simple atheroma in the\ndescending thoracic aorta. There are three aortic valve leaflets. The aortic\nvalve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is moderate thickening of the mitral valve chordae. Trivial mitral\nregurgitation is seen. There is no pericardial effusion.\n\nPost CPB:\nPreserved -venytricular systolic function.\nNo other change\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-16 00:00:00.000",
"description": "Report",
"row_id": 1615153,
"text": "Nursing Progress Note\nNeuro: , , following commands and answering questions appropriately. Restraints removed with extubation. Cough intact gag impaired, present but deep. Perla 3 brisk.\n\nCVS: temp 100.2, blood. HR 83 SR no ectopy. BP 136/59 on Nitro at 5. PA 23/7 cvp 5 co 5.38 ci 2.41. 2 a and 2 v wires attatched to pacer on vvi back up rate. A wires inappropriately sensing. Pacer box shut off for inapproprite sense and capture during aggitation while extubating. Right ij cordis introducer and swan line, right radial a line all zeroed and transduced with adequate waveforms. Pulses weak palp, skin pale and dry. Sternal and mediastinal dressings cdi, left leg ace wrap with steri strips intact underenath JP with serosang drainage from left knee. Chest tube with sang drainage, increased with turns. Crit 25.5, repeat 25, hemodilute, no new orders at that time.\n\nResp: Extubated at 0515 with RT. Suctioned for thick yellow. Lungs clear in upper lobes dim at bases, good cough effort when prompted, non-productive. Sats on 40 % face tent are >97.\n\nEndo: fs bs covered with IV regular insulin, weaned off, switch to sc scale.\n\nGI: abdomen soft non tender, bs hypoactive x 4 quads. Nause x 1 received reglan ivp.\n\nGU: Foley cath draining clear yellow urine to gravity.\n\nPain: received morphine iv overnight for pain relief.\n\nPlan: Probable deline. Will need oral agents/different iv agents to get off large dose of ntg.\n\nSee carevue flowsheets and mars for further details and values.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-15 00:00:00.000",
"description": "Report",
"row_id": 1615148,
"text": "70 yo s/p cabgx4. Arrived apaced for sinus brady underneath. SLightly oozy throughout case, last plavix ? 2 unit plts intra op. Received protamine 50mg upon arrival to csru. Labile BP +/- ntg. Intrinsic rhythm sr 60-70. no ecotpy. Assessment is as follows:\nNeuro: Arrived sedated on propofol. Once appropriate reversals given. Weaning propofol. PERRLA. moving legs but not to command yet\nCV: HR 58-60 nsr, bp as above labile +/- ntg see flowsheet. Trying to keep <120 due to bleeding. Ct slowing down, output serosang. no leak. A wires sense but do not capture only with asynchronous pacing. V wires sense and caputure at a ma 22. Dopplerable pedal pulses.\nResp: Arrived on IMV 500x14, now on Fio2 40%, peep at 10 to try to decrease bleeding, oxygenation good. Sats 100%. lungs clear to bases. JP in lt leg\nGi: OGt readvance upon arrival to csru. + placement confirmed by auscultation and xray. Abd soft. absent bs. Lg amount bilious drng via ogt which is to LCWS\nGu: FOley patent, uop clear yellow. A little bleeding around meatus.\nENdo: insulin gtt started per protocol. see flowsheet. Q1hr bs\nSOcial: family in and out at bedside. Updated on plan of care by Dr. and nurse. Icu packet given.\nPlan: Wake and wean and extubate when appropriate. COnt assess cardio/resp status. Assess for s/s bleeding. Advance per fast track protocol. Cont q1hr bs while on insulin gtt\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-15 00:00:00.000",
"description": "Report",
"row_id": 1615149,
"text": "Resp Care\nPt from OR s/p CABG. Current vent settings: SIMV 600 x 14 10P 40%. Current ABG: 7.35/41/168/24. RR increased from 10 to 14. PEEP increased from 5 to 10 due to bleeding. Decreased FIO2 from 100 to 60 and then to 40%. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-15 00:00:00.000",
"description": "Report",
"row_id": 1615150,
"text": "attempted wakeup but increasingly agitated(still flowwing commands),bending legs,attempting self extubation with hypertension,drop in spo2 & increased dark blood from ct's. discussed w dr. ,propofol resumed for sedationb & safety. will continue to closely monitor ct dng. lt. groin eccymotic,scant sero sang. dng noted from vein harvest site. family updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-15 00:00:00.000",
"description": "Report",
"row_id": 1615151,
"text": "ct dng unchanged,dark red w/ clots m.d. aware. seems underfilled with significant metabolic acidosis,hypertension with any stimulation,low filling pressures & amber urine. discussed with m.d.,volume infusing,will recheck labs. propofol & ntg increased for bp control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-11-16 00:00:00.000",
"description": "Report",
"row_id": 1615152,
"text": "Respiratory Care\nPt extubated W/O incident. Good cough and cuff leak, no gag observed with suction. Able to phonate post extubation. Appears comfortable NAD.\n"
},
{
"category": "ECG",
"chartdate": "2159-11-19 00:00:00.000",
"description": "Report",
"row_id": 163446,
"text": "Sinus bradycardia. Compared to prior tracing of the limb lead\nvoltage has improved. There are diffuse ST-T wave changes and persistence of\nthe T wave inversions in leads V1-V6 which are more prominent consistent\nwith evolving anterolateral ischemia. Followup and clinical correlation are\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2159-11-15 00:00:00.000",
"description": "Report",
"row_id": 163447,
"text": "Sinus rhythm. Low limb lead voltage. Precordial T wave abnormalities.\nSince previous tracing of the rate is faster. The limb lead\nvoltage is less.\n\n"
},
{
"category": "ECG",
"chartdate": "2159-11-12 00:00:00.000",
"description": "Report",
"row_id": 163448,
"text": "Sinus bradycardia\nLong P-R interval\nEarly R wave progression\nAnt/septal and lateral T wave changes may be due to myocardial ischemia\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"
}
] |
2,704 | 171,806 | 25yoF presented to OSH with 1 week of sore throat and sore tooth, which had progressed slowly to neck swelling and cellulitis. Afebrile. CT OSH demonstrated air and fluid in the subcutataneous neck and in the anterior mediastinum. Pt was transferred to for further surgical management of likely necrotizing fasciitis of the neck and mediastinum. Thoracic surgery and ENT surgical services took patient to OR for extensive neck exploration and chest tube placement on HD 1. HD 2 required repeat right chest and shoulder debridement in OR by and plastics. HD 3 required a sharp bedside debridement. Pathology of all procedures demonstrated tissue hemorrhage and necrosis as well signs of acute and chronic inflammation. Wound cultures demonstrated yeast, strep milleri and OSH would cx grew GPC and anaerobes. Vanco/Zosyn/Clinda course for broad coverage switched to Unasyn (but pancytopenia) then to Levo/Flagyl for three week coarse of broad spectrum. A vaccuum dressing was placed over the large debridement site; on HD 15 when plastic surgery did a split thickness skin graft from left thigh to anterior chest and vac replaced until HD 20. On removal, graft appeared well with good perfusion, with exception of inferior edge which demonstrated a mild amt of dehiscence. A trial of extubation was attempted on HD 20 but pt failed likely large mucous plugging and collapse of left lung, which resulted in emergent reintubation. Culture positive Cdif treated with Oral Vanco and Flagyl starting on HD 23. HD 25 patient extubated without complication however remained emotionally labile as well as extremely weak (unable to swallow safely, unable to cough productively); psychiatry, physical therapy, and speech and swallow were involved. Over subsequent 5 days of hospital stay, pt remained unable to swallow safely after multiple speech and swallow attempts, remained with doboff tube feeds to goal- ENT consult evaluated patient and assessed her to have a right vocal cord lateralization and therefore is an aspiration risk. PEG tube placed by Interventional radiology on HD 31, tube feeds brought to goal. Patient refused to go to recommended rehabilitation center-- after much counselling on the subject, patient discharged to home with VNA HD 33 with PEG tube feeds for further physical therapy. She needs to followup with Plastic Surgery (for likely future free flap), ENT (vocal cord immobility), Dentistry (further tooth extraction), and Speech/ Swallow (video swallow)- all appointments have been made for her and multiple discussions on necessity of followup were had with the patient and her boyfriend. | FINDINGS: An endotracheal tube terminates in somewhat low position with the distal tip approaching the right main stem bronchus. IMPRESSION: 1) Endotracheal tube, and left chest tube in good position. Bilateral soft tissue emphysema involving the shoulders is again noted. Postsurgical changes within the mediastinum and left neck with a soft tissue defect, left chest tube, mediastinal drains, pneumomediastinum and anterior subcutaneous air. AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: The right-sided PICC line is seen terminating with the tip in good position in the mid-superior vena cava. Also noted is partial atelectasis at the right lung base, associated right lower lobe infiltration. A partially layering moderate right pleural effusion is noted. CT OF THE ABDOMEN WITH IV CONTRAST: There is a small amount of ascites as well as a pericholecystic fluid. Within the right lung, note is made of a small to moderate pleural effusion. A radiopaque opacity overlies the central upper mediastinum that could represent a surgical drain. Status post chest tube removal. CONDITION UPDATED: PLEASE SEE CAREVUE FOR SPECIFICSNEURO: SEDATED ON FENT AND ATIVAN GTTS. STATUSD: CALMER TODAY..LETHARGIC BUT EASILY AROUSED..REMAINS ON ATIVAN & FENTANYL GTT'S WITH PRN HALDOL..NEURO UNCHANGEDA: ATIVAN & FENTANYL GTT DECREASED 3MGM & 350MCG RESPECTIVELY..VENT WEANED TO C-PAP WITH 12 IPS..TOL WELL..SUCTIONED FOR SM AMT THICK WHITE/TAN..VAC DSG INTACT WITH MIN SS DRAINAGE..LF THIGH GRAFT SITE DRAINING SM AMT SEROUS SANG..TF'D BEING INCREASED 10CC Q4H TO GOAL OF 75CC WITH MIN RESIDUALS..MIN LOOSE BROWN STOOL FIB INTACT..GOOD HUO'SR: IMPROVING MENTAL & PULMONARY STATUSP: CONTINUE WITH PRN HALDOL AT LOWER DOSE & WEAN ATIVAN & FENTANYL PER HO FOCUS: CONDITION UPDATED: SEE ICU ASSESSMENT SHEET FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENTS.REMAINS SEDATED ON FENATNYL/ATIVAN, SLOWLY WEANING. Moves LLE less actively than R but withdraws briskly bilat.CV: T max 99.7 po. EKG DONE QTC PROLONGED (THOUGHT TO BE DO TO HALDOL AND METHADONE WHICH WAS STARTED . A diminished epiglottic deflection and laryngeal elevation was demonstrated. L thoracotomy site healing, old suture removed.A: Stable, sedated, hypotensivePLAN: OR tomorrow for STSG to neck from ?Right thigh. Bilat wheezes noted at that time and ALB mdi started with good effect noted. Flushes and residual checks q4hr as ordered. A-line needing freq flushes; NBP checked q1hr. Flushes and TF residuals ordered. PT APNEIC RESUMED SIMV. CONDITION UPDATE: SEE CAREVIEW NOTES FOR SPECIFICSNEURO: PT SEDATED ON ATIVAN AND FENT GTT. DRESSING LEAKING MUCH LESS THAT 2 DAYS AGO.TOLERATING TUBE FEEDS, ADVANCING AS ORDERED.R: STABLE, SITLL WITH A SMALL PRESSOR REQUIREMENT.P: CONTINUE TO CLOSELY MONITOR, KEEP MAP>60, CALL HO WITH ANY CHANGES. Addendum to NPN:A-line dampened throughout shift. Trace generalized edema. Trace generalized edema. Addendum to NPN:Pt's K and Mg repleted as ordered. +1 generalized edema. Abdomen softly distended w/ +BS. IV AT 80/HR FOR HYDRATION.GU: U/O QS VIA FOLEYLABS: ELECTROLYTES REPLETED.WOUND: VAC DSG INTACT. PERRLRESP- LUNGS CLEAR WITH DIMINISHED BASES. DP/PT/radial/brachial pulses palpable.Pulm: Lungs sound coarse bilat. FS q6hr w/ RISS. Repeat Mg 1.7 (treated w/ another 2grams mag sulfate). She received on round of albuterol MDI this am. NUMBEROUS SERVICES BY TO SEE PATIENT AND DRESSING (PLASTICS/ENT/ID/TRAUMA/THORACIC).HEMODYNAMICALLY STABLE, REMAINS FEBRILE. To be put back on CPAP this am.CV: Afebrile. Resp Care Note:Pt cont intub with NETT sedated and on mech vent as per Carevue. SICU resident aware of pt being febrile. Plan to continue on settings, wean when pt comes off sedation. Tolerating slow TF increase w/minimal residuals. LYTES CHECKED AND REPLACED AS ORDERED.A LINE CURRENTLY NON FUNCTIONING, GOING BY CUFF WHICH HAS BEEN USED ALL SHIFT. Lung sounds ess clear after suct sm loose tan sput. BS'S CLEAR TO DIMINISHED. Lung sounds sl coarse and ess clear after suct for bld tinged sput (spec obt). SHE SETTLES DOWN W/O SPECIFIC INTERVENTION. Pt failed extubation, reinubated after decreasing sats. THIS PM, AGREED TO EXTUBATE PATIENT. Nursing note:NEURO: Remains sedated on Ativan/Fentanyl gtts. CONDITION UPDATE: SEE CAREVIEW FLOWSHEET FOR DETAILSNEURO: ,OPENS EYES SPONT, MAE, PERRL, OBEYS COMMANDS, NO SEDATION > 24 HRS. Pt picc line replaced at fluro. Tolerating extubation well. CVP 7-12.GI: Abdomen soft, minimal stool via FIB. Does not follow commands.RESP: Lung sounds clear, no vent changes overnight. TFs restarted at GR and thus far tolerating. Resp care: NT tube d/c'd . AROUSABLE TO VOICE-OPENS EYES, PERRL, OBEYS COMMAND TO SQUEEZE RIGHT HAND, WITHDRAWS UPPER AND LOWER EXTREM AND LOCALIZES.CV:NSR NO ECTOPY, MAP MAINTAINED >60 WITH LEVO AT 0.069. Condition updatePlease see carevue for specifics:Pt afebrile with tmax 98.9 ; HR 78-110 NSR to Sinus tach (with suctioning and turns). Hold sedation if possible for ?extubation in am. of care reviewed with both.PLAN: Cont CPAP. amounts serosanguinous drainage. FS covered per SLSC. Minimal residual; flushed q4hr. MN dose of Clonidine held. Focus: Status updatePt lightly sedated on ativan/fentanyl. CXR DONE. FS q6hr w/ RISS. CPT done q4hr.GI: Abdomen soft w/ hypoactive bowel sounds. Resp carePt cont. CONDITION UPDATE:SEE CAREVIEW FLOWSHEET FOR SPECIFICSNEURO: PT SEDATED ON FENT AND ATIVAN GTT. MDI's given as noted. MAG REPLETED X 1. CPT with result. suctioned prn. Replete lytes as necessary. Wean Propofol as tolerated. Monitor resp status and ABGs. abg's ok.cardiac: remains in nsr. IVIG D/C'D PER ID. Residual checks and flushes q4hr as ordered. WEAN LEVO AND SEDATION AS ABLE. TF @ goal rate; residual checked and NGT flushed q4hr. UO qs.Integ: VAC dsg intact; connected to wall suction w/ light serosang drainage. No grimacing except when turned and repositioned.CV: Tmax 100.1. ABG reveals Compensated Alkalosis w/ normoxia. Fentanyl and Ativan gtt continued. c/w full suppport. See CareVue for gtt rate and wean. vac dsg to low cont wall suction. fluconazole iv given.tube fdgs as ordered and tol well.response: monitor closely. HR 70-90s (NSR), but pt becomes tachycardic (110-140s) w/ activity; once settled, hr returns to normal. Lungs remain coarse bilat.Sxd by nursing. resp careremains intub/vented in simv mode. Focus: Status updatePt lightly sedated on fentanyl/ativan. tube fdgs at goal rate of 90cc/hr.skin: vac dsg intact and to low cont wall suction. Replace lytes as needed. DP/PT/radial/brachial pulses palpable. SUCTIONED OCCAS. Right femoral A-line changed over wire by Dr. . OK'd with team.Neck dressing changed-xeroform and DSD. RSBI to be done in AM> | 113 | [
{
"category": "Radiology",
"chartdate": "2116-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852405,
"text": " 1:30 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p intubation\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p chest\n tube removal\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 25-year-old status post drainage of the neck and chest abscess.\n\n Comparison is made to prior study of the same day earlier and this chest x-ray\n was obtained at 13:57 hours. Since the prior study, there has been inferior\n migration of the ET tube and the tip of it is in the right main stem bronchus.\n There has been complete atelectasis of the left lung. Also noted is partial\n atelectasis at the right lung base, associated right lower lobe infiltration.\n G-tube remains in place. The house staff are notified about these findings.\n\n IMPRESSION:\n\n The tip of the ET tube is in the right main stem bronchus resulting in\n complete atelectasis of the left lung.\n\n Right lower lobe partial atelectasis and infiltration. An associated right\n pleural effusion is also suspected.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853791,
"text": " 4:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lung reexpansion\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p\n chest tube removal, and now s/p failed extubation and reintubation.\n REASON FOR THIS EXAMINATION:\n eval lung reexpansion\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest dated compared to a previous study\n of approximately one hour earlier.\n\n INDICATIONS: Evaluate lung reexpansion.\n\n There has been marked improved aeration in the left lung, which was previously\n completely collapsed. There is some residual atelectasis remaining as well as\n a small left pleural effusion. A partially layering moderate right pleural\n effusion is noted. There has been interval repositioning of endotracheal\n tube, now terminating 4 cm above the carina. PICC line and feeding tube\n remain in place.\n\n IMPRESSION:\n\n 1) Marked improved aeration of the left lung, which was previously completely\n collapsed.\n\n 2) Successful repositioning of the endotracheal tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 851741,
"text": " 4:49 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: see indication prior indication\n Admitting Diagnosis: NECROTIZING FASCIITIS\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman w/ severe nec fasc. of the neck and mediastinum w/ hx of\n severe pancreatitis sp debridement w/ worsening septic picture.\n REASON FOR THIS EXAMINATION:\n see indication prior indication\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe necrotizing fasciitis of the neck and mediastinum, severe\n pancreatitis, S/P debridement, hypotension and increased erythema.\n\n COMPARISON: None\n\n TECHNIQUE: Axial MDCT images were obtained through the neck after\n administration of 75 cc of non-ionic Optiray contrast, used secondary to\n patient debility.\n\n CT OF THE NECK WITH CONTRAST: There is evidence of debridement with an open\n wound and packing within the left side of the neck. There is mediastinal air\n with drains as well as a left- sided chest tube. The trachea is slightly\n deviated to the right. There is soft tissue swelling throughout. No definite\n drainable fluid collections are identified. There is some scattered\n subcutaneous air within the right neck as well as some subtle hypoattenuation\n of the soft tissues and muscles. There are bilateral pleural effusions. There\n is mucosal thickening within the ethmoid and maxillary sinuses.\n\n IMPRESSION:\n 1. Post-surgical changes identified within the left neck with an open wound\n and packing, sternal drains and mediastinal air.\n 2. There is subcutaneous air and hypoattenuation within the right neck which\n may represent extension of disease, and was not debrided during the previous\n operation. No definite fluid collections seen.\n\n These findings were discussed with Dr. attending from surgery at the\n time of study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 851742,
"text": " 4:49 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: see prior indication\n Admitting Diagnosis: NECROTIZING FASCIITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman w/ severe nec fasc. of the neck and mediastinum w/ hx of\n severe pancreatitis sp debridement w/ worsening septic picture.\n REASON FOR THIS EXAMINATION:\n see prior indication\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe necrotizing fasciitis of the neck and mediastinum, history\n of severe pancreatitis, worsening septic picture including hypotension.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained from the lung apices through the\n symphysis pubis after the administration of 100 cc of nonionic Optiray\n contrast, used secondary to the patient's debility.\n\n CT OF THE CHEST WITH IV CONTRAST: Postsurgical changes are identified within\n the left neck with a soft tissue defect and packing material. There are also\n two mediastinal drains with pneumomediastinum. There is a left- sided chest\n tube with subcutaneous air along the anterior chest wall. There is no\n pneumothorax. There is some subtle hypo-attenuation within the soft tissues\n and muscles of the right neck with some scattered subcutaneous air in this\n region. There are bilateral pleural effusions. There are some increased\n septal lines within the lungs. There is reactive atelectasis at the lung\n bases. There are scattered, non-pathologically enlarged mediastinal nodes.\n There is diffuse, subcutaneous soft tissue stranding consistent with anasarca.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a small amount of ascites as\n well as a pericholecystic fluid. The pancreatic duct is significantly (1 cm)\n dilated and the CBD is prominent measuring up to 7 mm. There is some\n increased attenuation within the cortex of the left kidney, although the\n kidney enhances and excretes contrast. There is an apparent, 7 mm\n nonobstructing stone in the upper pole of the left kidney. The right kidney\n is unremarkable. The liver, spleen and adrenal glands are unremarkable. There\n is vicarious excretion of contrast within the gallbladder.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is free fluid within the pelvis. The\n distal ureters and bladder are unremarkable. There is a Foley catheter with\n iatrogenic air in the bladder. There is a right femoral CV line in\n appropriate position. There is again diffuse subcutaneous soft tissue\n stranding throughout consistent with anasarca.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n (Over)\n\n 4:49 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: see prior indication\n Admitting Diagnosis: NECROTIZING FASCIITIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Postsurgical changes within the mediastinum and left neck with a soft\n tissue defect, left chest tube, mediastinal drains, pneumomediastinum and\n anterior subcutaneous air. There is subtle hypo-attenuation within the soft\n tissues/muscles of the right neck as well as subcutaneous air. This may\n represent extension of disease which has not yet been explored.\n 2. Bilateral pleural effusions with reactive atelectasis. Small amount of\n free fluid within the abdomen and pelvis as well as anasarca.\n 3. Areas of hyper-attenuation within the cortex of the left kidney consistent\n with a persistent nephrogram. This can be seen in sepsis although the left\n kidney does appear to enhance and excrete contrast symmetrically to the right.\n 4. Significantly dilated pancreatic duct as well as prominence of the common\n bile duct of unknown etiology.\n\n These findings were discussed with Dr. , surgery attending, at the\n time of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-21 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 853742,
"text": " 10:33 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: feeding tube, post piloric\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p I&D neck\n\n REASON FOR THIS EXAMINATION:\n feeding tube, post piloric\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: A 25-year-old female with necrotizing fasciitis of the neck\n requiring an enteric tube for feeding.\n\n TECHNIQUE: A 12-French feeding tube was advanced under\n fluoroscopic guidance. The tip was positioned within the duodenum.\n Positioning was confirmed by injection of approximately 5 mL of water-soluble\n contrast.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852377,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p chest\n tube removal\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 25-year-old with status post drainages of the neck and chest\n abscesses. Status post chest tube removal. Evaluate for pneumothorax.\n\n The comparison is made to the prior study of earlier,the same day. Since the\n prior study, there has been removal of the left chest tube and no evidence of\n pneumothorax. Bilateral soft tissue emphysema involving the shoulders is\n again noted. There is partial atelectasis involving the lower lobes\n bilaterally as well as bilateral pulmonary vascular congestion. The tip of\n the ET tube is about 3.5 cm above the carina and is unchanged since the prior\n study. An NG tube is also in place; its tip is not included on the film.\n There is an area of segmental atelectasis in the medial aspect of the right\n upper lobe. Bilateral lower lobes partial atelectasis appears to be slightly\n better at this time.\n\n IMPRESSION:\n\n Interval removal of the left chest tube.\n\n Partial reexpansion of the lower lobes.\n\n Bilateral pulmonary edema, unchanged.\n\n Continued\n application of the ET tube and NG tube, unchanged in position.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 851628,
"text": " 1:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Locate tubes and lines.\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess\n REASON FOR THIS EXAMINATION:\n Locate tubes and lines.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 25-year-old female status post drainage of neck and chest\n abscesses. Locate tubes and lines.\n\n There are no prior studies for comparison.\n\n SINGLE AP VIEW OF THE CHEST: The endotracheal tube is seen terminating within\n the trachea, approximately 2 cm superior to the carina. Additionally, left\n chest tube is seen extending with the tip in the left thoracic apex. Two\n radiopaque densities are seen extending from the sixth and seventh ribs on the\n left, and at the left thoracic inlet. These possibly represent drainage\n tubes, or overlying packing material. Clinical correlation is recommended.\n Cardiac silhouette, hilar and mediastinal contours are normal in size.\n Pulmonary vasculature is normal. Bilateral lungs are clear. There is no\n evidence of infiltrates, or effusions bilaterally. The surrounding soft\n tissue and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1) Endotracheal tube, and left chest tube in good position.\n\n 2) Radiopaque densities overlying the left medial thoracic inlet, and the\n left mid thorax between the sixth and seventh rib, possibly representing\n packing material. Correlate clinically.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853785,
"text": " 3:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate placement of new endotracheal tube and r/o pneumoni\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p\n chest tube removal, and now s/p failed extubation and reintubation.\n REASON FOR THIS EXAMINATION:\n evaluate placement of new endotracheal tube and r/o pneumonia, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable chest , compared to previous study of .\n\n CLINICAL INDICATION: Evaluate placement of new endotracheal tube.\n\n An endotracheal tube has been either replaced or repositioned in the interval.\n It now terminates approximately 2 cm above the carina. There has been\n interval development of complete collapse of the left lung. There is an\n associated abrupt cut-off of the left main stem bronchus suggesting central\n mucous plugging. Within the right lung, note is made of a small to moderate\n pleural effusion. Moderate gastric distention is seen in the imaged portion\n of the upper abdomen. Surgical clips overlie the chest wall.\n\n IMPRESSION:\n\n Complete collapse of the left lung, which appears to be due to central mucous\n plugging.\n\n Persistent right pleural effusion.\n\n Relatively proximal location of endotracheal tube, terminating 2 cm above the\n carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 851782,
"text": " 10:44 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p mediastinal excision, r/o pneumo\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess\n\n REASON FOR THIS EXAMINATION:\n s/p mediastinal excision, r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n\n CLINICAL HISTORY: A 25-year-old woman status post drainage of neck and chest\n abscess.\n\n The endotracheal tube now lies 3.8 cm from the carina angle in a satisfactory\n position. The position of the chest tube is unchanged. The right chest\n remains clear. Some opacification is now present within the left lung field\n which was not seen on the prior film and the medial aspect of the left\n hemidiaphragm is obscured suggesting an infiltrate in the retrocardiac area as\n well. A left-sided pneumonia, therefore, may be present.\n\n Additionally, some subcutaneous emphysema is present on both sides of the\n neck.\n\n IMPRESSION:\n\n Probable left-sided pneumonia, new subcutaneous emphysema in lower neck.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-07 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 852320,
"text": " 3:57 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: S/P DEBRIDEMENT W/ WORSENING SEPTIC PICTURE\n Admitting Diagnosis: NECROTIZING FASCIITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman w/ severe nec fasc. of the neck and mediastinum w/ hx of\n severe pancreatitis sp debridement w/ worsening septic picture.\n REASON FOR THIS EXAMINATION:\n r/o new infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 25-year-old female with severe necrotizing fasciitis of the\n mediastinum with history of severe pancreatitis and worsening sepsis.\n\n TECHNIQUE: Axial CT imaging of the chest after the intravenous administration\n of 100 ml of Optiray. Nonionic contrast was used due to patient debility.\n\n COMPARISON: Comparison is made to a contrast CT of the chest from .\n\n FINDINGS:\n\n An endotracheal tube terminates in somewhat low position with the distal tip\n approaching the right main stem bronchus. An NG tube passes into the stomach.\n A surgical drain is in place in the anterior mediastinum posterior to the\n sternum. Bilateral pleural effusions are moderate in size and associated\n compressive atelectasis are identified. The remainder of the visualized lungs\n clear.\n\n There has been extensive resection of the soft tissues of the anterior chest\n wall and anterior neck. Air and fluid is seen in the post-pectoral region\n bilaterally. Air and fluid is also seen in the anterior mediastinum posterior\n to the sternum. Overall, the amount of fluid in the anterior mediastinum has\n decreased when compared to . The areas of air and fluid in the\n anterior chest wall soft tissues appear to be in communication with the\n patient's surgical resection site.\n\n There is diffuse edema within the soft tissues.\n\n Limited views of the liver and spleen are within normal limits. The adrenal\n gland is within normal limits. There is a possible nonobstructing stone\n within the posterior left kidney. There is extensive stranding in the\n pancreas with dilatation of the pancreatic duct as seen on the prior abdominal\n CT.\n\n Bone windows show no definite evidence of bone destruction.\n\n IMPRESSION:\n\n 1. Extensive post-surgical changes within the neck, anterior mediastinum, and\n anterior chest wall with areas of air and fluid within the debridement site.\n (Over)\n\n 3:57 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: S/P DEBRIDEMENT W/ WORSENING SEPTIC PICTURE\n Admitting Diagnosis: NECROTIZING FASCIITIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Bilateral pleural effusions with associated atelectasis.\n\n 3. Extensive peripancreatic fat stranding with dilatation of the pancreatic\n duct as described on the abdominal CT of .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-20 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 853643,
"text": " 1:21 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: feeding tube post p.\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with\n REASON FOR THIS EXAMINATION:\n feeding tube post p.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Placement of postpyloric feeding tube.\n\n COMPARISON: None.\n\n TECHNIQUE: A 12-French enteric feeding tube was advanced through the\n esophagus into the stomach under fluoroscopic imaging guidance. We are unable\n to advance the tip of the tube beyond the pylorus. The tip remains positioned\n within the stomach, with confirmation of position via injection of 10 mL of\n water- soluble contrast.\n\n Results were conveyed to Dr. at 2:05 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-08 00:00:00.000",
"description": "P PLEURAL ASP BY RADIOLOGIST PORT",
"row_id": 852430,
"text": " 6:01 PM\n PLEURAL ASP BY RADIOLOGIST PORT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n Reason: pleural effusion, please send samples for WBC, prot, glucose\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with necrotizing faciitis, s/p I&D nsck and midiasternum\n REASON FOR THIS EXAMINATION:\n pleural effusion, please send samples for WBC, prot, glucose, GS, and culture\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Ultrasound guided thoracocentesis.\n\n INDICATION: Patient with necrotizing fasciitis. Effusions present on CT\n scan. For sampling to rule out infection.\n\n TECHNIQUE: Informed consent was obtained from the patient's mother via\n telephone. This was witnessed by the staff nurse care. The\n patient was placed in a right decubitus position. Son was performed at\n the bedside to identify a suitable spot for thoracocentesis. After this, and\n after performing a pre-procedural timeout to confirm patient identity and\n indication for examination, the patient was cleansed and draped in a standard\n fashion. Local anesthetic was infiltrated into the spot that had been\n identified, and the needle was advanced into the collection. Despite\n multiple attempts at sampling the collection, and despite definitive\n visualization that the needle was in the collection on , only 2\n ml of clear fluid were aspirated and sent for Gram stain and culture. Patient\n tolerated the procedure well and there were no immediate complications.\n\n CONCLUSION:\n\n Technically difficult and limited bedside thoracocentesis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854047,
"text": " 9:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p mucous plug removal. fever o/n\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p\n chest tube removal, and now s/p failed extubation and reintubation.\n REASON FOR THIS EXAMINATION:\n s/p mucous plug removal. fever o/n\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest.\n\n COMPARISON: Compared to .\n\n CLINICAL INDICATION: Fever.\n\n FINDINGS:\n\n An endotracheal tube has been slightly withdrawn in the interval, now\n terminating about 5.5 cm above the carina. A right PICC line and a feeding\n tube remain in place. Cardiac and mediastinal contours are normal. Again,\n demonstrated are bilateral pleural effusions, partially layering on this semi\n erect study, right greater than left. No new areas of consolidations are seen\n within the lungs to suggest an area of pneumonia.\n\n IMPRESSION:\n\n Persistent bilateral pleural effusions, right greater than left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852267,
"text": " 9:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: asses for chest tube pull\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess\n\n REASON FOR THIS EXAMINATION:\n asses for chest tube pull\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Neck and chest abscess drainages.\n\n FINDINGS:\n\n Comparisons made to a previous study from .\n\n A left-sided chest tube terminates within the left lung apex. An endotracheal\n tube terminates at the thoracic inlet. An NG tube passes into the distal\n stomach. A radiopaque opacity overlies the central upper mediastinum that\n could represent a surgical drain. Diffuse subcutaneous emphysema is seen.\n Bilateral pleural effusions are identified. No pneumothorax is seen. There\n is slight prominence of the pulmonary vasculature with interstitial opacities\n suggestive of mild pulmonary edema. There is unchanged left lower lobe\n opacity representative of atelectasis or pneumonia.\n\n IMPRESSION:\n\n 1) Stable exam when compared to the previous day with lines and tubes in\n stable position. A radiopacity overlies the central upper mediastinum, which\n could represent a surgical drain; however, clinical correlation should be\n performed to exclude a retained foreign body.\n\n 2) Stable bilateral pleural effusions, pulmonary edema, subcutaneous gas, and\n opacity within the left lower lobe suggestive of atelectasis versus pneumonia.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-12 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 852737,
"text": " 9:48 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with LUE > RUE\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient post-op with necrotizing fasciitis. Now left upper\n extremity swelling.\n\n TECHNIQUE: scale, color flow and pulse-wave Doppler analysis of the deep\n veins of the left upper extremity was performed. Dynamic compression maneuvers\n were performed where appropriate.\n\n COMPARISON: No study is available for comparison.\n\n REPORT: Because of the patient's extensive debridement, the interrogation of\n the left axillary region was difficult. The left internal jugular vein,\n subclavian vein, brachial, and basilic veins were all identified and are\n patent with normal compressibility, augmentation and respiratory variation\n where appropriate. Limited views of the left axillary vein also appear to be\n normal. Cephalic vein is patent.\n\n CONCLUSION:\n Technically slightly limited examination, but no evidence of left sided deep\n venous thrombosis is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-25 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 854262,
"text": " 9:37 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: replacement of tube feeding\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with\n\n REASON FOR THIS EXAMINATION:\n replacement of tube feeding\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Feeding tube placement.\n\n The feeding tube is coiled in the body of the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852113,
"text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: increased coarse breath sounds\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess\n\n REASON FOR THIS EXAMINATION:\n increased coarse breath sounds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 25 year old woman with status post drainage of neck and chest\n abscess.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the prior chest radiograph dated .\n\n FINDINGS: The patient is status post intubation, with tracheostomy\n tube and left-sided chest tube unchanged compared to the prior study.\n Nasogastric tube is coursing down below the left hemidiaphragm. Again note is\n made of massive subcutaneous emphysema. The heart is normal in size. The\n mediastinal and hilar contours are unchanged compared to the prior study.\n Again note is made of bilateral pleural effusions, associated with bibasilar\n atelectasis. Opacity in the left lower lobe is again noted, representing\n pneumonia vs. atelectasis. Mild congestive heart failure is again noted.\n\n IMPRESSION: Tubes and lines as described above. Extensive subcutaneous\n emphysema. Bilateral pleural effusions and atelectasis. Left lower lobe\n opacity, representing either atelectasis vs. pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 852438,
"text": " 8:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o pneumothx\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p chest\n tube removal\n REASON FOR THIS EXAMINATION:\n r/o pneumothx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 24-year-old with drainage of the neck abscess.\n\n This study was obtained at 20:27 hours. Comparison is made to the prior study\n of the same day at 13:57 hours. Since the prior study, there has been partial\n withdrawal of the ET tube. The left upper lobe has reexpanded. The left\n lower lobe remains atelectatic. There is also partial atelectasis involving\n the right lower lobe. No evidence of pneumothorax. There is an NG tube in\n place. The tip is in the distal gastric antrum.\n\n IMPRESSION:\n\n Repositioning of the endotracheal tube. The tip is about 3 cm above the\n carina. Bilateral lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 853630,
"text": " 10:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PICC placement\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess, s/p\n chest tube removal\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 25-year-old female status post drainage of neck and chest\n abscess. The patient is status post chest tube removal and PICC line\n placement. Evaluate.\n\n Comparison is made with a prior supine portable chest x-ray dated .\n\n AP SEMI-UPRIGHT PORTABLE CHEST X-RAY: The right-sided PICC line is seen\n terminating with the tip in good position in the mid-superior vena cava. An\n endotracheal tube is seen approximately 1 cm superior to the carina.\n Retraction is recommended. Nasogastric tube is seen descending below the\n diaphragm with the tip not seen. The cardiac silhouette is normal in size.\n The mediastinal and hilar contours are normal. When compared with the prior\n examination, there is improved aeration of bilateral lungs with interval\n resolution of bibasilar atelectasis. No pleural effusions are seen\n bilaterally. The surrounding soft tissue and osseous structures again reveal\n multiple skin staples overlying the upper thorax consistent with the patient's\n history of cyst drainage.\n\n IMPRESSION:\n 1. Right-sided PICC line in good position with tip in mid-superior vena cava.\n 2. Endotracheal tube approximately 1 cm superior to the carina. Retraction\n by 1 to 2 cm is recommended. This finding was called to the nurse taking care\n of the patient at 12:10 p.m. on .\n 3. Interval resolution of bibasilar atelectasis from prior chest x-ray on\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-25 00:00:00.000",
"description": "P PORTABLE ABDOMEN PORT",
"row_id": 854259,
"text": " 8:28 PM\n PORTABLE ABDOMEN PORT Clip # \n Reason: DUBHUFF\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with\n REASON FOR THIS EXAMINATION:\n DUBHUFF\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Feeding tube placement.\n\n Distal end of feeding tube is in distal esophagus and requires advancement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-04 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 851927,
"text": " 9:30 PM\n PORTABLE ABDOMEN Clip # \n Reason: s/p ngt\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p drainage of neck and chest abscess\n\n REASON FOR THIS EXAMINATION:\n s/p ngt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post neck and chest abscess drainage. NG tube placed.\n Check status.\n\n FINDINGS:\n\n A single AP supine image of the lower thorax and upper abdomen is provided.\n The new NG line tip is well positioned in the distal portion of the stomach.\n The left chest tube remains in good position. The heart shows slight LV\n enlargement. There is no evidence of collapse/consolidation of the left lower\n lobe behind the heart. Some patchy atelectasis is also noted in the lingula.\n Slight blunting of the left costophrenic angle suggests a small associated\n effusion. The upper thorax is not displayed on this examination.\n\n IMPRESSION:\n\n 1). Satisfactory placement of new NG line.\n\n 2). Persistent left lower lobe collapse/consolidation.\n\n 3). Some bibasilar atelectasis and a small left effusion noted.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-03 00:00:00.000",
"description": "PERC PLCMT GASTROMY TUBE",
"row_id": 855102,
"text": " 6:32 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: 25 YEAR OLD WOMAN WITH NECR FASC OF NECK STSG TO NECK\n Admitting Diagnosis: NECROTIZING FASCIITIS\n Contrast: CONRAY Amt: 10\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF EXAM: .\n\n HISTORY: 25 year old woman with necrotizing fasciitis and failed swallow\n study requiring G tube for long-term feeding access.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and who\n was present and supervising throughout. After informed consent was obtained,\n the patient's abdomen was prepped and draped in standard sterile fashion.\n Under fluoroscopic guidance the patient's Dobbhoff tube was withdrawn into the\n stomach. Air was insufflated through the Dobbhoff tube. The image\n intensifier was obliqued to confirm that the stomach was adjacent to the\n anterior abdominal wall and that there was no intervening bowel. 1% lidocaine\n was then introduced at the designated skin site. An 11 blade scalpel was used\n to make a small incision. The stomach was then percutaneously accessed with a\n 18 gauge sheathed needle. An Amplatz wire was advanced into the stomach. The\n tract was progressively dilated with 8, 10, and 12 French dilators. A 12\n French Wills- feeding tube was then advanced over the wire into the\n stomach. The wire and dilator were removed. The pigtail was formed and locked\n within the stomach. 10 cc of Conray were then injected through the tube\n demonstrating appropriate position of the tube within the stomach. The tube\n was then secured with an 0 Prolene suture and statlock. The patient tolerated\n the procedure well and there were no immediate post procedure complications.\n\n IMPRESSION: Successful placement of 12 French Wills- gastrostomy tube.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-28 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 854592,
"text": " 11:09 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: dobhoff placement\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with s/p I&D neck\n\n REASON FOR THIS EXAMINATION:\n dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post I&D of the neck, please place feeding tube.\n\n PROCEDURE: Under fluoroscopic guidance, a 12 French feeding\n tube was advanced into the proximal jejunum. Approximately 10 cc of contrast\n was administered to confirm proper positioning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-02-28 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 854587,
"text": " 10:43 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: swallowing function, coughing with clears\n Admitting Diagnosis: NECROTIZING FASCIITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old woman with cervical cellulitis, s/p debridement and STSG, Now\n extubated after prolonged intubation.\n REASON FOR THIS EXAMINATION:\n swallowing function, coughing with clears\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cervical cellulitis, status post debridement. Now extubated\n after prolonged intubation. Evaluate swallowing function.\n\n VIDEO OROPHARYNGEAL SWALLOW: A limited study was performed, consisting of two\n swallows of nectar consistency. There was severe aspiration due to premature\n spillover from the oral cavity. A diminished epiglottic deflection and\n laryngeal elevation was demonstrated. There was improvement with the chin\n tuck maneuver. However, secretions were noted to spill over to the level of\n the vocal cords from the piriform sinuses.\n\n IMPRESSION:\n\n Swallowing abnormalities as described. Aspiration of nectar consistency.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-21 00:00:00.000",
"description": "Report",
"row_id": 161963,
"text": "Sinus rhythm\nNonspecific ST-T wave changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-19 00:00:00.000",
"description": "Report",
"row_id": 161964,
"text": "Sinus rhythm. Low limb lead voltage. Diffuse non-specific ST-T wave flattening.\nQ-T interval prolongation. Compared to the previous tracing of the\nQ-T interval is prolonged, there is ST-T wave flattening and the rate has\nslowed. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-02-02 00:00:00.000",
"description": "Report",
"row_id": 161965,
"text": "Sinus rhythm\nModest inferior T wave changes - are nonspecific and tracing may be within\nnormal limits\nNo previous tracing for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-18 00:00:00.000",
"description": "Report",
"row_id": 1297481,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: SEDATED ON FENT AND ATIVAN GTTS. OPENS EYES TO NAME AND STIMULI, INTERMITTENTLY FOLLOWS COMMANDS. MAE WITH EQUAL STRENGTH\nCV: T MAX 100.5 BUT BAIR HUGGER HAD BEEN ON- NOW 99.5. TACHYCARDIC TO 150- DR NOTIFIED, BP STABLE AT THIS TIME. PT AWAKE AND ANXIOUS. FENT GTT INCREASED TO 450 AND ATIVAN GTT TO 4.5 WITH SUBSEQUENT DECREASE IN HR TO 80-100.\nRESP: NO VENT CHANGES, BS DIMINISHED IN BASES OTHERWISE CLEAR. SX FOR SCANT AMT THIN WHITE SECRETIONS\nGI: ABD SOFT AND NON-TENDER WITH + BS. TF RESTARTED ANDS SLOWLY ADVANCED TO 20CC BUT RESIDUAL AFTER 4 HRS WAS 150, NOW ON HOLD\nGU: ADEQUATE AMTS CLEAR YELLOW\nWOUND: VAC DRESSING INTACT ON CHEST. LEFT THIGH DRESSING HAS MOD AMT SEROSANG STAINING\nENDO: PT REMAINS OFF INSULIN GTT. LAST BS 128- TX'D WITH 2 UNITS REGULAR INSULIN\nA: HEMODYNAMICS AND RESP PARAMETERS MONITORED, SX PRN, ATIVAN AND FENT GTTS FOR SEDATION/PAIN CONTROL\nR: STABLE POST-OP, CONTINUE PRESENT PLAN OF CARE, WEAN SEDATION AS TOL, VAC DRESSING TO BE CHANGED BY TEAM ON FRIDAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-18 00:00:00.000",
"description": "Report",
"row_id": 1297482,
"text": "RESPIRATORY CARE\nPT stable and remains on the ventilator. Pt put on cpap trials, PT failed due to hypoventilation related to an increase in sedation meds. Plan to continue to wean to extubate as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-18 00:00:00.000",
"description": "Report",
"row_id": 1297483,
"text": "STATUS\nD:AGITATED PULLING ON LINES & VAC DSG..NOT FOLLOWING COMMANDS..REMAINS ON ATIVAN & FENTANYL GTT'S WITH ONLY MIN SEDATIVE EFFECT\nA: STARTED ON PRN IV HALDOL..MUCH MORE COMF NOW LETHARGIC BUT EASILY AROUSED..ATIVAN DECREASED TO 4MGM..ALSO STARTED ON CLONIDINE & METHADONE TO HELP WITH WEANING OF NARCOTICS..VENT WEANED TO C-PAP WITH GOOD SAT'S BUT RESP RATE <12 SO PLACED BACK ON IMV..OOZING MOD AMT SEROUS FROM GRAFT SITE..VAC DSG DRAINING SM AMT SEROUS SANG..TF'S ON HOLD DUE TO HIGH RESIDUALS..STARTED ON REGLAN..FIB INTACT WITH SM AMT BROWN STOOL..GOOD HUO'S\nR: IMPROVED SEDATION WITH HALDOL\nP: WEAN ATIVAN & FENTANYL AS TOL..WEAN VENT AS TOL\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-19 00:00:00.000",
"description": "Report",
"row_id": 1297484,
"text": "POD#2 STSG CHEST\nSEE FLOW SHEETS FOR SPECIFICS\nNEURO:PT RESPONDS TO COMMAND SOMETIMES, PURPOSEFUL MOVEMENTS, SEDATED ON FENTYNAL 400MCG AND ATIVAN 4MG IV.\nCV:PT HYPOTENSIVE SBP 88/29. TF OFF DUE TO HIGH RESIDUALS NO MAINTAINENCE IV. 250ML NS BOLUS GIVEN X2 WITH RETURN OF SBP TO BASELINE 90-100. PT BECAME BRADYCARDIC HR 50'S. EKG DONE QTC PROLONGED (THOUGHT TO BE DO TO HALDOL AND METHADONE WHICH WAS STARTED . PLAN:MONITOR QTC NOTIFY H.O. IF QTC PROLONGS FURTHER, USE HALDOL SPARINGLY. CONTINUE NS WITH 20MEQ KCL AT 100ML/HR UNTIL TF RESTARTED.\nPULM:INTUBATED ON VENT O2SATS STABLE. NO ALINE,PLACEMENT ATTEMPTED BY DR W/O SUCCESS. PLAN WEAN TO CPAP AND PRESSURE SUPPORT. FOLLOW SATS.\nGI:TF RESTARTED AT 0100 RESIDUALS MINIMAL. ADB SOFT, BS PRESENT. NO STOOL OTHER THAN WHAT WAS IN FECAL BAG,LIQUID BROWN SCANT AMOUNT. PLAN: INCREASE TF AS ORDERED UNTIL AT GOAL 75ML/HR.\nGU:U/O ADEQUATE.\nFAMILY SUPPORT: BOYFRIEND '' CALLED X2. PT TOLD CALLED.\nPLAN:PROVIDE INFORMATION TO PT'S BOYFRIEND, GIVE EMOTIONAL SUPPORT TO PT AND BOYFRIEND \n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-19 00:00:00.000",
"description": "Report",
"row_id": 1297485,
"text": "STATUS\nD: CALMER TODAY..LETHARGIC BUT EASILY AROUSED..REMAINS ON ATIVAN & FENTANYL GTT'S WITH PRN HALDOL..NEURO UNCHANGED\nA: ATIVAN & FENTANYL GTT DECREASED 3MGM & 350MCG RESPECTIVELY..VENT WEANED TO C-PAP WITH 12 IPS..TOL WELL..SUCTIONED FOR SM AMT THICK WHITE/TAN..VAC DSG INTACT WITH MIN SS DRAINAGE..LF THIGH GRAFT SITE DRAINING SM AMT SEROUS SANG..TF'D BEING INCREASED 10CC Q4H TO GOAL OF 75CC WITH MIN RESIDUALS..MIN LOOSE BROWN STOOL FIB INTACT..GOOD HUO'S\nR: IMPROVING MENTAL & PULMONARY STATUS\nP: CONTINUE WITH PRN HALDOL AT LOWER DOSE & WEAN ATIVAN & FENTANYL PER HO\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-20 00:00:00.000",
"description": "Report",
"row_id": 1297486,
"text": "Nursing note:\nNEURO: Sedated on Ativan 3mg/hr and Fentanyl 350mcg/hr. PRN Haldol given w/excellent effect on generalized restlessness. Opens eyes to voice, MAE, does not follow commands. Grimaces to pain at times. Pupils unequal @ baseline.\nRESP: Lung sounds clear, dim to bases. No vent changes, tolerating CPAP overnight. No aline in place for ABGs. Sats stable, RR stable. Suctioned occ. for thick oral secretions.\nCV: SB-SR in 50s-60s, no ectopy. Afebrile. CVP 6-12. Palpable pulses bilaterally, skin pale, warm and dry.\nGI: Abdomen soft, +BS, FIB in place for small amount dark liquid stool. High residuals of TF aspirated, so decreased and then held x2 hours; restarted @ 20cc/hr, will continue to follow residuals.\nGU: Foley patent adequate amount clear yellow urine.\nENDO: Glucose stable, SSRI PRN.\nSKIN: Vac dressing intact to chest. STSG site to L. thigh intact w/Vaseline gauze to cover, area clean, skin raw appering. Duoderm to R. foot, no other areas of breakdown noted.\n\nA/P: Stable, tolerating CPAP overnight. Comfortable on Haldol/Ativan/Fentanyl. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-20 00:00:00.000",
"description": "Report",
"row_id": 1297487,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV support throughout the night with no parameter changes. No morning abg results this am.\n\nRSBI = 75.7 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-20 00:00:00.000",
"description": "Report",
"row_id": 1297488,
"text": "FOCUS: CONDITION UPDATE\nD: SEE ICU ASSESSMENT SHEET FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENTS.\nREMAINS SEDATED ON FENATNYL/ATIVAN, SLOWLY WEANING. TO NAME, MOVES ALL EXTREMITIES, DOESN'T FOLLOW COMMANDS. PUPILS REACTIVE, RIGHT BIGGER THAN LEFT, YET REACTS TO LIGHT.\nRIGHT ARM PICC PLACED BY IV, +PLACEMENT PER CXRAY, FEM. MULTILUMEN DC/D, TIP SENT FOR CULTURE.\nWENT TO FLURO TO PASS POST PYLORIC FEEDING TUBE, UNABLE TO PASS PAST PYLORIS IN RADIOLOGY, LEFT IN STOMACH.\nON CPAP MOST OF THE DAY, DID TIRE LATER IN AFTERNOON, WITH DECREASEING RESP. RATE AND PERIODS OF APENA, PLACED BACK ON RATE, WILL REST OVERNIGHT AND TRY ON CPAP IN AM.\nRECEIVED LASIX 10 MG ONCE, WITH GOOD DIURESIS, K REPLACED ONCE.\nMOTHER AND BOY FRIEND .\nP: CONTINUE WITH SLOW WEAN OF FENT/ATIVAN, GIVE HALDOL AS NEEDED.\nMONITOR TUBE FEEDS/URINE OUTPUT.\nCALL HO WITH ANY CHANGES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-20 00:00:00.000",
"description": "Report",
"row_id": 1297489,
"text": "Respiratory Care\nPt remains on ventilatory support. PT went to fluro for picc line placement. PT too sedated for cpap/ps trials. MDIs given as ordered. Continue with vent settings and wean when pt more awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1297438,
"text": " Condition update\nPlease see carevue for specifics:\n\nPt vss with a tmax 100.1 axillary, requiring no treatments- hr 65-90 with PVC's on evening shift, returning to NSR without ectopy once electrolytes were repleated. sbp with MAP>60 throughotu noc and levophed gtt off at 0200 and pt maintaining adequate blood pressures. CVP 4-8 with poor tracing; foley draining 250-600 cc cyu/hr. pt nss- opening eyes to pain, mae to painful stimuli, +dp/pp, pupils equl and reactive wiht 2-3mm/2-3mm and sluggish (d/t ativan and fentanyl gtt's). Pt 's ativan gtt was increased d/t appearance of pain at rest with eye opening and movement of arms/legs- pain now under good control. LS coarse throughout requiring q 1-2 hour suctioning fo thick tan mucous plugs- pt was placed on humidified air by RT on evenings to help with suctioning, but pt still requires lavaging at times. ABG's wnl, and no changes made to vent, but pt did have an episode lasting 20 minutes where 02 sats dropped to 87-90% continuously, increased with 100% 02- pt had been rotating in bed, rotation stopped, and suctioned for large amolunts of mucous plugs, then 02 returned to 96-100% on .40 fi02; Ho made aware but ABG just previous was wnl, so no changes were made. CT to 20cm suction and draining scant amounts of sersang drainage- site cdi with dsd- no noted crepitus. abd +bs x 4 pvernoc- NGT placed to lcs for 2 gours to decompress stomach Before starting tubefeeds- 150cc bilious drainage out, and strangth impact with fiber was started at 10cc/hr- residuals ok, and will cont at 10cc/hr, per HO. Chest wound open- transparent dsg intact with reinforcements- oozing brown drainage around armpits and neck areas, needing chucks to help absorb drainage ad frequent changing. labs q 4 hours per HO (electrolytes, HCT, ABG's with lactate) and electrolytes have been replaced frequently (mg+ and K+), NA+ was 147 this am and slowly rising- HO aware, but no changes made at this time. Cont to monitor labs, vs, i/o's, ns, pain. Pt admin IVIG this evening to help boost antibodies- no reaction noted, and pt to receive 1 dose q day for 8 more days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1297477,
"text": "CONDITION UPDATE: SEE CAREVIEW FLOWSHEET FOR DETAILS\n\nNEURO: Neuro exam stable. Pt ,opens eyes spont, R pupil>L pupil both briskly reactive to light. +MAE. Pt sedated and cooperative most of day. Moves LLE less actively than R but withdraws briskly bilat.\n\nCV: T max 99.7 po. NSR with occasional ST. Monitoring NBP. BP 88-105 syst/33-43 diast with MAP > 55 most of day. Hypotensive at 1800. MAP 50. Fent gtt decreased to 350 mcg/hr, Ativan gtt decreased to 3 mg/hr. Pt crossmatched for 2 units blood for OR tomorrow.\n\nRESP: Lung sounds course throughout and diminished LLL. Suctioned for mod amts thick white sputum. ETT rotated to R side. 02 sats 97-100%. No vent changes, cont on SIMV.\n\nGI: ABd soft non-dist. +brown loose stool via fecal bag. TF impact with fiber at 75cc/hr. Last residual 75 cc at 1600. Plan to stop TF at MN for NPO status for OR.\n\nGU: Clear lt yell urine output 85-280cc/hr.\n\nENDOCRINE: Insulin gtt at 0.5 units/hr all day. Fs glucose 123-138.\n\nSKIN: Sternal/neck wound with VAC dsg intact draining scant serosang. L thoracotomy site healing, old suture removed.\n\nA: Stable, sedated, hypotensive\n\nPLAN: OR tomorrow for STSG to neck from ?Right thigh. Mother and boyfriend aware of OR plan. Stop TF at MN ?IV fluids ?d/c insulin gtt.\nTelephone consent witnessed by SICU nurse.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-17 00:00:00.000",
"description": "Report",
"row_id": 1297478,
"text": "NEURO: INTACT, UNABLE TO ASSESS ORIENTATION. REMAINS ON FENTANYL AND ATIVAN DRIPS FOR PAIN CONTROL.\nCV: SEE FLOW SHEET FOR DETAILS. BP LOW WHEN SLEEPING. TX WITH BOLUS 500 CC NS X 1 WITH IMPROVEMENT.\nPULM: BS COARSE TO RHONCHOROUS. SX FOR THICK WHITE\nGI: TF AT 75/HR, TOL WELL. NPO AFTER MN FOR OR TODAY. IV AT 80/HR FOR HYDRATION.\nGU: U/O QS VIA FOLEY\nLABS: ELECTROLYTES REPLETED.\nWOUND: VAC DSG INTACT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-17 00:00:00.000",
"description": "Report",
"row_id": 1297479,
"text": "status\nD: EASILY AROUSED AGITATED AT TIMES PICKING AT LINES & CHEST VAC DSG REMAINS ON FENTANYL,INSULIN & ATIVAN GTT'S\nA: ATIVAN GTT INCREASED TO 4MGM FENT GTT 'S 100 INSULIN GTT DC'D..TO O.R. @ 1330 FOR SKIN GRAFT..RETURNED @ 1545 REVERSED LETHARGIC BUT EASILY AROUSED..HYPOTHERMIC PLACED ON HUGGER..CHEST VAC DSG & LF THIGH GRAFT SITE DSG INTACT..RESTARTED ON FENT & ATIVAN GTT'S..CONTINUES TO BE 80/S INITIALLY BUT UP AFTER SHORT TIME..TF'S CHANGED..GOOD HUO'S\nR: STABLE\nP: MONITOR VS CLOSELY.. HUGGAR AS NEEDED..INCREASE TF'S TO GOAL CONINUE WITH MEDS FOR SEDATION\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-17 00:00:00.000",
"description": "Report",
"row_id": 1297480,
"text": "Respiratory Care Note:\n Patient s/p OR today for placement of a skin graft to neck and chest. She appears comfortable with stable vital signs on previous vent settings. She does not have an arterial line. Suctioned for small amount of thick whitish sputum. She received on round of albuterol MDI this am. She is sedated on fentanyl and ativan. Plan to maintain support and continue monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1297439,
"text": "RESP CARE: Pt remains nasally intubated/sedated/on vent on AC 500/16/.40/5 PEEP. Sxd earlier in shift for thick plugs/Heated circuit placed on vent. Bilat wheezes noted at that time and ALB mdi started with good effect noted. Presently lungs are coarse RLL, Dim LLL with wheeze noted. No vent changes this shift. Continue supportive care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1297440,
"text": "respiratory care\npt remains stable and on vent. plan to cont. on vent\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-06 00:00:00.000",
"description": "Report",
"row_id": 1297441,
"text": "NEURO; PUPILS FREQUENTLY SLUGGISH BUT REACTIVE, WITHDRAWS LOWER EXTREMITIES TO NAILBED PRESSURE, BUT NOT UPPER EXTREMITIES UNTIL THIS PM AFTER FENT AND ATIVAN RATE DECREASED SECONDARY TO HYPOTENSION, PT THEN ABLE TO MOVE BOTH ARMS UP TOWARD CHEST WHILE BEING SUCTIONED AND OPENED EYES BRIEFLY, OTHERWISE DOES NOT OPEN EYES TO VOICE OR STIMULATION, POSITIVE GAG, MAE, REMAINS ON ATIVAN AND FENTANYL GTTS\n\nCARDIOVASCULAR; TEMP MAX 101.2 AX, MEDIC PRN WITH TYLENOL, CVP- POOR WAVEFORM, VIA FEMORAL LINE, ? ACCURACY, TACHYCARDIC EPISODE WITH HYPOTENSION THIS AM, HR UKP TO 128 AND SYS DOWN TO 77, GIVEN FLUID BOLUS OF 1 LITER LR AND LEVO RESTARTED, SECOND TRANSIENT EPISODE OF HYOTENSION THIS PM WITHOUT TACHYCARDIA, BRIEF FLUID BOLUS AND LEVO INCREASED, PRESENTLY AT 0.056 MCG/KG/MIN, RECEIVING IGG PER PROTOCOL, CLOSE MONITORING FOR FURTHER HYPOTENSION OR ANAPHYLAXIS, GENERALIZED EDEMA, REMAINS SEVERAL LITERS POSITIVE\n\nRESPIR; SUCTIONED FOR THICK TAN SECRETIONS, SMALL AMTS, REMAINS ON CMV MODE, COARSE BREATH SOUNDS THROUGHOUT\n\nGI; TUBE FEEDS HELD FOR RESIDUAL OF 100CC/HR, SICU TEAM IN AND PT RESIDUAL CURRENTLY 80CC, TUBE FEEDS AT 20CC/HR\n\nWOUND; OPEN STERNOTOMY AND PACKING BY TRAUMA TEAM, WITH PROPOFOL BOLUS OF 20 MGM AND FENT BOLUSES, DSG WILL BE CHANGED AGAIN BY TEAM TONOC\n\nPLAN; MONITOR CLOSELY WITH IV IGG THERAPY, MONITOR FOR SX SEPSIS, ADMINISTER PAIN AND SEDATION AS REQUIRED, OPEN WOUND PRECAUTIONS\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 1297442,
"text": "FOCUS: CONDITION UPDATE\nD: SEE ICU FLOW SHEET FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENTS.\nPATIENT REMAINS SEDATED, FENTANYL WEANED TO 300, LEVO WEANED TO OFF FOR A SHORT PERIOD OF TIME, YET PATIENT SEEMS TO NEED A LITTLE \"SQUEEZE\" PROVIDED BY LEVO TO KEEP MAP>60. FEBRILE, T101.7--TYLENOL GIVEN.\nAROUSABLE TO PAIN, OPENS EYES AND MOVES ALL FOUR EXTREMITIES WHEN TURNED. DRESSING LEAKING MUCH LESS THAT 2 DAYS AGO.\nTOLERATING TUBE FEEDS, ADVANCING AS ORDERED.\nR: STABLE, SITLL WITH A SMALL PRESSOR REQUIREMENT.\nP: CONTINUE TO CLOSELY MONITOR, KEEP MAP>60, CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-05 00:00:00.000",
"description": "Report",
"row_id": 1297436,
"text": " Condition Update\nPlease see carevue for specifics:\n\nPt vss with hr 70-90's NSR with a 5 beat run of vtach at 0200, resolving on own and maintaining map>60 with levophed gtt on/off .010 to .030 mcg/kg/min. Pt spkied temp to 101.3 axillary at 0400- pt was pan cultured and tylenol 650mg admin pr. pt kep t sedated all noc on ativan gtt at 4mg/hr and fentanyl at 400mcg/hr- at beginning of shift pt appeared agitated and was blinking rapidly and moving extremities- especially during family visits, and ativan/fent were titrated to keep pt sedated.. Neuro signs stable- pupils equall and sluggishly , to painful stimuli, but pt completely seated, so no eye opening and LOC unclear.+dp/pp. LS clear at beginning of shift and became coarse overthe evening and reamined so- suctioning large amounts of thick bloody secretions from lungs; No vent changes overnoc and ABG's wnl. 02 sats 92-95%. most likely d/t ventilating pt with same settings and pt is no longer paralyzed. Chest tube in place- dressing CDI with no crepitus noted- fluctuating and draining moderate amounts of straw colored drainage at 20 son of suction- cont to monitor. Abd with hypoactive BS- NGT placed in left nare this evening to start tubefeeds in am (placement checked by xray and manually). foley draining large amounts oof cyu q hour- cvp 11-17 (not accurate d/t groin line). electrolytes replaced on evenings. Pt with drop foot on right foot (previous to this admission). many family issues- social work needs to be consulted for family dynamics and setting limits as far as information. Cont to monitor labs, vs, ns, pain, i/o's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-26 00:00:00.000",
"description": "Report",
"row_id": 1297508,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt much more today than yesterday. Ox3. Follows commands and MAE. Anxious @ times, but no lorazepam/haloperidol needed. R>L pupil (bilat briskly reactive to light). Pt able to make needs known; very weak/soft voice post extubation.\n Pt extubated @ 1200. O2 sat and RR WNL on 40% face mask. No c/o SOB. ABG post extubation showed slight metabolic alkalosis. Freq suction for thick, white secretions. Pt w/ strong cough and able to expectorate phlegm. -trach sxn x1 performed. Lung sounds rhonchi immediately after extubated, but clearer in afternoon. Lung bases diminished.\n Tmax 100. HR 70-90s (NSR), but increases 120-140s w/ sxn and activity. ABP 130-140s/60-80s. +1 generalized edema. DP/PT pulses palpable. K 3.0 in AM; treated w/ total of 60meq KCl. Repeat K was 3.6; and another 20meq KCL given. Mg 1.3 in AM and was treated w/ 4grams magnesium sulfate. Repeat Mg 1.7 (treated w/ another 2grams mag sulfate).\n DSD to neck/sternum intact. Left upper thigh w/ Xeroform OTA; no drainage noted. Abdomen soft w/ +BS. TF via DHT @ 70cc/hr (goal 80). FIB intact; scant amount loose brown stool. FS q6hr w/ RISS. Foley intact w/ clear yellow urine; qs.\n Pt seen by PT/OT, but unable to get OOB d/t femoral A-line. Pt T&R in bed w/ 1 asssist. RN update pt's boyfriend and mother w/ plan of care. Boyfriend visited; mom called.\n : Continue to monitor VS, I's and O's. Monitor neuro/resp status. Notify HO w/ any changes. Replete lytes as needed. Update family w/ plan of care. Maintain skin integrity. Continue ICU care and treatments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-27 00:00:00.000",
"description": "Report",
"row_id": 1297509,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT , ORIENTED X 3, VOICE BECOMING STRONGER BY THE MORNING, MAE. PERRL\nRESP- LUNGS CLEAR WITH DIMINISHED BASES. TURNED SEVERAL TIMES FOR DEEP BREATHING, CHEST PT AND COUGHING. COUGH REMAINS WEAK AND PT NEEDS ENCOURAGEMENT TO RAISE SECRETIONS, USING YANKAUER. O2 SAT 100% ON 4L, NO SOB.\nCV- HR 60'S WITHOUT ECTOPY, NSR, RISING QUICKLY TO 130'S UPON EXERTION (SITTING UP IN BED).\nGI/GU- ABD SOFT, WANTING TO EAT/DRINK, TUBE FEEDS AT GOAL. UOP DIMINISHING OVERNIGHT, DISCUSSED GIVING LASIX, HOWEVER AFTER REPOSITIONING AND ADJUSTING CATHETER, UOP INCREASED. LASIX NOT GIVEN OVERNIGHT.\nID- TMAX 99.4\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-15 00:00:00.000",
"description": "Report",
"row_id": 1297471,
"text": "Addendum to NPN:\nPt's K and Mg repleted as ordered. ABG without significant changes; shows metabolic alkalosis: pH 7.46, PaCO2 43, PaO2 102, BE 5, bicarb 32. Plan is to take pt to OR on Monday for split thickness skin graft.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-15 00:00:00.000",
"description": "Report",
"row_id": 1297472,
"text": "Respiratory Care:\nPatient remains on SIMV ventilatory support with no parameter changes made throughout the night. Morning abg results are consistent with a partially compensated metabolic alkalemia with good oxygenation on the current settings (see CareVue).\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-15 00:00:00.000",
"description": "Report",
"row_id": 1297473,
"text": "CONDITION UPDATE: SEE CAREVIEW NOTES FOR SPECIFICS\n\nNEURO: PT SEDATED ON ATIVAN AND FENT GTT. AROUSES TO VOICE,OPENS EYES SPONT, OBEYS COMMANDS, MAE, PUPILS R>L 3MM/2MM BOTH BRISKLY REACTIVE TO LIGHT.\n\nCV: AFEBRILE,NSR/ST, GOAL TO KEEP MAP> 55. MAP 60'S. + PULSES. A-LINE DAMPENING. MED WITH PROPOFOL 40MG FOR ATTEMPTED NEW A-LINE PLACEMENT WITHOUT SUCCESS, A-LINE REWRAPPED ON ARMBOARD AND FLUSHED WITH IMPROVEMENT.\n\nRESP: CONTINUES ON SIMV WITH PS. ATTEMPTED CPAP WITH PS THIS AM. PT APNEIC RESUMED SIMV. LS COARSE THROUGHOUT. SXN FOR SM AMTS THICK WHITE. OLD CHEST TUBE SITE HEALING + SUTURE REMAINS, NO DRESSING.\n\nGI: ABD SOFT, NON-DIST. + BS. APPROX 200 CC LOOSE BROWN STOOL VIA FIC. BAG CHANGED X 1. TF AT 75CC/HR RESIDUALS 10-50CC.\n\nGU: U/O CL LT YELLOW 100-300 CC/HR.\n\nENDO: INSULIN GTT CURRENTLY AT 0.5 U/HR. FS 88-160.\n\nSKIN: VAC DSG AT 75MM HG INTACT DRAINING SEROSANG 150CC. COCCYX PINK. KCI TRIADYNE BED NOT FUNCTIONING WELL, SEAT DEFLATED. COMPANY REP OUT AND BED EXCHANGED.\n\nPLAN: CONT NEURO CHECKS, VAC DSG, ATIVAN AND FENT GTT,MONITOR FS/INSULIN GTT, TUBE FEEDS, ICU CARE, ?PLAN OR FOR STSG SUNDAY OR MONDAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1297474,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: No change in neuro exam (q2hr). MAE; follows commands. R>L pupil at times; bilat pupils briskly reactive to light. Increase agitation/restlessnes/anxiety ; Ativan gtt increased to 5mg/hr (Dr. notified and aware). Fentanyl increased to 325mcg/hr d/t pain (pt grimacing and frowning w/ activity). Bilat restraints on; pt attempts to pull at ETT, lines, drains (Dr. aware; restraint order obtained).\nCV: Afebrile; hr 60-90s (NSR). HR increases to 100-120s w/ T&R and activity, but then immediately returns to NSR once pt is settled. MAP maintained >55 (goal). A-line dampened (Dr. aware; unable to place new A-line during day shift). A-line needing freq flushes; NBP checked q1hr. CVP 10-17. 24hr net body balance: -1570cc. Trace generalized edema. DP/PT/radial/brachial pulses palpable.\nPulm: Lungs sound coarse bilat. Sxn for thick, clear/white secretions. No vent changes. Pt remains on SIMV w/ PS: 40%, Vt 0.5x14, PEEP5, PS 12. No shortness of breath noted. O2 sat WNL.\nGI: Abdomen soft w/ +BS. TF @ 75cc/hr (goal rate) via NGT. Flushes and residual checks q4hr as ordered. FIB intact w/ loose dark brown stool.\nEndo: Continue insulin gtt; fs q1hr.\nGU: Foley intact w/ large amount clear, light-yellow urine.\nInteg: VAC dsg to 75mmHg sxn intact w/ small amount serosanguinous drainage. Coccyx area pink; skin intact and no drainage noted. Left anterior chest (old chest tube site) w/ suture OTA; redness noted around area, but no drainage noted. Left posterior chest w/ DSD C/D/I.\nSocial: boyfriend called x2 (RN updated w/ plan of care).\nPlan: Cont to monitor VS, I's and O's. Titrate fentanyl/ativan gtt to sedation and for pain. Insulin gtt w/ fs q1hr. Keep MAP>55. Maintain skin integrity. OR on Monday for split thickness skin graft. Continue ICU care and treatments. Update family w/ plan of care; notify w/ significant events.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1297475,
"text": "Addendum to NPN:\nA-line dampened throughout shift. Very difficult to draw blood off A-line, but flushable. After AM blood drawn, A-line was not tracing. Dr. notified. At 0430, HO attempted to change line over a wire, but clotted. Per HO, follow NBP for now, and team will place new A-line in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-05 00:00:00.000",
"description": "Report",
"row_id": 1297437,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CARE VUE FOR SPECIFIC VITAL SIGNS/ASSESSMENT/LAB INFORMATION.\nCONTINUES TO BE SEDATED ON FENT/ATIVAN/ WITH SMALL AMOUNTS OF LEVO.\nDRESSING CHANGES TWICE BY TRAUMA TEAM, PINK WITH SOME CLEAR BROWN DRAINAGE WITH FIRST CHANGE. SOME FURTHER DEBRIEDMENT OF LEFT CHEST WITH THIS CHANGE. MUCH LESS DRAINAGE ON SECOND CHANGE. NUMBEROUS SERVICES BY TO SEE PATIENT AND DRESSING (PLASTICS/ENT/ID/TRAUMA/THORACIC).\nHEMODYNAMICALLY STABLE, REMAINS FEBRILE. APPROPRITE ANTIBIOTIC COVERAGE AT THIS POINT PER ID.\nTURNED UNEVENTFULLY, SKIN INTACT.\nLABS PER FLOW SHEET, LYTES REPLACED AS ORDERED.\nMOTHER CALLED, BOYFRIEND IN BRIEFLY.\nIVIG ORDERED, WILL ADMINISTER AFTER CHECKING WITH HO RE:TYLENOL/BENADYL ADMINISTRATION PRE.\nP: CONTINUE TO CHECK LYTES/ MONITOR VS.\nALL PAIN MEDS AND SEDATION INCREASED AS NEEDED DURING DAY AND WITH DRESSING CHANGES.\nWILL CALL HO WITH ANY CHANGES.\nDR. AWARE OF ALL OF ABOVE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-25 00:00:00.000",
"description": "Report",
"row_id": 1297504,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n No neuro changes. Pt still very lethargic. Methadone and clonidine doses decreased. Follows simple commands; MAE. R>L pupil; bilat pupils briskly reactive to light. When turned, +posturing, abnormal flexion of entire body and extremities. Pt agitated and restless in afternoon, but lorazepam not given per Dr. . After repositioned, pt asleep. No sedation needed.\n Tmax 100.8; blood cx (2 sets) and urine cx sent. blood cx in aerobic bottle grew Gram + rods per microbiology (Dr. aware). HR 60-90s, ABP 130-140s/60-80s. Trace generalized edema. DP/PT weakly palp.\n Pt not extubated d/t LOC. Able to tolerate CPAP 0/0 for 4hrs. ABG showed metabolic alkalosis. Placed back on CPAP w/ PS 40%/ PEEP5/ PS5. No SOB noted. ? extubate in AM if more . Sxn for thick white/yellow secretions (less secretion in afternoon).\n TF restarted after Dr. told RN that pt is not being extubated today. TF currently @ 60cc/hr (goal 80cc/hr). Flushes and TF residuals ordered. Abdomen softly distended w/ +BS. Fecal incontinence bag intact w/ scant amount loose, brown stool. Foley intact w/ clear yellow urine; uo qs.\n boyfriend and mother called; RN updated them w/ plan of care.\n Neck/sternum w/ Xeroform and DSD. Left upper thigh w/ Xeroform OTA; small amount bloody drainage. R foot w/ duoderm intact.\n Plan: Cont to monitor temp, BP, I's and O's. Replete lytes as needed. Monitor neuro and respiratory status. Plan to extubate in AM. Continue ICU care and treatments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-26 00:00:00.000",
"description": "Report",
"row_id": 1297505,
"text": "Respiratory Care:\nPatient remains on vnetilatory support (CPAP/PSV) with no parameter changes made throughout the night. Morning abg results determined a mild, partially compensated metabolic alkalemia with excellent oxygenation on the current settings.\n\nRSBI = 27.8 on 0-PEEP and 5 cm PSV.\n\nPlan is to wean to extubate today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-16 00:00:00.000",
"description": "Report",
"row_id": 1297476,
"text": "Respiratory Care:\nPatient remains on ventilatory support (SIMV/PSV) with no parameter changes made throughout the night. Morning abg results reveal a partially compensated metabolic alkalemia with excellent oxygenation (see CareVue).\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-04 00:00:00.000",
"description": "Report",
"row_id": 1297431,
"text": "FOCUS: CONDITION UPDATE\nSEE ICU FLOW SHEET FOR SPECIFIC LAB VALUES/VITAL SIGNS/ASSESSMENTS.\nD: RETURNED FROM OR AROUND 2230, S/P FURTHER DEBRIEDMENT OF NECK/CHEST FOR ?NECROTIZING FASCITIS. OPERATIVE DRESSING REMAINS INTACT, YET OOZING LARGE AMOUNTS OF SEROUS DRAINAGE AROUND DRESSING. PATIENT NOT TURNED, LINNENS FREQUENTLY CHANGES TO KEEP PATIENT DRY.\nPATIENT ON CIST/FENT/ATIVAN/LEVO FOR BP CONTROL AND SEDATION. HEMODYNAMICALLY STABLE. DIURESING ON OWN. LYTES CHECKED AND REPLACED AS ORDERED.\nA LINE CURRENTLY NON FUNCTIONING, GOING BY CUFF WHICH HAS BEEN USED ALL SHIFT. HO AWARE. PLAN TO REWIRE LINE.\nP: RETURN TO OR\n KEEPT SEDATED AND PARALYZED.\n FREQUENT LAB CHECKS.\nWILL CALL HO WITH ANY CHANGES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-04 00:00:00.000",
"description": "Report",
"row_id": 1297432,
"text": "Resp Care Note:\n\nPt received from OR cont intub with NETT paralyzed/sedated on mech vent as per Carevue. Lung sounds ess clear after suct sm loose tan sput. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-04 00:00:00.000",
"description": "Report",
"row_id": 1297433,
"text": "Respiratory Care\nPt taken to the operating room for debreedment of her infected areas. Placed on imv of 16 upon her return. Breath sounds equal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-26 00:00:00.000",
"description": "Report",
"row_id": 1297506,
"text": "NPN (NOC): PT REMAINS INTUBATED. CURRENT VENT SETTINGS: \"5&5\" X 40%. RR IN TEENS, VT'S 300'S TO 500'S, SATS HIGH 90'S. AM ABG ESSENTIALLY UNCHAGED. BS'S CLEAR TO DIMINISHED. SX'D Q 4 HRS FOR SM AMTS OF THICK WHITE SECRETIONS. TMAX 101.4, TYLENOL GIVEN. RPT TEMP 98.2. NO SEDATION GIVEN . PT HAS SLEPT MOST OF THE NIGHT, BUT AROUSES TO VOICE. SHE DOES NOT MOUTH WORDS, BUT DOES FOLLOW COMMANDS PRETTY CONSISTANTLY. SHE SOMETIMES AWAKENS SPONTANEOUSLY AND BECOMES MILDLY RESTLESS AND TACHYCARDIC. SHE SETTLES DOWN W/O SPECIFIC INTERVENTION. TF WAS OUT ~ 1 FOOT EARLIER. HO REPLACED. RPT X-RAY CONFIRMS PLACEMENT. TOL TF WELL. UO IS ADEQUATE. 20 IVKCL REPLACED IN AM, NEEDS 4 AMPS MG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-26 00:00:00.000",
"description": "Report",
"row_id": 1297507,
"text": "Respiratory Care:\nPt extubated at noon time today & placed on cool mist. Pt able to vocalize & cough with encouragement. Tolerating extubation well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-04 00:00:00.000",
"description": "Report",
"row_id": 1297434,
"text": "Events\n\nPt to OR for further neck, chest, right shoulder debridment, small upper area sternotomy, area opened and packed with kerlix transparent OR dressing intact, 1u PRBC in OR for HCt25, cont to check serial HCT, and recheck coags PTT,PT monitor for bleeding, remains paralyzed and sedated on fent, ativan, cisat, monitoring TOF, PERL, CV levo for MAP>60 HS distant S1 S2 Left pleural CT t0 20cm sx, drg serous fluid, CSM palp +, Resp-AC no vent changes, LS coarse upper lobes dim at bases, soa2 100 following ABG, and lactate, GI-plan for DHT GI absent BS BS covered with SS insulin, GU foley to cd u/o>,\n\nPlan-cont to wean neo as tol, follow serial HCT and ABG, DHT placed by SICU and ?TF, team aware absent BS, assess wound and risk for bleeding open chest tray at BS, wean cisat remain sedated\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-05 00:00:00.000",
"description": "Report",
"row_id": 1297435,
"text": "Resp Care Note:\n\nPt cont intub with NETT sedated and on mech vent as per Carevue. Lung sounds sl coarse and ess clear after suct for bld tinged sput (spec obt). ABGs stable; no vent adjustments required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-24 00:00:00.000",
"description": "Report",
"row_id": 1297500,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patients temp climbed overnight to a tmax of 101.8 despite tylenol being given earlier in shift. SICU resident aware of pt being febrile. Patient has been receiving lasix with large amts of diuresis and it appears that episodes of tachycardia with rate up to 150 seem to occur just after diuresis. Fluid balance prior to eve dose of lasix negative ~3L sicu resident notified but still wanted lasix given. This am wt down 4KG which correlates to fluid balance at midnight. Electrolyte imbalances continue with Na currently up to 147. Patient making adequate amts of urine. TF off all night for ?extubation in am.\n No other significant events overnight. No sedation was required slept in naps and was calm/cooperative and at times following simple commands but is not very considering she has not received any sedation all shift. Tolerated CPAP 5/5 overnight. Secretions decreasing.\nPLAN:\n Pulmonary toilet\n ? stop diuresing\n ? Pan culture\n ?Decrease methadone\n Continue to monitor and correct lytes\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-24 00:00:00.000",
"description": "Report",
"row_id": 1297501,
"text": "CONDITION UPDATE: SEE CAREVIEW FLOWSHEET FOR DETAILS\n\nNEURO: ,OPENS EYES SPONT, MAE, PERRL, OBEYS COMMANDS, NO SEDATION > 24 HRS. STILL GROGGY. ON METHADONE AND CLONIDINE. METHADONE DOSE DECREASED TO 10 PO BID.\n\nCV: NSR. FEBRILE 101.9 T MAX AXIL, TEAM AWARE, X 1, PAN CULTURED LAST NIGHT.\n\nRESP: LS DIMINISHED, SATS 100%, CPAP, DECIDED NOT TO EXTUBATE, SPUTUM CX POSITIVE, AWAITING ID APPROVAL FOR PO VANCO, ?EXTUBATE IN AM.\n\nGI: TF AT 50. +C DIFF REPORTED, UNABLE TO SEND ANOTHER SPEC TODAY NOT ENOUGH IN FECAL BAG, HOLD TF TONIGHT.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE.\n\nENDO: RISS FS 152.\n\nPLAN: MONITOR TEMPS, IV ABX, AWAIT CX RESULTS, ? EXTUBATE IN AM., PULM TOILET.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-25 00:00:00.000",
"description": "Report",
"row_id": 1297502,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient with tmax 102.3- SICU resident (Dr. aware-no cultures ordered d/t last cultured<24hrs. PO vanco was started for +cdiff results and tylenol was given for fever. Lasix was d/c'd earlier in day so by midnight fluid balance was +1L but urine output remained>30cc/hr. ABG reflecting a metabolic alkalosis.\n No vent changes were made overnight. Suctioned only every couple of hours for thinner secretions. Remains on CPAP 5/5 and tolerating well. But still does not appear appropriate\n Patient more since dose of methadone decreased but still lethargic. Follows more commands but when repositioning or moving at all patient almost appears to do some posturing abnl flexion/extension of entire body and extremeties. No episodes of aggitation overnight and no sedation given.\nPLAN:\n Cont to minimize sedation\n Pulmonary toilet\n Replete lytes if imbalance persists (am results pending)\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-25 00:00:00.000",
"description": "Report",
"row_id": 1297503,
"text": "Respiratory Care:\nPatient remains on ventilatory support with no parameter changes made throughout the night. Morning abg results revealed a partially compensated metabolic alkalemia with excellent oxygenation.\n\nRSBI = 48.8 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-03 00:00:00.000",
"description": "Report",
"row_id": 1297426,
"text": "Resp Care Note:\n\nPt received from OR intub with NETT and placed on mech vent as per Carevue. Lung sounds clear. ABGs stable. Cont mech vent ? plan to wean and extub today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-03 00:00:00.000",
"description": "Report",
"row_id": 1297427,
"text": "S/P I+D LEFT NECK INFECTION\nFROM OR, NOT REVERSED, ON PROPOFOL AT 50 MCG/KG/MIN\nNEURO: AWAKE THIS AM, NODDING APPROPRIATELY, MAE, PERL. ON PROPOFOL AT 20 MCG. FENTANYL AT 50 MCG/HR FOR PAIN.\nCV: LOW GRADE TEMP, HR STABLE. BP DROPPED TO 80'S NS BOLUSES 1000CC X 3 TOTAL. . BP GOOD WHEN AWAKE. SEE FLOW SHEET FOR DETAILS.\nRESP: BS CLEAR SX FOR THICK TAN. VENTILATED WITH ETT SEWED INTO RT NARE FOR AIRWAY PROTECTION.\nGU: FOLEY DRAINING 30-40 CC/HR.\nPOST OP: TRIPLE ABX, RT GROIN LINE, RT A LINE PLACED. NECK DSG SATURATED WITH SEROSANG, CHANGED SEVERAL TIMES THIS AM. 4 PENROSE DRAINS IN PLACE. IRRIGATED BY HOUSE STAFF. WBC ELEVATED THIS AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-21 00:00:00.000",
"description": "Report",
"row_id": 1297490,
"text": "Nursing note:\nNEURO: Remains sedated on Ativan/Fentanyl gtts. Haldol PRN. to voice, purposeful movements. Pupils unequal as per baseline. Does not follow commands.\nRESP: Lung sounds clear, no vent changes overnight. To be put back on CPAP this am.\nCV: Afebrile. SB in 50s-60s, no ectopy. SBP 90s-110. Palpable pulses bilaterally. PICC intact. CVP 7-12.\nGI: Abdomen soft, minimal stool via FIB. Tolerating slow TF increase w/minimal residuals. Continues w/maint. IVF fluid until @ goal of TF.\nGU: Foley intact for adequate amounts pale yellow urine.\nENDO: Glucose stable.\nSKIN: Vac dressing intact, Duoderm to R. foot, MPBs in place. STSG site to L. thigh w/Vaseline guaze intact, small amount serosang. drainage. No other areas breakdown.\n\nA/P: Stable , tolerating slow sedation and vent wean.\nContinue TF increase, skin care, CPAP today. Monitor closely for change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-21 00:00:00.000",
"description": "Report",
"row_id": 1297491,
"text": "Respiratory Care:\nPatient switched from SIMV mode to CPAP/PSV. RR increased with a drop of PSV from 12 cm to 10 cm. No morning abg results at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-21 00:00:00.000",
"description": "Report",
"row_id": 1297492,
"text": "FOCUS: CONDITION UPDATE\nD: SEE ICU FLOW SHEET FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENT.\nPATIENT WEANED FROM VENT TO CPAP 5/5. DOING WELL, WITH CLEAR LUNG SOUNDS, SUCTIONED FOR MINIMAL AMOUNTS THICK WHITE. COMFORTABLE BREATING PATTERN ON CPAP, WAS VERY LETHARGIC, YET EASILY . DID FOLLOW SIMPLE COMMANDS.\nSEEN BY DR. THIS PM, AGREED TO EXTUBATE PATIENT. MOTHER HERE AT THE TIME.\nIMMEDIATLY AFTER EXTUBATION, PATIENT BECAME CONGESTED, UNABLE TO COUGH SECRETIONS, SATS DROPPED IMMEDIATLY TO 70S. TEAM CALLED, PATIENT REINTUBATED, YET STILL UNABLE TO GET SATS >85. CXRAY SHOWED COMPLETE LEFT LUNG WHITE OUT. BRONCH DONE BY DR. , LARGE AMOUNTS OF PLUGS REMOVED.\nCXRAY POST BRONCH MUCH IMPROVED, WITH IMPROVED SATS.\n FROM SOCIAL WORK WITH FAMILY DURING THIS TIME.\nFEM A LINE NOW BEING PLACED.\nR: FAILED EXTUBATION. LACKING STREGNTH TO SECRETIONS AND PREVENT FROM PLUGGING.\nWILL KEEP SEDATED ON PROPOFOL OVER NIGHT. BEGIN TO WEAN AGAIN, NOT WITH GOAL OF EXTUBATION IN NEAR FUTUER.\nPOST PYLORIC FEEDING TUBE PLACED TODAY.\nWILL CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-21 00:00:00.000",
"description": "Report",
"row_id": 1297493,
"text": "Respiratory Care\nPt currently on vent. support. Pt picc line replaced at fluro. Pt failed extubation, reinubated after decreasing sats. Post intubation, sats still low - films showed total white-out of left lung. Pt bronched; et tube pulled back; suctioned out large amount of thick plugs. PT sats and films improved post bronch. Remains on stable on vent. Plan to continue on settings, wean when pt comes off sedation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-03 00:00:00.000",
"description": "Report",
"row_id": 1297428,
"text": "Events:\nPt admitted s/p cervical and anterior mediastinal necrotizing infection ?from tooth abscess, tooth removed, pt with PMH of pancreatitis 4 week and repeat 3 week stays at , ?bone tumor removed right shoulder, plan for old records form \n\nFluid resucitation for drop SBP 80's LR/NS boluses and 2u PRBC for HCT 19 plan for HCT ck q6hours, WBC high 24 cont on triple ABX, hepatitis serologies sent, CD4 count sent and ID consult,pt remains nasally intubated sedated for airway and edema of upper neck and chest\n\nNeuro-arouses to voice grimace and agitated to stimuli at times soothes to voice attempt to talk reoriented frequently, PERL MAEW med with fentanly gtt and prop weaned D/C ativan gtt started, fent and ativan increased for pts comfort\n\nCV-MP SR no VEA SBP >85 per SICU team fluid boluses, CVP after fluid 16, cool UE warm LE SCDS, heparin SQ DVT prophylaxis, SBP improved after fluid boluses HS S1 S2 monitor for pericardidtis, neck and chest penrose drains intact with reddness and swelling, penrose drains irrigated q4 hours with SNS by ENT resident\nResp- remains on AC no vent changes, LS coarse upper lobes sx for thick yellow\nGI-hypo BS plan for FT, BS WNL\nGU-u/o 25-30cc/hr LR at 200cc/hr\nID triple ABX ID following\n\nPlan- evaluate old chart, ?etiology of pancreatitis, cont ABX follow serial HCTs, follow ABG, cont to evlaute wound and reddness, levo if needed for sbp<85, cont sedation, cont current care\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-03 00:00:00.000",
"description": "Report",
"row_id": 1297429,
"text": "Respiratory Care\nPt remains on mechanical ventilation, changes to settings made as a result of ABG results. CT planned for whole body scan, pending. Continued metabolic acidosis being treated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-03 00:00:00.000",
"description": "Report",
"row_id": 1297430,
"text": "NPN Addendum\n\nEvents\n\nIncrease erythema neck to right shoulder, +blanching and sl firm, Dr. to BS right neck penrose site, area opened by MD red, packed with SNS, hypotensive slightly acidotic BE-6 repeat HCT 25.6 2u PRBC given, 500 NS fluid bolus, extrem cool pale sole feet mottled, levo started titrated for SBP>85, pt sent for CT scan of neck, abd, chest, and pelvis, s/p CT sent to OR for wound debrid,\n\nPlan-postop care, septic, levo for SBP>85, ?need for PA line, cont fluid resucitation, assess HCT and acid base balance, please see flow sheet\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-22 00:00:00.000",
"description": "Report",
"row_id": 1297494,
"text": "SICU NPN:\nS-Intubated and sedated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-VSS overnight. SBP slighltly down into the 90s, post brisk diuresis, maintaining MAP in the 60s. MN dose of Clonidine held. Ativan drip discontinued, no PRN Ativan given overnight. Continues Propofol at 20mcgs/kg/min with small boluses with turning. Opens eyes to voice since Ativan off, following simple commads. MAEs on bed. Breaths clear and dim at bases. FiO2 weaned to 40% and remains on IMV, following SaO2 and maintained > 95%. AM ABG unremarkable. CPT with result. Suctioning for thick yellow secrestion in moderate amounts. Low grade temps overnight. Continue triple abx, recent sputum and stool cx from pending. HUO brisk but down post diuresis, maintaining above 30cc/hr. Passing loose brown stool. FIB re-inforced then later re-applied and thus far intact. TFs restarted at GR and thus far tolerating. FS covered per SLSC. AM lytes repleted.\n\nA/P:Necrotizing fasciatis c/b sepsis and failure to wean\nSugggest continuing to rest on IMV/CPAP, would not attempt to extubate\nFollow temp curve\nContinue to monitor\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-22 00:00:00.000",
"description": "Report",
"row_id": 1297495,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. MDI'S given.Sedated with propofol. Temp 100.3.No spontaneous resp. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-22 00:00:00.000",
"description": "Report",
"row_id": 1297496,
"text": "Resp care\nPt cont. on mech. ventilation. Weaned to minimal settings (see flowsheet). ABG's show well oxygenated and ventilated. BS essentially clear and dimin. Sx sm-mod thick yellow secretions. MDI's given as noted. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-22 00:00:00.000",
"description": "Report",
"row_id": 1297497,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n\nNeuro: Pt lightly sedated on Propofol 10mcg/kg/min. Attempted to wean off ppf today, but pt became agitated and anxious; svc aware. Lorazepam and haloperidol given x1 w/ good effect for anxiety. Per Dr. , okay to leave ppf gtt on today and tonight d/t no planned extubation until tomorrow. Bilat wrist restraints on d/t pt attempting to pull at ETT and A-line. Pt easily by voice. MAE on bed. Follows simple commands; can weakly squeeze RN's hands on command. R>L pupil at times (not new; svc aware); bilat pupils briskly reactive to light. Pt does not appear to be in pain; no grimacing noted.\n\nCV: Tmax 100.8; Dr. notified. Tylenol 650mg given via DHT per HO...temp 99.5. Goal MAP>/=60 maintained. HR 70-90s (NSR), but increases to 120-150s w/ activity (Dr. aware). QTc 0.32-0.36; CVP 7-15. DP/PT pulses palpable. Slight generalized edema noted. SCDs and MPB on BLE.\n\nPulm: Lungs sound coarse/clear and diminished at bases. CPAP w/ PS (40%, PEEP5, PS 5). ABG and O2 sat WNL. RSBI 37.4. Freq sxn for thick, yellow secretions. CPT done q4hr.\n\nGI: Abdomen soft w/ hypoactive bowel sounds. Impact w/ fiber @ 50cc/hr via DHT (goal rate). Minimal residual; flushed q4hr. FS q6hr w/ RISS. Loose brown stool; fecal incontinence bag intact.\n\nGU: Foley intact w/ clear, yellow urine. UO qs.\n\nInteg: VAC dsg to chest/neck removed by Dr. (plastic svc); Dr. applied Xeroform , 4x4 gauze, and ABD pads over graft site; small amount serosang drainage noted. Incision to sternum OTA; pink around edges, but no drainage/no odor noted. Left upper thigh (donor site) w/ SofSorb and gauze intact. Lateral aspect of right foot w/ healing blisters; duoderm re-applied; no drainage.\n\nSocial : boyfriend called x2; RN updated pt's boyfriend w/ plan of care.\n\nPlan: Monitor VS, I's and O's. Keep MAP>60. Wean Propofol as tolerated. Monitor resp status and ABGs. Plan to extubate in AM per SICU team. Ativan and haloperidol prn for anxiety. Continue ICU care and treatment. Upate family w/ plan of care and notify w/ significant events. Notify svc w/ any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-23 00:00:00.000",
"description": "Report",
"row_id": 1297498,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient had an uneventful night. Rested on CPAP 5/5 overnight. Plan is for RT to do a RSBI and then SBT, draw an ABG and extubate at 8am if all wnl. Lightly sedated overnight on PPF @10mcg/kg/min which will be stopped when doing SBT.\n Otherwise all vitals and specifics are documented in the flowsheet.\nPLAN:\n Extubate in am\n Pulmonary toilet\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-23 00:00:00.000",
"description": "Report",
"row_id": 1297499,
"text": "CONDITION UPDATE: SEE CAREVIEW FLOWSHEET FOR SPECIFICS\n\nNEURO: Pt , opens eyes spont, obeys commands, MAE, PERRL. Calm most of shift. Med x 2 with 2mg Haldol IV for agitation with good effect. Propofol gtt off since 0530 per team.\n\nCV: T max 100.8. MAP>60. NSR with multiple episodes for SVT 130-160.\nPotassium repleted 40mg liq po K. Mag repleted 4mg IV. repeat K 3.1 repleted with another 40mg liq po and 40 mg IV.\n\nRESP: Coarse LS diminished at bases. Sxn for small amt's thick white sputum. Pt on CPAP. Pt's neck hard upon palpation,?swelling. Cuff leak checked, no cuff leak. Cuff left down for most of shift. Cuff leak noted at 1400, air put back in. 02 sats 95-100% with one Episode of desat to 91%. AbG checked, unchanged, HO aware.\n\nGI: Abd soft. +loose brown stool. Fecal bag changed. TF on hold at 0830 per team.\n\nGU: Foley draining lg amts clear yellow urine. Lasix x 1.\n\nENDO: fs 133, 111. RISS.\n\nSOCIAL: Mother and boyfriend called. of care reviewed with both.\n\nPLAN: Cont CPAP. Hold sedation if possible for ?extubation in am. Haldol prn for agitation. Hold Tube feeds. Lytes pending. Cont nursing care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1297448,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LAB VALUES/ASSESSMENTS.\nDRESSING TODAY CHANGED TO VAC DRESSING. INSULIN DRIP STARTED FOR BLOOD SUGARS>150. TOLERATING TUBE FEEDS AT 70CC HR. LEVO REQUIREMENT UP TO 0.08 AFTER ONE BP DROP TO 70/--?ETIOLOGY, RESPONDED TO FLUID AND INCREASING LEVO.\nNASAL ETT CHANGED TO ORAL ETT UNEVENTFULLY, CXRAY DONE TO CONFIRM PLACEMENT.\nFAMILY CALLED, NO ONE INTO SEE AT THIS POINT.\nP: ?FLEURO FOR DIAGNOSTIC TIP, MONITOR BLOOD SUGARS, CHECK DRESSING FOR ANY S/S BLEEDING, CHECK LABS AS ORDERED. CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-09 00:00:00.000",
"description": "Report",
"row_id": 1297449,
"text": "focus hemodynmnics\ndata: neruro: opens eyes to stimuli. does not focus when being spoken to. perla #3 bilaterally and reacts briskly. moves all extremites on the bed. opens eyes spontanously. on ativan and fentanyl gtt.\n\nresp: suctioned for mod amt of thick yellow sputum. o2sats 96-100%.po2= 150's and fio2 decreased to 40%. left thorencentiis done by the radiologist. small amt of fluid obtained and sent to the lab for culture and gm stain.\n\ncardiac: remains in nsr. magnesium level 1.7 and repleted with 2gms of magnesium sulfate. k 4.6\n\ngu: foley patent and draining yellow urine.\n\ngI: abd soft. no stool. hypoactive bowel sounds. tube fdgs tol at 80c/hr.\n\nskin: wound vac to chest wound. draining serosang drainage. on iv clindamycin, vancomycin and pipercilllin.\n\naction: labs as ordered. suctioned prn. on iv fentanyl and ativan gtt for pain and restlessness. levophed gtt to maintain mean > 60. tube fdgs infusing. goal rate 90cc. thorecentis to l side. tol procedure well. small amt of fluid obtained and sent to lab for culture. magnesium level 1.7 and repleted with 2gms of magnesium sulfate iv.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-09 00:00:00.000",
"description": "Report",
"row_id": 1297450,
"text": "Respiratory Care Note:\n Patient remains intubated and sedated and on fentanyl, versed, and ativan. She is on levophed. Plan for switch to PSV as tolerated. Presently on AC. Suctioned for small amounts of thick whitish sputum and recieves albuterol mdis app Q4. Plan to maintain support at htis time. See Carevue flowsheet for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-09 00:00:00.000",
"description": "Report",
"row_id": 1297451,
"text": "FOCUS: CONDITION UPDATE\nD: SEE ICU FLOW SHEET FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nPATIENT SLIGHTLY MORE AWAKE TODAY, FOLLOWING SIMPLE COMMANDS. OPENS EYE WHEN NAME CALLED. REMAINS LOW GRADE FEBRILE. TUBE FEEDS AT GOAL, TOLERATING WELL, SMALL BOWEL MOVEMENT THIS AFTERNOON.\nVAC DRESSING INTACT, EXTRA SUCTION CATH PLACED WITHIN DRESSING THIS AM BY PLASTICS, DRAINED 200CC SEROUS FLUID.\nBLOOD SUGARS STABLE ON INSULIN DRIP.\nSLOWLY WEANING LEVO, YET DID DROP PRESSURE WHEN BED BEGAN TO TURN PATIENT. ATIVAN WEANED TO 4 MG/HR.\nCPAP TRIED, PATIENT DID NOT BREATH BACK ON AC. WILL TRY FURTHER VENT WEAN WHEN PATIENT MORE AWAKE.\nHO AWARE OF ALL OF ABOVE.\nWILL CALL WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 1297443,
"text": "CONDITION UPDATE:\nSEE CAREVIEW FLOWSHEET FOR SPECIFICS\n\nNEURO: PT SEDATED ON FENT AND ATIVAN GTT. AROUSABLE TO VOICE-OPENS EYES, PERRL, OBEYS COMMAND TO SQUEEZE RIGHT HAND, WITHDRAWS UPPER AND LOWER EXTREM AND LOCALIZES.\n\nCV:NSR NO ECTOPY, MAP MAINTAINED >60 WITH LEVO AT 0.069. ONE EPISODE OF ST 120'S MED WITH 5MG LOPRESSOR. T MX 101.0 AX. TEAMS AWARE. TYLENOL X 2. IVF AT 200/HR CONTINUES PER TEAM. MAG REPLETED X 1. HCT IMPROVING. IVIG D/C'D PER ID. A-LINE DAMPENED THIS AM, DIFFICULT TO DRAW LABS THIS AM BUT WAVEFORM SINCE IMPROVED AND ABLE TO DRAW LABS WITHOUT DIFFICULTLY.\n\nRESP: LS COARSE THROUGHOUT. CONT WITH THICK TAN SPUTUM WITH SXN, LEFT CHEST TUBE TO WATER SEAL THIS AM AND REMOVED AT NOON. ELASTOPLAST DSG TO SITE. CXR DONE. PT TO HAVE REPEAT CXR POST CHEST TUBE REMOVAL, RADIOLOGY NOTIFIED. CT SCAN OF CHEST DONE THIS EVENING.\n\nGI: ABD SOFT, +BS, TUBE FEED AT 50 ,RESIDUALS 20-40.\n\nGU: U/O 200-400/HR CL YELLOW.\n\nENDO: FS 158 AND 180. RISS.\n\nSKIN: GENERALIZED EDEMA, WARM EXTREM, RIGHT ORBITAL EDEMA IMPROVED FROM YEST, RIGHT EAR REMAINS ERYTHEMATOUS NO BREAKDOWN, TOWEL ROLL TO DECREASE PRESSURE, DRESSING CHANGE TO CHEST BY TRAUMA TOL WELL WITH FENT AND PROPOFOL BOLUS. OPSITES AND LARGE TEGADERMS APPLIED OVER KERLIX PACKING. SMALL AMT SEROUS DRAINAGE MOSTLY FROM RIGHT SIDE.\n\nPLAN: DRESSING CHANGES BY TRAUMA TEAM. KEEP MAP > 60 WITH LEVO. FENT GTT, ATIVAN GTT, IV ABX, CONT TO ADVANCE TF AS TOL TO 90CC/HR GOAL. CONT NEURO CHECKS, Q4 HR LABS. D/C IVIG.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-07 00:00:00.000",
"description": "Report",
"row_id": 1297444,
"text": "Resp Care: Pt remains nasally intubated/sedated. Sx'd for mod amt thick yellowish tan sputum. MDI's given as ordered. Transported to and from Ct scan w/o incident. ABG WNL. No vent changes made this shift. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1297445,
"text": "focus hemodynmics\ndata: neuro:on ativan and fentanyl gtt. responds to stimuli. opens eyes slightly. moves legs slightly on the bed. moves arms on the bed. perla and reacts briskly.\n\nresponse: remains nasally intubated. suctioned for lg amt of thick yellow tan sputum. lavaged and ambued. abg's ok.\n\ncardiac: remains in nsr. magnesium level 1.6-1.7. repleted x3. k 5.0 and iv d51/2ns with 20meq kcl at 100cc/hr. rate decreased from 200cc/hr. lopressor 5mg iv x2 given. levophed gtt infusing and map > 60.\n\ngu: foley patent and draining yellow urine.\n\ngI abd soft and tube fdg infusing at 60cc/hr. goal= 90cc/hr. no stools.\n\nskin: chest and neck wound intact and changed by the residents. propofol given prior to dsg change. area pink, wet to dry dsg applied.\n\naction: labs as ordered. levophed , fentanyl and ativan gtt infusling. chest and neck dsg changed by the surgical team. tube fdg increased to reach goal of 90cc/hr. suctioned prn.\n\nresponse: monitor closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1297446,
"text": "pt remained on A/C throughout PM with an ABG in normal range. Her secretions became thick, chunky and yellow during shift. A RSBI was attempted unsuccfully due to no spont resp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-08 00:00:00.000",
"description": "Report",
"row_id": 1297447,
"text": "Resp care: NT tube d/c'd . Pt orally intubated w/ #7.5 ETT secured 24cm at lip. BS decreased on L. Cxray reveals R main intubation. Found at ~26cm at lip. Pulled back to 22cm at lip. BS bilat. MDI's given as ordered. No vent changes made today. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-12 00:00:00.000",
"description": "Report",
"row_id": 1297462,
"text": "7a-7p Nursing note:\nNursing Assessment:\n\nNeuro: Patient moves all extremeties. Occasionally will move extremities to command, othertimes purposfully to pain. Pupils are equal and reactive. Pain controlled by Fentanyl, weaned as able. Multipourous boots for foot drop.\n\nCV/GU: BP controlled via Levophed, to keep MAP greater than 55. At times unable to follow A-line pressures due to dampened waveforms, following cuff pressures when necessary. Voiding large amounts of clear yellow urine via foley cath. Edema to LUE, doppler study negative.\n\nGI: rectal bag draining mod amount brown loose stool. BS positive, Tube feeding via NGT at 90cc/hr. Small dose Insulin gtt, titrated to effect.\n\nResp: SIMV weaned,currently on CPAP with peep 5 pressure support 10, Maintaining adequate tidal volumes. Spontaneous breathing trial unable d/t patient's sleepiness and failure to breathe on own.\nLung sounds coarse in all lobes, patient suctioned for white thick secretions.\n\nSkin: LLE with blood blisters x3 intact. Large chest wound with vac dressing to low wall suction. Draining mod. amounts serosanguinous drainage. Left back with DSD old chest tube site clean dry and intact.\n\nPlan: Wean levo to off keeping MAP greater than 55. Wean Fentanyl down as able maintaining good pain control. Insulin gtt titrated as needed, finger sticks Q1-2 hours. Wean vent as able, monitor blood gases as appropriate. Wean Ativan as able. Monitor urine ouput as Levo weaned.\nContinue with current nursing care.\n\nPlease view flowsheet for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-13 00:00:00.000",
"description": "Report",
"row_id": 1297463,
"text": " Condition update\nPlease see carevue for specifics:\n\nPt afebrile with tmax 98.9 ; HR 78-110 NSR to Sinus tach (with suctioning and turns). Goal MAP>55, pt was started back on levo gtt at 2400 for MAP consitently 52-53 (dr. was made aware before gtt was re-started); after levo went back on at .016mcg pt sbp was MAp 55-65. LS coarse throughout lung field and suctioning small amount sof thin white secretions with no change in LS, pt with weak cough. at 2330 pt 02 sats dropped to 82-84%, resolving with fi02 increased to 100%, but not with suctioning; RT came to see pt and lavagd and suctioned. PT was admin albuterol, with minimal effect, and pt was on CPAP taking 10-12 bpm with TV .200-.400; switched to SIMV with rate of 14 and pt not overbreathing- apparently tired on CPAP. Dr. was made aware. ABG's showing metabolic alkalosis (as ealier) and no changes are being made d/t abg's. abd +bs x 4 and tolerating impact with fiber at 90cc/hr- residuals 50-60cc and flushing well. FIB draining small amounts of liquid brown stool. FOley draining adequate amounts of CYU- CVP (?accuracy). Aline dampening at times- dr. attempted placing aline in left radial artery but was unsuccessful- aline requires flushing to help with waveform. +dp/pp, +rp, +bp. pt opening eyes to voice and following commands- MAE, perrla 3mm/3mm briskly reactive. Pt appears to have pain when beign rolled- premedicated with 1 mg ativan with good results. electrolytes replaced. glucose levels wnl on .5units insulin/hr. Cont to monitor labs, vs, i/o's, ns, pain needs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-14 00:00:00.000",
"description": "Report",
"row_id": 1297469,
"text": "Focus: Status update\nPt lightly sedated on ativan/fentanyl. Appears comfortable. Arouses to voice. Follows commands consistently. Right pupil noted to be larger than left at times. Both pupils briskly reactive. Moves all extremities. Temp max 99.8.\n\nNormal sinus rhythm on telemetry. No ectopy noted. No edema noted. CVP 4-7. MAP > 60 throughout shift. Did not reqiure levo. Tachycardic only during turning.\n\nLungs coarse despite suctioning. Suctioned frequently for small amounts thin white/clear secretions. No vent changes made today.\n\nAbdomen soft, nondistended. Bowel sounds present. Tolerating tube feedings of impact with fiber at goal. Continue on insulin gtt at .5 units/hr. Blood sugars well controlled. FIB in place draining small-moderate amounts liquid brown stool.\n\nFoley with clear, light yellow urine of adequate amounts.\n\nVac dressing changed today.\n\nPlan: Continue with VAC drain. IV antibiotics. Pain control with ativan/fentanyl drips. Plan to stay intubated until returns to OR possibly Monday. Blood sugar control with insulin gtt. MAP > 55 as ordered. Replete lytes as necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-15 00:00:00.000",
"description": "Report",
"row_id": 1297470,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Neuro exam q2hr; unchanged. Easily by voice. Follows commands. MAE (able to lift and hold BUE). R>L pupil; both pupils briskly reactive to light. Dr. aware; no interventions at this time. Fentanyl and Ativan gtt increased d/t agitation, anxiety, and pain (see CareVue for specifics). Pt attempted to pull at ETT. dsg, and foley. Pt grimaces and frowns at times; gtt increased w/ good effect.\nCV: Afebrile; hr 70-90s NSR. HR increased to low 100s w/ activity, but immediately returns to NSR once pt is settled. Goal MAP>55. ABP 100-110s/40-50s. CVP 3-7. DP/PT/radial/brachial pulses palpable. Multipodus boots on for footdrop. Pt's 24hr net body balance: -2526cc. Dr. aware; per HO, no IVF replacement at this time (VSS, hr WNL, uo qs).\nPulm: Lungs sound diminished/coarse. Freq sxn for thick, white/clear secretions. No vent changes: SIMV w/ PS 40%, Vt 0.5x14, PEEP 5, PS 12. No shortness of breath noted.\nGI: Abdomen soft w/ +BS. Impact w/ fiber @ 75cc/hr (goal) via NGT. Residual checks and flushes q4hr as ordered. FIB bag intact for liquid/loose dark brown stool.\nEndo: Insulin gtt @ 0.5unit/hr. BS stable.\nGU: Foley intact w/ large amount clear, light-yellow urine.\nInteg: VAC dsg to sternum and left neck intact; VAC to 75mmHg suction w/ small amount serosang drainage. Pt T&R q2hr.\nSocial: boyfriend, , called x2 ; updates given by RN.\nGoal: Continue to monitor VS, I's&O's. Keep MAP>55. Neuro exam q2hr and notify HO w/ any changes. Titrate fentanyl and Ativan gtt for pain and sedation. Continue insulin gtt and check BS q1-2hr. Maintain skin integrity. Replace lytes as needed. Continue ICU care and treatments. Update family w/ plan of care and notify w/ any significant events.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-27 00:00:00.000",
"description": "Report",
"row_id": 1297510,
"text": "See carevue for objective data.\n\nAwake and . Asking appropriate questions with a hoarse voice.\nArterial line dc'd right groin with + CSM to lower extremity. PIC patent.\nL/S-clear diminished in the bases with faint crackles. O2 weaned to off with adequate sat.\nBrief episiodes of HR 120's with activity but was self limiting.\nBP non-labile.\nSpeech up to evaluate at bedside for swallow. This required duo tube to be pulled re: coiled in the back of mouth. Pt did well with custard but coughed with thin liquids. Plan: leave duo tube out/po meds with custard until AM and then video swallow in AM and if duo tube needs to be replaced it will occur then. OK'd with team.\nNeck dressing changed-xeroform and DSD. Area pink with minimal drainage.\nRequiring ativan-\"I need something for anxiety\". Pt napping for short periods and immediately upon waking requesting something for pain. MSO4 IV added to therapy with fair effect.\nOOB for one hour with much encouragement in the afternoon. Did well and took a few steps to chair. IS given to pt with teaching and requires increase encouragement to perform as well as coughing and deep breathing.\nMother in for short period.\n\nContinue with pulmonary toileting,monitor and support hemodynamics,\nencourage increase activity,IVAB as ordered and continue to support\npt and significant others.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-28 00:00:00.000",
"description": "Report",
"row_id": 1297511,
"text": "nursing note\nslept most of night, frequent call for headache med, denies incisional pain. 2l NC applied for o2 sat 91%RA. Enc to C+DB, IS. Boyfriend stayed over night, lessened anxiety with pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-11 00:00:00.000",
"description": "Report",
"row_id": 1297458,
"text": "FOCUS: STATUS UPDATE\nDATA:\nSEE CAREVUE FOR DETAILS.\n\nPT EASILY TO VOICE, MOVING ALL EXTREMITIES TO COMMANDS INCONSISTENTLY. TACHYCARDIC WITH TURNING. CONTINUES ON ATIVAN AND FENTANYL DRIPS.\n\nCONTINUES TO REQUIRE LEVOPHED TO MAINTAIN MAP>60. VERY DIFFICULT INSERTION OF R ULNAR ARTERIAL LINE BY DR. AFTER MULTIPLE ATTEMPTS.\n\nLEFT ARM MORE EDEMATOUS THAN RIGHT ARM. PALPABLE RADIAL PULSE. PRIMARY TEAM AND SICU TEAM AWARE.\n\nLUNGS COARSE BILAT, SUCTIONED FREQUENTLY FOR THICK TAN SPUTUM. NO VENT CHANGES TODAY. ABG'S STABLE. CONTINUES FEBRILE.\n\nSTERNAL WOUND VAC DRESSING CHANGED BY DR TODAY. WOUND PINK AND CLEAN/GRANULATING . FENTANYL/PROPOFOL BOLUSES REQUIRED FOR DRESSING CHANGE. THORACIC/PLASTICS TEAMS PRESENT.\n\nTOLERATING TUBE FEEDS AT GOAL RATE WITH MINIMAL RESIDUALS. LOOSE STOOL REQUIRING FECAL BAG PLACEMENT TO MAINTAIN CLEANLINESS OF FEMORAL LINE.\n\nCONTINUES ON INSULIN GTT WITH STABLE GLUCOSES.\n\nMOTHER AND BOYFRIEND UPDATED BY TELEPHONE TODAY.\n\nPLAN:\nWEAN SEDATION AND LEVO AS ABLE. CONSULT WITH TEAM RE: NEED FOR NIVS OF LEFT ARM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-11 00:00:00.000",
"description": "Report",
"row_id": 1297459,
"text": "resp care\nremains intub/vented in simv mode. no changes made today. abg within acceptable limits. metabolic alkalosis. sxned for tannish sputum. sedated. few to no spont efforts. c/w full suppport.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-12 00:00:00.000",
"description": "Report",
"row_id": 1297460,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Neuro exam unchanged. Follows commands; MAE. Pt can lift up RUE and RLE at times. Easily by voice. PERRLA; pupils sluggishly reactive to light, but brisk at times (Dr. aware). Fentanyl and Ativan gtt increased d/t restlessness and pain w/ good effect.\nCV: Tmax 100.3. Levo gtt to keep MAP>60; able to wean down levo (see CareVue for wean specifics and VS). CVP 4-7. HR 70-90s (NSR), but pt becomes tachycardic (110-140s) w/ activity; once settled, hr returns to normal. Generalized edema. LUE more edematous than RUE. BUE elevated on pillows. Radial pulses weakly palpable; bilat brachial pulses dopplerable. DP/PT palp.\nPulm: Lungs sound coarse. Sxn for thick, tan secretions. No vent changes. SIMV w/ PS: 40%, Vt0.5 x 14, PS 12, PEEP5).\nGI: Abdomen soft w/ +BS. TF @ goal rate; residual checked and NGT flushed q4hr. Fecal incontinence bag intact. Small amount liquid, dark brown stool.\nEndo: Continue insulin gtt @ 1unit/hr. FS q1hr.\nGU: Foley intact w/ clear, light yellow urine. UO qs.\nInteg: VAC dsg intact; connected to wall suction w/ light serosang drainage. VAC dsg changed AM. Pt T&R frequently.\nSocial: boyfriend called x2 and updated by RN.\nPlan: Monitor VS; keep MAP>60. Titrate and wean levo as tolerated. Titrate lorazepam and fentanyl gtt for comfort and sedation. Continue insulin gtt and check fs q1hr. Update family w/ plan of care and notify of significant events. Continue ICU care and treatments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-12 00:00:00.000",
"description": "Report",
"row_id": 1297461,
"text": "pt remained on IMV throughout PM, and was sx'd for medium amounts of thick seceretions. Her AM ABG shows a mild metabolic alkalosis. RSBI will be attempted in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-13 00:00:00.000",
"description": "Report",
"row_id": 1297464,
"text": "RESP CARE: Pt recieved on CPAP with 15 PS. RR 5-10 bpm, total MV less than 5 liters. Pt having episodes of 02 sats in 80s, responding to an increase in FI02. Pt placed back on SIMV/PS overnight,sxd mod amt thick white sputum. Pa02 improved with positive pressure ventilation. Suggest increasing PEEP during PS wean to minimize derecruiting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-13 00:00:00.000",
"description": "Report",
"row_id": 1297465,
"text": "Focus: Status update\nPt lightly sedated on fentanyl/ativan. Fentanyl increased to 200mcg/hr this am due to crying/grimacing, tachycardia to 120's and tachypnea. Appears more comfortable after intervention. Follows commands consistently. Moves all extremities. Temp max 99.4. Pupils equal and reactive.\n\nNormal sinus rhythm on telemetry. No ectopy noted. Trace upper extremity edema. MAP > 55 as ordered with small doses levo on/off (see carevue for specifics). Recieved 1 unit PRBC for hct 19. Post transfusion hct 21.6. Awaiting arrival of 2nd unit. CVP 6-10.\n\nLungs coarse. Does not clear with suctioning. Continues on SIMV + PS, .40% FiO2, RR 14, 5 PEEP, 12 PS. NO vent changes this shift. O2 sats 97-100%.\n\nAbdomen soft, nondistended. Tolerating impact with fiber at goal of 75cc/hr. FIB in place with moderate amounts liq stool. Insulin gtt continues at .5 units/hr. Blood sugars wnl.\n\nFOley with clear yellow urine.\n\nWound VAC in place with adequate suction. Scant amounts sero-sang drainage noted in canister. Due to be changed .\n\nPlan: Continue to keep comfortable with fentanyl/ativan. Keep MAP > 55. Wound vac. Plan to return to OR ? when. 2nd unit PRBC when arrives. Emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-14 00:00:00.000",
"description": "Report",
"row_id": 1297466,
"text": " Condition Update\nPlease see carevue for specifics:\n\nPt vss and afebriel with tmax 99.7 (orally), sbp with MAp >60, hr 75- with no ectopy noted. Pt LS coarse throughout into bases and suctioning moderate amounts - no vent changes made and ABg's still showing met alkalosis- dr. aware. Abd +bs x 4 on full strength impact with fiber @75 with min residuals and flushing well. FIB replaced as pt passig moderate amount sof liquid brown stool. pt follows commands and MAE- +pp/dp/bp/rp; pupils asymetrical and briskly reactive (dr. aware- no changes made). Pt anxious and in apparent pain and fent gtt and ativan gtt increased- dr. aware. Pt got very agitated adn attempted to pull out a line- aline now is dampened, but will have sharp waveforms after flushing. KCL and Mg+ replaced . Cont to monitor labs, vs, i/o's, resp status, pain. ?placement of new alione today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-14 00:00:00.000",
"description": "Report",
"row_id": 1297467,
"text": "RESP CARE: Pt remains intubated/on vent on SIMV/PS 500/14/.40/5 PEEP/12PS. No changes in settings overnight. Lungs remain coarse bilat.Sxd by nursing. Continue full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-14 00:00:00.000",
"description": "Report",
"row_id": 1297468,
"text": "Resp Care\nPt remains on mech vent-parameters noted. No wean this shift. Coarse breath sounds bilat. Suction for small amt of thick white secretions. Alb MDI x 3. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-10 00:00:00.000",
"description": "Report",
"row_id": 1297452,
"text": "focus hemodynmics\ndata: neuro: opens eyes to stimuli. moves all extremties on the bed. does not focus on you when talking to her. slight squeeze of hand upon command.perla #3 bilaterally. ativan and fentanyl for sedation.\n\nresp: suctioned for thick yellow sputum. breath sounds course. on cmv o2sats 95-100% abg's ok.\n\ncardiac: remains in nsr. k 4.6 magnesium level 1.6-1.7 and repleted with 2gms of magnesium sulfate. levophed gtt to maintain mean of 60. gtt increased to maintain goal of map of 60. iv d51/2 at 100cc/hr.\n\ngu: foley patent and draining yellow urine.\n\ngI abd soft and no stools. tube fdgs at goal rate of 90cc/hr.\n\nskin: vac dsg intact and to low cont wall suction. draining serosang drainage.\n\nendocrine: on insulin gtt and blood sugars done q1hr.\n\naction: suctioned prn. labs as ordered. vac dsg to low cont wall suction. tol well. fenatanyl and ativan gtts for pain and sedation. levophed gtt for bp control. map goal> 60.insulin gtt with q1 hr blood sugars. on vanco, clindamycin and pipercillin. fluconazole iv given.\ntube fdgs as ordered and tol well.\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-10 00:00:00.000",
"description": "Report",
"row_id": 1297453,
"text": "pt's ABG showing a metabolis alkalosis in AM. Pt sx'd for tick secretiond throughout shift. RSBI to be done in AM>\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-10 00:00:00.000",
"description": "Report",
"row_id": 1297454,
"text": "Resp Care: Pt remains intubated via #7.5 ETT secured 22cm at lip. BS coarse bilat. Sx'd for mod amt thick tan sputum. In AM on A/C , ABg reveals Uncompensated Metabolic alkalosis. Changed to SIMV. ABG reveals Compensated Alkalosis w/ normoxia. Sedation being slowly weaned by Nsg. Please see carevue for further vent inquiries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-10 00:00:00.000",
"description": "Report",
"row_id": 1297455,
"text": "FOCUS: STATUS UPDATE\nDATA:\nSEE CAREVUE FOR DETAILS.\n\nPATIENT EASILY AROUSABLE TO VOICE AND FOLLOWING COMMANDS. MOVING ALL EXTREMITIES IN BED AND TO COMMAND. PUPILS SLUGGISH TO BRISK. CONTINUES ON FENTANYL AND ATIVAN, WEANED DOWN TODAY WITHOUT PROBLEMS. OPEN EYES TO VOICE BUT DOES NOT TRACK.\n\nLUNGS COARSE BILATERALLY, CLEARING SOME AFTER SUCTIONING. SUCTIONED OCCAS. FOR THICK TAN SPUTUM. CULTURE SENT TO LAB. CHANGED TO SIMV W/PS. RATE AND PS INCREASES DUE TO ABG'S THROUGHOUT THE DAY WITH SOME EFFECT.\n\nCONTINUES FEBRILE. STOOL, SPUTUM AND BLOOD CULTURES DONE PER ID REQUEST.\n\nCONTINUES ON LEVOPHED TO MAINTAIN MAP>60.\n\nDIURESING WELL WITH LARGE HOURLY URINE OUTPUTS.\n\nPLAN:\nFEMORAL LINE CHANGE THIS PM, SEND TIP FOR CULTURE. WEAN LEVO AND SEDATION AS ABLE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-11 00:00:00.000",
"description": "Report",
"row_id": 1297456,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\nNeuro: Neuro exam q2hr; unchanged. Easily arousable by voice; MAE. Follows commands. PERRLA (3-4mm; sluggish-brisk). Fentanyl and Ativan gtt continued. Fentanyl gtt weaned down to 100mcg/hr. See CareVue for gtt rate and wean. Pt slept most of night; no agitation noted. No grimacing except when turned and repositioned.\nCV: Tmax 100.1. HR 70-90s (NSR); increases to 100-110s w/ activity, but then goes back down to 70s immediately once pt is settled. Goal keep MAP >60. Levophed gtt weaned down to 0.05mcg/kg/min (see flowsheet for specifics). CVP 2-8. D5 1/2NS @ 100cc/hr infusing. Right femoral A-line changed over wire by Dr. . Left A-line unable to be changed over wire; Dr. , Dr. , and Dr. unable to place new A-line (attempted 4 times). Per Dr. , SICU team will place A-line in AM. Following NBP. Generalized edema. BUE elevated on pillows. DP/PT easily palpable. Bilat radial/brachial pulses dopplerable (Dr. and Dr. aware).\nPulm: Lung sounds coarse. Freq sxn for thick, tan secretions. SIMV w/ PS: 40% FiO2, f14, PEEP5, PS 12. Dr. aware that RN unable to obtain ABG d/t no A-line. No shortness of breath; no apparent distress.\nGI: Abdomen soft; + bowel sounds. BMx1; liquid dark green stool. TF @ 90cc/hr via NGT. Residual checked and NGT flushed q4hr as ordered.\nGU: Foley intact w/ large amount clear, light yellow urine.\nEndo: Insulin gtt infusing @ 0.5unit/hr. Q1hr fs.\nInteg: Large VAC dsg to sternum and neck (connected to wall suction); serosanguinous drainage. DSD to R&L wrist d/t small amount of bloody drainage from A-line attempts. Dr. and Dr. aware of large amount of serosanguinous drainage on left groin from A-line attempts (per HO, large serosang drainage d/t edema). No redness noted on left groin; no ecchymosis. Left upper thigh w/ skin tears; no drainage noted; covered w/ DSD.\nSocial: boyfriend called x1; update given by RN.\nPlan: Monitor VS, I's&O's. Continue gtts. Goal to wean off Levophed, Ativan, and fentanyl. Keep MAP>60. Place A-line in AM. Q1hr fs while on insulin gtt. Maintain skin integrity. Neuro exams q2hr; call HO w/ any changes. Continue ICU care and treatments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-02-11 00:00:00.000",
"description": "Report",
"row_id": 1297457,
"text": "Addendum to NPN:\nPt being followed by SICU, Trauma, Plastics, and Thoracic services. VAC dsg will be changed by trauma service today. Plan to d/c insulin gtt and to start pt on NPH and RISS. IV heplocked per Dr. .\n"
}
] |
25,441 | 154,962 | The patient is a 57 year-old female who presented with Headache and difficulty of ambulating. she was initially evaluated by her primary care doctor, her chest radiograph showed left upper lung mass which is promt to do a head CT. Head CT revealed rigth frontal, right parietal and left cerebellar mass further evaluation with MRI confirmed the lesions and she admitted to Neurosurgery service. She started on dexamethasone, mannitol, Keppra, GI prophylaxis which ultmialtely made her walking better. She still has left visual field cut. Infectious disease consulted for non-neoplastic origin of the brain lesion infection vs tumor; ID sugessted to diagnosis and send for aerobic, anaerobic cx, gram stain, mycobacterial cx, AFB, Modified AFB, fungal stain, fungal cx, nocardia culture. Dr from Neuro-oncology assed the patient and discussed her options. Thoracic surgery offered brochospcopy at the thoracic clinic if needed. Thoracic surgery will arrange follow up at the clinic. Thoracic surgery clinic number is with Dr . Patient has been afebrile hospital stay, vital signs has been stable. She will be on dexamatehasone for now, then will readjust. Mannitol stopped on hospital day three. Patient discharged home with follow up and discharge intructions. | The aorta and great vessels appear unremarkable except atherosclerotic calcifications. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is sigmoid diverticulosis without evidence of diverticulitis. The abdominal aorta and its tributaries appear patent. R/O abcess vs metatsis; Also has basilar tip aneurysm REASON FOR THIS EXAMINATION: R/O abcess vs met and assess anuerysm. Liver, gallbladder, spleen, adrenal glands, and left kidney are within normal limits. Bladder, uterus, and rectum appear within normal limits. Mild downward displacement of the left cerebellar tonsil is seen probably related to the large cerebellar lesion and there is partial effacement of the left posterior quadrigeminal cistern. Large signal flow void involving the basilar tip which should be further evaluated on the MRA exam of the circle of to follow. Sigmoid diverticulosis without evidence of diverticulitis. Multiplanar T1- and T2-weighted images of the brain were obtained without and with intravenous gadolinium administration. The visualized anterior, middle, and posterior cerebral arteries are patent. Pt on mannitol IV. Condition UpdatePlease see carevue for specifics.Pt arrived to unit approx 2100 post MRI, CT. Neuro intact. There is mass effect involving the left pontomedullary junction due to the presence of a large left cerebellar lesion and slight compression of the fourth ventricle inferiorly. As suspected on the CT examination, there is a large aneurysm involving the basilar tip, which measures 1.1 x 1 cm. MDCT acquired axial images of the abdomen without contrast, followed by chest and abdomen with intravenous contrast, followed by 3 minute delayed imaging of the abdomen and pelvis. TECHNIQUE: Oncology torso with intravenous contrast. IMPRESSION: Large 1.1 x 1 cm aneurysm involving the basilar tip. There are atherosclerotic calcifications of the abdominal aorta and iliac vessels. CT OF THE ABDOMEN WITHOUT AND WITH CONTRAST: There is a subcentimeter hypoattenuating lesion in the left lobe of the liver, which most likely represents a cyst but malignancy cannot be excluded, and MRI would be recommended if further evaluation is indicated. There is slight enhancement seen peripherally following intravenous gadolinium administration. The intracranial (Over) 3:34 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MR CONTRAST GADOLIN Reason: R/O abcess vs met and assess anuerysm. The right kidney contains two hypoenhancing lesions that are too small to characterize, but most likely represent renal cysts. Correlation is made to a CT examination dated . Two subcentimeter hypoattenuating lesions in the right kidney, most likely representing cysts. (Over) 8:13 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: R/O Multiple metastises Admitting Diagnosis: BRAIN METS;TELEMETRY Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) BONE WINDOWS: No suspicious lytic or blastic lesions are seen. Metastatic lesions, however, cannot be excluded; an ultrasound opr MRI may be helpful for clarification if indicated. MRI +/-gado plus mra Admitting Diagnosis: BRAIN METS;TELEMETRY Contrast: MAGNEVIST Amt: 15 FINAL REPORT (Cont) circulation is patent. There is mild surrounding vasogenic edema. Assess for metastasis. These are most likely consistent with metastatic lesions probably related to the patient's underlying lung mass. Q 1 hour neuro checks. Emphysematous changes predominantly at the lung apices. Approved: FRI 3:51 PM RADLINE ; A radiology consult service. There are mild atelectatic changes at the left lung base. Subcentimeter hypoattenuating lesion in the left lobe of the liver too small to accurately characterize. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. 02 sats 97-100% RA. Pt oob to the commode to void. IMPRESSION: No abnormal tracer activity to suggest metastic disease. This most likely represents a cyst; however, if clinically indicated, an MRI for further assessment would be helpful. C/O headache. The liver is otherwise unremarkable. CT OF THE CHEST WITH INTRAVENOUS CONTRAST: No axillary, mediastinal, or hilar lymphadenopathy is seen. Mild increased activity in the cervical and lumbar spine suggestive of degenerative change. 3:34 PM MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # MR CONTRAST GADOLIN Reason: R/O abcess vs met and assess anuerysm. MRI +/-gado plus mra FINAL REPORT MRI OF THE BRAIN WITH CONTRAST AND MRA OF THE CIRCLE OF CLINICAL INDICATION: Cystic lesions seen on head CT. Also history of lung mass. The study overall is insensitive to detect tiny aneurysms less than 3 mm in diameter. The pancreas, stomach, and opacified loops of large and small bowel appear unremarkable. Emphysematous changes are seen predominantly at the lung apices. IVF. 8:13 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: R/O Multiple metastises Admitting Diagnosis: BRAIN METS;TELEMETRY Field of view: 36 Contrast: OPTIRAY Amt: 130 MEDICAL CONDITION: 57 year old woman with large mass on chest plain film and multiple brain lesions REASON FOR THIS EXAMINATION: R/O Multiple metastises No contraindications for IV contrast FINAL REPORT INDICATION: Mass on chest plain film and multiple brain lesions, rule out multiple metastases. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2118-03-16 00:00:00.000",
"description": "Report",
"row_id": 1594320,
"text": "Condition Update\nPlease see carevue for specifics.\n\nPt arrived to unit approx 2100 post MRI, CT. Neuro intact. PERRL. C/O headache. 2 mg morphine sulfate given w + effect. SBP goal < 150. Pt written for a nicardipine gtt, but bp maintained under goal without it. NSR, no ectopy noted. No c/o sob. 02 sats 97-100% RA. IVF ns w/ 20mek kcl infusing. Pt oob to the commode to void. Pt told she can eat for now since bp under md . Integ intact. Pt on mannitol IV. Pt on the phone early this am calling her contacts to get affairs in order.\n\nPlan: continue with current plan of care per sicu/ neuro sx teams. Maintain sbp < 150. Pt has nicardipine gtt ordered if needed. IVF. IV mannitol q 6 hours. Monitor NA + osms q 6 hours. Q 1 hour neuro checks. Pain mgmt.\n"
},
{
"category": "Radiology",
"chartdate": "2118-03-15 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 906561,
"text": " 8:13 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: R/O Multiple metastises\n Admitting Diagnosis: BRAIN METS;TELEMETRY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with large mass on chest plain film and multiple brain\n lesions\n REASON FOR THIS EXAMINATION:\n R/O Multiple metastises\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mass on chest plain film and multiple brain lesions, rule out\n multiple metastases.\n\n No prior CT studies are available on PACS for comparison purposes.\n\n TECHNIQUE: Oncology torso with intravenous contrast. MDCT acquired axial\n images of the abdomen without contrast, followed by chest and abdomen with\n intravenous contrast, followed by 3 minute delayed imaging of the abdomen and\n pelvis.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: No axillary, mediastinal, or hilar\n lymphadenopathy is seen. Emphysematous changes are seen predominantly at the\n lung apices.\n\n A large mass is seen in the left upper lobe measuring 5.4 cm in maximal\n diameter. No other lung masses or nodules are seen. There are mild\n atelectatic changes at the left lung base. No pleural effusions are seen. The\n heart is normal in size, there is no pericardial effusion. The aorta and\n great vessels appear unremarkable except atherosclerotic calcifications.\n\n CT OF THE ABDOMEN WITHOUT AND WITH CONTRAST: There is a subcentimeter\n hypoattenuating lesion in the left lobe of the liver, which most likely\n represents a cyst but malignancy cannot be excluded, and MRI would be\n recommended if further evaluation is indicated. The liver is otherwise\n unremarkable. Liver, gallbladder, spleen, adrenal glands, and left kidney are\n within normal limits. The right kidney contains two hypoenhancing lesions\n that are too small to characterize, but most likely represent renal cysts.\n Metastatic lesions, however, cannot be excluded; an ultrasound opr MRI may be\n helpful for clarification if indicated. The pancreas, stomach, and opacified\n loops of large and small bowel appear unremarkable. No mesenteric or\n retroperitoneal lymphadenopathy is seen. The abdominal aorta and its\n tributaries appear patent. There are atherosclerotic calcifications of the\n abdominal aorta and iliac vessels. No ascites or free air is seen.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is sigmoid diverticulosis\n without evidence of diverticulitis. Bladder, uterus, and rectum appear within\n normal limits. No free fluid is seen within the pelvis. No pelvic or\n inguinal lymphadenopathy is detected.\n (Over)\n\n 8:13 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: R/O Multiple metastises\n Admitting Diagnosis: BRAIN METS;TELEMETRY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are seen.\n\n IMPRESSION:\n 1. Large lung mass in the left upper lobe consistent with lung cancer.\n 2. Subcentimeter hypoattenuating lesion in the left lobe of the liver too\n small to accurately characterize. This most likely represents a cyst;\n however, if clinically indicated, an MRI for further assessment would be\n helpful.\n 3. Two subcentimeter hypoattenuating lesions in the right kidney, most likely\n representing cysts. Ultrasounds or MRI would be recommended if further\n assessment is indicated.\n 4. Sigmoid diverticulosis without evidence of diverticulitis.\n 5. Emphysematous changes predominantly at the lung apices.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-03-17 00:00:00.000",
"description": "BONE SCAN",
"row_id": 906756,
"text": "BONE SCAN Clip # \n Reason: 57 YO WITH MET CA, UNKNOWN PRIMARY, MOST LIKELY LUNG PT WITH MULTIPLE BRAIN METS AND LUNG MASS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic cancer\n\n INTERPRETATION:\n\n Whole body images of the skeleton obtained in anterior and posterior\n projections show mild increased uptake in the cervical and lumbar spine that are\n suggestive of degenerative change. No increased activity suggestive of\n metastatic disease is seen.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: No abnormal tracer activity to suggest metastic disease. Mild\n increased activity in the cervical and lumbar spine suggestive of degenerative\n change.\n\n\n , M.D.\n , M.D. Approved: FRI 3:51 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2118-03-16 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 906688,
"text": " 3:34 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: R/O abcess vs met and assess anuerysm. MRI +/-gado plus mra\n Admitting Diagnosis: BRAIN METS;TELEMETRY\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with large cystic lesions on head CT, large lung tumor recent\n hx of root canal. R/O abcess vs metatsis; Also has basilar tip aneurysm\n REASON FOR THIS EXAMINATION:\n R/O abcess vs met and assess anuerysm. MRI +/-gado plus mra\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE BRAIN WITH CONTRAST AND MRA OF THE CIRCLE OF \n\n CLINICAL INDICATION: Cystic lesions seen on head CT. Also history of lung\n mass. Assess for metastasis.\n\n Multiplanar T1- and T2-weighted images of the brain were obtained without and\n with intravenous gadolinium administration. Correlation is made to a CT\n examination dated .\n\n There are several large cystic lesions of increased T1 and T2 signal involving\n the left cerebellar hemisphere, the right parietal lobe posteriorly, and the\n right frontal lobes. The lesions demonstrate increased T1 signal probably\n related to the presence of high content of protein. There is slight\n enhancement seen peripherally following intravenous gadolinium administration.\n The largest of these lesions is seen within the right posterior\n occipitoparietal region and measures 5.2 x 3.6 cm. There is mild surrounding\n vasogenic edema. These are most likely consistent with metastatic lesions\n probably related to the patient's underlying lung mass. There is mass effect\n involving the left pontomedullary junction due to the presence of a large left\n cerebellar lesion and slight compression of the fourth ventricle inferiorly.\n No hydrocephalus is seen. There is slight midline shift to the left by 3 mm.\n Mild downward displacement of the left cerebellar tonsil is seen probably\n related to the large cerebellar lesion and there is partial effacement of the\n left posterior quadrigeminal cistern. No pathologic meningeal enhancement\n seen following intravenous gadolinium administration. There are no acute\n territorial infarcts noted on diffusion image.\n\n IMPRESSION: Several large lesions of increased T1 and T2 signal involving the\n left cerebellar, right frontal, and right occipitoparietal lobes with\n surrounding vasogenic edema most likely consistent with diffuse brain\n metastases possibly related to the patient's underlying lung mass. Large\n signal flow void involving the basilar tip which should be further evaluated\n on the MRA exam of the circle of to follow.\n\n MRA OF THE CIRCLE OF : 3D time-of-flight MRA of the circle of \n was performed. As suspected on the CT examination, there is a large aneurysm\n involving the basilar tip, which measures 1.1 x 1 cm. The visualized\n anterior, middle, and posterior cerebral arteries are patent. No other\n aneurysms are seen in the region of the MCA trifurcation. The intracranial\n (Over)\n\n 3:34 PM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: R/O abcess vs met and assess anuerysm. MRI +/-gado plus mra\n Admitting Diagnosis: BRAIN METS;TELEMETRY\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n circulation is patent. The study overall is insensitive to detect tiny\n aneurysms less than 3 mm in diameter.\n\n IMPRESSION: Large 1.1 x 1 cm aneurysm involving the basilar tip. Correlation\n with neurosurgical consultation and followup is helpful.\n\n"
}
] |
11,586 | 196,500 | By the morning following her admission, the patient's clinical status was substantially improved. She was breathing comfortably and her oxygen saturation was 94% on room air. She continued to refuse oxygen by nasal cannula and BiPAP, but she was continued on metered-dose inhalers and steroids. She was initially started on azithromycin for congestive obstructive pulmonary disease exacerbation, but this medication was stopped on hospital day two. In terms of her pulmonary status, she was discharged with inhalers as noted below, and a short course of steroids as noted below. Given that the patient was ruled out for myocardial infarction by cardiac enzymes at the outside hospital, and given her absence of significant electrocardiogram findings on admission to the , she was not ruled out for a myocardial infarction by cardiac enzymes here. She was continued on Telemetry during hospital days one and two without any significant events. Due to the patient's markedly elevated TSH at the outside hospital, the Endocrinology service was consulted for their recommendations for further management of her hypothyroidism. Of note, her TSH here was found to be 64, and her free T4 was 0.6. Overall, the Endocrine service agreed with the management that had already taken place, and agreed to continue the patient on the prior standing dose of levothyroxine 225 mcg po q day. In terms of her diabetes, given her symptoms of congestive heart failure, she was not deemed to be a good candidate for metformin or a TZD at this time. Because of her evidently poor glycemic control, a Nutrition consult was recommended for outpatient management of a diabetic diet, the nutritionist left materials with the patient regarding how to eat a proper diabetic diet. In addition, a hemoglobin A1C level was checked prior to discharge, digoxin level was pending at the time of discharge, but would certainly be expected to be high given the appearance of poor glycemic control on an outpatient basis. Given that the patient was transferred to the from an inpatient psychiatric facility, a Psychiatry service consult was requested. During extensive history taking, the Psychiatry service learned that the patient has an extensive past psychiatric history, including major depression, possible posttraumatic stress disorder, dissociative disorder, not otherwise specified, and psychosis due to cocaine. Patient has seen psychiatrist since she was a young girl, and reported an early and chronic history of sexual abuse by her stepfather, uncle, and other male relatives since age six. She has had multiple psychiatric admissions for episodes of depression and multiple suicide attempts. Her last hospitalization was at earlier this month for a question of depression and suicidal ideations. She has had other hospitalizations at , , , and . She described multiple suicide attempts including one episode when she drank bleach and Pinesol when her brother died from AIDS. She also gave a history of cutting her arms and legs, as well as shooting herself with gun in the leg. The patient also described of assault where she "becomes like a zombie" and flies into a rage. She stated that she had attacked people with bats and various other objects. She states that she "blacks out" and has no control or recall of the details of these events. She also described a history of head trauma wherein she "passed out once", but was unable to provide any details of that event. Because of the patient's persistent suicidal ideation, she was discharged to the Inspiratory Psychiatry Unit on the day of discharge as she was medically cleared for discharge from the Medicine service. | Mediastinal and hilar contours are unremarkable. Soft tissue and osseous structures are unremarkable. However, no focal opacities or pleural effusions are appreciated given this. No pneumothorax. Normal ECG. FINDINGS: Due to the patient's body habitus and technique, evaluation of the lung bases is limited. There is no prior for comparison. IMPRESSION: Allowing for body habitus and technique, no definite abnormalities appreciated. No previous tracing available for comparison. The heart is upper limits of normal in size. with CP. with CP. However, evaluation of the lung bases is limited due to these factors. The pulmonary vasculature is normal. Sinus rhythm. REASON FOR THIS EXAMINATION: 44 yr old pt with cyanosis and wheezing assoc. 8:14 PM CHEST (PORTABLE AP) Clip # Reason: 44 yr old pt with cyanosis and wheezing assoc. A dedicated PA & lateral view is recommended for better evaluation. FINAL REPORT AP PORTABLE CHEST: INDICATION: 44 y/o female with cyanosis, wheezing and associated chest pain. | 2 | [
{
"category": "Radiology",
"chartdate": "2201-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 787830,
"text": " 8:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 44 yr old pt with cyanosis and wheezing assoc. with CP.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with RAD, HTN, DM, and etoh abuse.\n REASON FOR THIS EXAMINATION:\n 44 yr old pt with cyanosis and wheezing assoc. with CP.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST:\n\n INDICATION: 44 y/o female with cyanosis, wheezing and associated chest pain.\n\n There is no prior for comparison.\n\n FINDINGS: Due to the patient's body habitus and technique, evaluation of the\n lung bases is limited. However, no focal opacities or pleural effusions are\n appreciated given this. The heart is upper limits of normal in size.\n Mediastinal and hilar contours are unremarkable. No pneumothorax. The\n pulmonary vasculature is normal. Soft tissue and osseous structures are\n unremarkable.\n\n IMPRESSION: Allowing for body habitus and technique, no definite abnormalities\n appreciated. However, evaluation of the lung bases is limited due to these\n factors. A dedicated PA & lateral view is recommended for better evaluation.\n\n"
},
{
"category": "ECG",
"chartdate": "2201-06-01 00:00:00.000",
"description": "Report",
"row_id": 168460,
"text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
}
] |
22,352 | 141,238 | By systems. 1. Cardio-Respiratory: The infant remained in room air during his brief hospitalization at . Oxygen saturation range was 92-95%. There was no apnea noted. The murmur persisted during his stay. 2. Fluids, electrolytes and nutrition: tube was placed and maintained to gravity. The infant was made NPO. Intravenous 10% Dextrose therapy was initiated at 80 cc/kg/d. The birth weight was 3130 grams. 3. Gastrointestinal. The bowel was pink, and the colon was very mildly dilated. General Surgery was present to inspect the viscera and accompanied the baby back to . 4. Hematology. CBC showed a Hct 43.9, Plts 406k, and WBC 4.3 with 27 polys and 4 bands. 5. Infectious Disease. Blood culture was sent and the infant was started on Ampicillin and Gentamycin. 6. Neurology. There were no neurologic issues. | To receive Ampi. PKU done. Gent presently being given. HL placed in R hand. BP 74/38 (52). Bowel wrapped. Seen in CH AFCC reportedly by Dr. . Baby meds given. On arrival T 100.1x. Will give initial dose of ampicillin and gentamicin. Viscera bag applied. CBC and diff sent. CH General Surgery called and present. DS 103. Down to 99.2x. BBS clear and =. Gauze wrapped. Followed with serial ultrasounds. Received intrapartum antibiotic coverage. Will obtain cbc, blood culture, clot, and newborn screen. NSVD with Apgars 8, 9.Pink small and mildly dilated large bowel noted. Upon arrival to NICU abdomen wrapped in 4 x 4's soaked with warmed saline and kerlex. Belly soft. 10F repogle to gravity in place. Tolerated well. Antepartum remarkable for fetal gastroschisis noted on prenatal survey. Questions answered. Perfusion uncompromised. 7 North aware. Vitamin K administered in DR. saline gauze applied. Plan early transfer.Primary pediatrician not yet identified, but family anticipates to be at .Will require follow up of HBsAg and RPR. Color pink. HR's 150-170's. D10W infusing without difficulty @ 80cc/k. 4 x 4's and kerlex removed by TCH surgeon. Loud murmur heard. Hepatitis B vaccine given d/t unknown status. To NICU.Exam notable for pink, well-appearing infant in no distress with soft AF, pink color, nl facies, intact palate, no gfr, clear breath sounds, 2/6 systolic murmur at llsb, present femoral pulses, flat soft n-t abdomen, pink small bowel and mildy dilated large bowel, anus present, nl phallus, testes in scrotum, stable hips, nl tone/activity.Term infant with gastroschisis. No known sepsis risk. Lower body wrapped in plastic bag. Shown to family. Antepartum also notable for positive vaginal chlamydia culture treated by OB.Admitted this morning in labor. No obvious void or stool yet. Will administer hepatitis B vaccine. Unable to obtain clot. Transfer Note: Pls see attending MD's note for mom's history and DR . O2 sats 91-95% in RA. Last U/S on notable for no echogenic areas and absent bowel dilatation. No maternal fever. | 2 | [
{
"category": "Nursing/other",
"chartdate": "2178-11-29 00:00:00.000",
"description": "Report",
"row_id": 1983750,
"text": "Neonatology Attending\n\nFT infant with gastroschisis admitted for NICU management prior to transfer.\n\nInfant born at 38 weeks to 25 yo G1 A+, Ab-, GBS-, HBsAg pending, RPR pending woman. Antepartum remarkable for fetal gastroschisis noted on prenatal survey. Followed with serial ultrasounds. Last U/S on notable for no echogenic areas and absent bowel dilatation. Seen in CH AFCC reportedly by Dr. . Antepartum also notable for positive vaginal chlamydia culture treated by OB.\n\nAdmitted this morning in labor. Received intrapartum antibiotic coverage. No maternal fever. NSVD with Apgars 8, 9.\n\nPink small and mildly dilated large bowel noted. Vitamin K administered in DR. saline gauze applied. Gauze wrapped. Viscera bag applied. Tolerated well. To NICU.\n\nExam notable for pink, well-appearing infant in no distress with soft AF, pink color, nl facies, intact palate, no gfr, clear breath sounds, 2/6 systolic murmur at llsb, present femoral pulses, flat soft n-t abdomen, pink small bowel and mildy dilated large bowel, anus present, nl phallus, testes in scrotum, stable hips, nl tone/activity.\n\nTerm infant with gastroschisis. Bowel wrapped. No known sepsis risk. Will obtain cbc, blood culture, clot, and newborn screen. Will give initial dose of ampicillin and gentamicin. CH General Surgery called and present. 7 North aware. Plan early transfer.\n\nPrimary pediatrician not yet identified, but family anticipates to be at .\n\nWill require follow up of HBsAg and RPR. Will administer hepatitis B vaccine.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-29 00:00:00.000",
"description": "Report",
"row_id": 1983751,
"text": "Transfer Note: Pls see attending MD's note for mom's history and DR . Upon arrival to NICU abdomen wrapped in 4 x 4's soaked with warmed saline and kerlex. Lower body wrapped in plastic bag. 10F repogle to gravity in place. 4 x 4's and kerlex removed by TCH surgeon. On arrival T 100.1x. Down to 99.2x. HR's 150-170's. BP 74/38 (52). Color pink. Perfusion uncompromised. Loud murmur heard. O2 sats 91-95% in RA. BBS clear and =. Belly soft. No obvious void or stool yet. DS 103. HL placed in R hand. D10W infusing without difficulty @ 80cc/k. CBC and diff sent. Unable to obtain clot. PKU done. Hepatitis B vaccine given d/t unknown status. Baby meds given. Gent presently being given. To receive Ampi. Shown to family. Questions answered.\n"
}
] |
93,203 | 100,855 | 1. Alcohol intoxication: Intoxicated on arrival to the ED with initial EtOh level of 306. Reported history of withdrawal seizures, most recent 3 months ago. SW consult was placed as pt expressed the desire to attempt to undergo treatment for this issue. PPD placed on as part of screening process, per pt has been negative in the past. 2. Alcohoic / diabetic ketoacidosis: Presented with + anion gap and ketones in the urine; possible combination of alcoholic and diabetic ketoacidosis. After insulin and IVF, gap closed. 3. Chronic pancreatitis: Abdominal pain was consistent with prior chronic pancreatitis, although initially appeared comfortable. Pain worsened and was transitioned to IV pain medications and made NPO with improvement in his pain. Diet was restarted and advanced and initiallly he complained of pain and had to return to IV medication, but it was then noted that patient was electing to eat a regular diet by getting his own food, despite clear instruction to remain NPO. He was returned to PO pain medication only. 4. Thrombocytopenia: Recently noted with possible direct alcohol effect. No evidence of cirrhosis on exam and INR/albumin were preserved. 5. Hand Cellulitis/abscess- infection developed on right hand at site of his IV, treated with Kelflx for one week. 6. Diabetes mellitus, on insulin: On insulin sliding scale inpatient and small dose NPH . Pt with very high sugars in 300-400's once diet restarted. Given questionable ability to comply with complex insulin regimen, discharged home with once daily Lantus and f/u with PCP 1 week. Pt instructed to log blood sugars at home and bring log to next PCP appt on . 7. Smoker: Nicotine gum prescribed. 8. Homeless: Pt given vouchers/train pass to get to Fall Rivers where his mother lives. Medications on Admission: | TheQ waves in leads V1-V2 are compatible with anteroseptal myocardial infarction,age undetermined. Fat stranding within umbilical hernia. Fat stranding within umbilical hernia. Fat stranding within umbilical hernia. FINDINGS: The visualized lung bases are unremarkable. IMPRESSION: No acute intracranial abnormality. No contraindications for IV contrast PFI REPORT 1. There is an umbilical hernia containing fat and stranding. FINAL REPORT EXAM: Non-contraast and Contrast-enhanced CT of the abdomen. The gallbladder is unremarkable. IMPRESSION: No signs for acute cardiopulmonary process. The cardiac silhouette and mediastinum is normal. Sinus rhythm. The spleen and kidneys are unremarkable. Pancreatic calcifications consistent with chronic pancreatitis. Pancreatic calcifications consistent with chronic pancreatitis. Pancreatic calcifications consistent with chronic pancreatitis. COMPARISON: Multiple prior CTs, most recently CT of the abdomen . TECHNIQUE: Axial CT images were acquired through the head without intravenous contrast. FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or vascular territorial infarction. (Over) 10:18 AM CT ABD W&W/O C Clip # Reason: history of multiple episodes pancreatitis; now with acute ep Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj FRI 7:14 PM 1. There are coarse calcifications throughout the pancreas consistent with chronic pancreatitis. Osseous structures are unremarkable. Ventricles and sulci are normal in size and in configuration. 12:02 AM CT HEAD W/O CONTRAST Clip # Reason: ? There is no ascites or free air in the abdomen. Bony structures are grossly intact. 10:18 AM CT ABD W&W/O C Clip # Reason: history of multiple episodes pancreatitis; now with acute ep Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS Contrast: OPTIRAY Amt: 100 MEDICAL CONDITION: 38 year old man with etoh related acute pancreatitis REASON FOR THIS EXAMINATION: history of multiple episodes pancreatitis; now with acute episode not improving with usual measures. IMPRESSION: 1. Compared to the previoustracing of the Q wave in lead V2, as well as a small R wave in lead V3,are new but again may be related to lead placement. , F. MED 5S 10:18 AM CT ABD W&W/O C Clip # Reason: history of multiple episodes pancreatitis; now with acute ep Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS Contrast: OPTIRAY Amt: 100 MEDICAL CONDITION: 38 year old man with etoh related acute pancreatitis REASON FOR THIS EXAMINATION: history of multiple episodes pancreatitis; now with acute episode not improving with usual measures. There is diffuse fatty infiltration of the liver which is more prominent when compared to prior exam. No evidence of any complications associated with acute pancreatitis. No evidence of any complications associated with acute pancreatitis. No evidence of any complications associated with acute pancreatitis. Evaluate for acute process. Delayed R wave progression may be due to lead placement. There are no pseudocysts, areas of necrosis, hemorrhage or abscess within the pancreas. The mastoid air cells are clear. 3. 3. 3. Clinical correlation is suggested. The lungs are clear. FINDINGS: Comparison is made to the previous study from . There is no fracture. There is no evidence of portal vein or splenic vein thrombosis. COMPARISON: . 2. 2. 2. Diffuse fatty infiltration of the liver increased since prior exam in . Diffuse fatty infiltration of the liver increased since prior exam in . Diffuse fatty infiltration of the liver increased since prior exam in . INDICATION: 38-year-old man with alcoholic pancreatitis, now with acute episode not improving. Coronal and sagittal reformatted images were also reviewed. There is increased fat stranding when compared with prior exam . TECHNIQUE: CT of the abdomen was performed with 64-slice MDCT before and after the administration of IV and oral contrast. 8:34 AM CHEST (PORTABLE AP) Clip # Reason: Please evalute for acute process Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS MEDICAL CONDITION: 38 year old man with ETOH intoxication REASON FOR THIS EXAMINATION: Please evalute for acute process FINAL REPORT STUDY: AP chest, . | 5 | [
{
"category": "Radiology",
"chartdate": "2185-08-05 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1153935,
"text": " 10:18 AM\n CT ABD W&W/O C Clip # \n Reason: history of multiple episodes pancreatitis; now with acute ep\n Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with etoh related acute pancreatitis\n REASON FOR THIS EXAMINATION:\n history of multiple episodes pancreatitis; now with acute episode not improving\n with usual measures.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj FRI 7:14 PM\n 1. Diffuse fatty infiltration of the liver increased since prior exam in\n .\n 2. Pancreatic calcifications consistent with chronic pancreatitis. No\n evidence of any complications associated with acute pancreatitis.\n 3. Fat stranding within umbilical hernia.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Non-contraast and Contrast-enhanced CT of the abdomen.\n\n INDICATION: 38-year-old man with alcoholic pancreatitis, now with acute\n episode not improving.\n\n TECHNIQUE: CT of the abdomen was performed with 64-slice MDCT before and\n after the administration of IV and oral contrast.\n\n COMPARISON: Multiple prior CTs, most recently CT of the abdomen .\n\n FINDINGS: The visualized lung bases are unremarkable. There is diffuse fatty\n infiltration of the liver which is more prominent when compared to prior exam.\n The gallbladder is unremarkable. There are coarse calcifications throughout\n the pancreas consistent with chronic pancreatitis. There are no pseudocysts,\n areas of necrosis, hemorrhage or abscess within the pancreas. There is no\n evidence of portal vein or splenic vein thrombosis. The spleen and kidneys\n are unremarkable. There is an umbilical hernia containing fat and stranding.\n There is increased fat stranding when compared with prior exam . There is no ascites or free air in the abdomen. Osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. Diffuse fatty infiltration of the liver increased since prior exam in\n .\n 2. Pancreatic calcifications consistent with chronic pancreatitis. No\n evidence of any complications associated with acute pancreatitis.\n 3. Fat stranding within umbilical hernia.\n (Over)\n\n 10:18 AM\n CT ABD W&W/O C Clip # \n Reason: history of multiple episodes pancreatitis; now with acute ep\n Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-07-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1153008,
"text": " 8:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evalute for acute process\n Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with ETOH intoxication\n REASON FOR THIS EXAMINATION:\n Please evalute for acute process\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 38-year-old man with alcohol intoxication. Evaluate for acute\n process.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The cardiac silhouette and mediastinum is normal. The lungs are clear. Bony\n structures are grossly intact.\n\n IMPRESSION:\n\n No signs for acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-08-05 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1153936,
"text": ", F. MED 5S 10:18 AM\n CT ABD W&W/O C Clip # \n Reason: history of multiple episodes pancreatitis; now with acute ep\n Admitting Diagnosis: ALCOHOLIC KETOACIDOSIS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with etoh related acute pancreatitis\n REASON FOR THIS EXAMINATION:\n history of multiple episodes pancreatitis; now with acute episode not improving\n with usual measures.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Diffuse fatty infiltration of the liver increased since prior exam in\n .\n 2. Pancreatic calcifications consistent with chronic pancreatitis. No\n evidence of any complications associated with acute pancreatitis.\n 3. Fat stranding within umbilical hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2185-07-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1152985,
"text": " 12:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ACUTE PROCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with found laying in trafic\n REASON FOR THIS EXAMINATION:\n acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SPfc SAT 1:15 AM\n no acute intracranial abnormality\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Man found lying in traffic.\n\n COMPARISON: .\n\n TECHNIQUE: Axial CT images were acquired through the head without intravenous\n contrast. Coronal and sagittal reformatted images were also reviewed.\n\n FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or\n vascular territorial infarction. Ventricles and sulci are normal in size and\n in configuration. There is no fracture. The mastoid air cells are clear.\n\n IMPRESSION: No acute intracranial abnormality.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2185-07-30 00:00:00.000",
"description": "Report",
"row_id": 227103,
"text": "Sinus rhythm. Delayed R wave progression may be due to lead placement. The\nQ waves in leads V1-V2 are compatible with anteroseptal myocardial infarction,\nage undetermined. Clinical correlation is suggested. Compared to the previous\ntracing of the Q wave in lead V2, as well as a small R wave in lead V3,\nare new but again may be related to lead placement.\n\n"
}
] |
85,828 | 136,980 | 45 year old male with HIV (on HAART, CD488 and viral load <75), Raynaud's, hypothyroidism, scleroderma, chronic renal insufficiency interstitial lung disease who initially presented with high fevers, chills, cough and post-tussive emesis X1 day, transferred to MICU for recurrent fever, hypoxia and tachypnea. . This patient had a long and storied course here at with several transfers in and out of the MICU for bouts of hypotension and tachypnea most likley related to underlying illness and/or medicaion effects. He never required pressor support or mechanical ventilation. A problem based list is found below as well as transitional issues that need follow up in the immediate future. . # Fevers/ Hypoxia: Overall workup for his illness has been negative thus far including Flu, respiratory viral panel, urine legionalla antigen, Blood(bacterial and fungal) cultures, 2 negative PCP smears, serum cryptococcal and stool cultures on admission. His presentation is most consistent with a respiratory illness including atypical/viral pneumonia. Patient was improving then acutely decompensated requiring MICU transfer and there was concern of aspiration/HCAP consequently was started on Vanc/Cefepime for broad coverage. He continues to improve on vanc and cefepime and should continue vancomycin and cefepime antibiotics until for a total of 8 days. Patient was empirically treated for pcp on admission, then following bronch BAL negative for pcp was decreased to prophlaxic dosing. The next day he developed increasing RR consequently decision was made to treat for pcp (as well as HCAP Vanc/Cefepime as above). He will complete a 21 day course of bactrim treatment on after which he will reduce his dose to prophylaxic dose until his CD4 count recovers. He was afebrile with no oxygen requirement on the day of discharge. | New mild septal thickening, suggesting mild interstitial edema. New mild septal thickening, suggesting mild interstitial edema. Septal thickening, suggesting mild interstitial edema. Sinus rhythm with borderline sinus tachycardia. Sinus rhythm with borderline sinus tachycardia. Bilateral diffuse hazy opacities are present as well as more confluent consolidative opacities in the right mid and both lower lung regions. Moderate right pleural effusion is present, possibly focusing with pleural thickening. The esophagus is patulous, as on prior studies, again compatible with known history of scleroderma. Dilated esophagus, in keeping with scleroderma. Dilated esophagus, in keeping with scleroderma. These findings are superimposed upon basilar predominant chronic interstitial fibrosis. There is a small right-sided pleural effusion. There is a small right-sided pleural effusion. Stable mediastinal adenopathy, likely reactive. Stable mediastinal adenopathy, likely reactive. Stable mediastinal adenopathy, likely reactive. Superimposed on background chronic basal predominant interstitial changes, ground-glass opacities, particularly within the right hemithorax have mildly decreased in extent. crohns, chronic appendicitis). Incidental note is made of an umbilical hernia containing fat (series 2, image 52). There are small volume retroperitoneal lymph nodes. Basilar-predominant bronchiectasis and fibrotic change, with conspicuous honeycombing at the right lung base. Basilar-predominant bronchiectasis and fibrotic change, with conspicuous honeycombing at the right lung base. Sinus tachycardia with ventricular premature beats. There is mediastinal adenopathy, though similar in appearance to . COMPARISON: and chest CT dated . Retroperitoneal and pelvic adenopathy, stable and unchanged when compared to prior CT, likely related to known systemic sclerosis / HIV. Bibasilar fibrosis consistent with known UIP and systemic sclerosis. There is a small right pleural effusion. FINDINGS: CT ABDOMEN: Again there is fibrosis, traction bronchiectasis and honeycombing noted within the lower lobes bilaterally consistent with known usual interstitial pneumonitis and systemic sclerosis, stable and unchanged when compared to prior imaging. The findings may reflect infection or mildly improving edema. FINDINGS: There are chronic reticular opacities in the bilateral bases with low lung volumes, compatible with known fibrotic lung disease. Basilar-predominant pulmonary fibrosis, most compatible with fibrotic NSIP related to the patient's known diagnosis of scleroderma. The appearance is most compatible with fibrotic NSIP related to patient's scleroderma, though UIP could have a simlar appearance. This is most likely infectious in etiology, though there is likely also a component of mild pulmonary edema, as indicated by presence of mild smooth septal thickening. Associated esophageal dilatation is also noted. Associated esophageal dilatation is also noted. FINDINGS: Heart is mildly enlarged. New ground-glass and consolidative opacities, which could represent pulmonary edema, opportunistic infection such as PCP, hemorrhage, or acute exacerbation of known interstitial lung disease. Findings are compatible with a fibrotic NSIP, though UIP could have a similar appearance, and are in keeping with the patient's known diagnosis of scleroderma. Findings are compatible with a fibrotic NSIP, though UIP could have a similar appearance, and are in keeping with the patient's known diagnosis of scleroderma. Worsening interstitial disease? Worsening interstitial disease? Small volume inguinal lymph nodes are also identified. Pulmonary edema? Pulmonary edema? 4:57 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: Any evidence of perforation, appendicitis, obstruction? The patient is status post right middle lobe wedge resection, with stable postoperative appearance. This may reflect worsening infection (especially atypical infection such as PCP), worsening edema, or less likely acute worsening of the background interstitial process. Prominence of the main pulmonary artery, suggesting pulmonary hypertension. Prominence of the main pulmonary artery, suggesting pulmonary hypertension. Prominence of the main pulmonary artery, suggesting pulmonary hypertension. Again small bilateral hypodensities in both kidneys consistent with simple hepatic cysts. Possible small left pleural effusion as well. Of note, the history of NSIP raises the additional possibility of acute interstitial pneumonia, though this would be a diagnosis of exclusion. Of note, given the history of NSIP, acute interstitial pneumonia could also be considered, though this would be a diagnosis of exclusion. Of note, given the history of NSIP, acute interstitial pneumonia could also be considered, though this would be a diagnosis of exclusion. Delayed R wave progression.Modest low amplitude T wave changes. CT PELVIS: There is pelvic adenopathy. There is a large lucent region in the paramediastinal right lower lobe which is unchanged from prior studies. There is still mediastinal and pulmonary vascular engorgement suggesting cardiac decompensation but if pneumonia was present previously, it is improving. Ground-glass opacity is also superimposed upon the basilar fibrosis, likely reflecting the same process seen in the upper lobes. Ground-glass opacity is also superimposed upon the basilar fibrosis, likely reflecting the same process seen in the upper lobes. REASON FOR THIS EXAMINATION: Any evidence of perforation, appendicitis, obstruction? Stable prominent left extrarenal pelvis. Stable prominent left extrarenal pelvis. Associated esophageal dilatation also related to scleroderma is also noted. There is again a low-density lesion identified within the tail of the pancreas measuring 5 mm (series 2, image 30) stable when compared to prior imaging. There is calcification noted which may be consistent with a small appendicolith (series 2, image 66) versus calcification in the wall. FRONTAL CHEST RADIOGRAPH: The heart remains enlarged. Since theprevious tracing of sinus tachycardic rate is slower and ventricularectopy is not seen.TRACING #1 Differential diagnosis includes mucocele, granulomatous process of the appendix such as TB, or primary neoplasm of the appendix or carcinoid tumor. Coronal and sagittal reformations have been provided. There is a partially calcified 4.6 x 4.9 cm (series 2, image 38) complex parapelvic cyst in the left kidney, stable and unchanged when compared to prior imaging. The trachea and central airways are patent. Widening of the mediastinum is likely due to distended vascular structures and is accompanied by pulmonary vascular engorgement. | 12 | [
{
"category": "Radiology",
"chartdate": "2139-05-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1191522,
"text": " 9:38 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 43cm left picc. tip?\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 43cm left picc. tip?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:53 A.M. ON :\n\n HISTORY: New left PIC line.\n\n IMPRESSION: AP chest compared to through 29:\n\n Tip of the left PIC catheter extends at least a cm beyond the end of the wire\n in either the mid SVC or conceivably the azygos vein at that point. Lateral\n view would be needed to distinguish between the two locations. Peripheral\n consolidation in the right lung and small right pleural effusion have both\n decreased since . Consolidation at the left lung base has also\n improved. There is still mediastinal and pulmonary vascular engorgement\n suggesting cardiac decompensation but if pneumonia was present previously, it\n is improving. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1191206,
"text": " 7:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with HIV and pulmonary fibrosis, now with recurrence of fever\n to 101.6\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV with pulmonary fibrosis.\n\n COMPARISON: and chest CT dated .\n\n FRONTAL CHEST RADIOGRAPH: The heart remains enlarged. On background chronic\n basal predominant interstitial changes, ground-glass opacities have increased\n within the right hemithorax, particularly in the upper lobe. This may reflect\n worsening infection (especially atypical infection such as PCP), worsening\n edema, or less likely acute worsening of the background interstitial process.\n There is a small right-sided pleural effusion. No pneumothorax is\n appreciated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1191297,
"text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with HIV and pneumonia\n REASON FOR THIS EXAMINATION:\n Evaluate interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV and pneumonia.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The heart is moderately enlarged. Superimposed on\n background chronic basal predominant interstitial changes, ground-glass\n opacities, particularly within the right hemithorax have mildly decreased in\n extent. The findings may reflect infection or mildly improving edema. There\n is a small right-sided pleural effusion. No pneumothorax is appreciated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-19 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1190724,
"text": " 1:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Infectious cause overlying baseline interstitial disease? Pu\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cough, fever despite substantial antibiotic regimen.\n REASON FOR THIS EXAMINATION:\n Infectious cause overlying baseline interstitial disease? Pulmonary edema?\n Worsening interstitial disease?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy TUE 5:42 PM\n 1. Basilar-predominant bronchiectasis and fibrotic change, with conspicuous\n honeycombing at the right lung base. Findings are compatible with a fibrotic\n NSIP, though UIP could have a similar appearance, and are in keeping with the\n patient's known diagnosis of scleroderma. Associated esophageal dilatation is\n also noted.\n\n 2. New extensive ground-glass opacities throughout both lungs, most apparent\n at the right apex. Ground-glass opacity is also superimposed upon the basilar\n fibrosis, likely reflecting the same process seen in the upper lobes. This is\n most likely infectious in etiology, and given the history of HIV, PCP should\n be considered. Atypical infectious processes such as mycoplasma pneumonia, or\n viral pneumonias, should also be considered. Bacterial pneumonia is\n considered less likely given the radiographic appearance. Of note, given the\n history of NSIP, acute interstitial pneumonia could also be considered, though\n this would be a diagnosis of exclusion.\n\n 3. New mild septal thickening, suggesting mild interstitial edema.\n\n 4. Stable mediastinal adenopathy, likely reactive.\n\n 5. Dilated esophagus, in keeping with scleroderma.\n\n 6. Prominence of the main pulmonary artery, suggesting pulmonary\n hypertension.\n\n 7. Stable prominent left extrarenal pelvis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old male with cough and fever. The patient also has a\n history of HIV, scleroderma, and associated interstitial lung disease.\n\n COMPARISON: Multiple prior studies, dating back to , and most\n recently .\n\n TECHNIQUE: Non-contrast MDCT imaging of the chest was performed, with images\n reviewed in 5-mm axial, coronal, and sagittal soft tissue algorithm\n reformations as well as 5- and 1.25-mm collimated axial lung algorithm\n reformations.\n\n CT CHEST WITHOUT CONTRAST:\n (Over)\n\n 1:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Infectious cause overlying baseline interstitial disease? Pu\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The heart is normal in size, and there is no pericardial effusion. The aorta\n is unremarkable in caliber and contour. Main pulmonary artery is prominent,\n measuring up to 3.5 cm, suggesting underlying pulmonary hypertension. There is\n mediastinal adenopathy, though similar in appearance to . This\n may be reactive. There are no new or enlarging mediastinal nodes identified\n compared to prior study. The trachea and central airways are patent. There\n are no endobronchial lesions identified. The esophagus is patulous, as on\n prior studies, again compatible with known history of scleroderma.\n\n In the visualized upper abdomen, note is made of multiple retained pills\n within the stomach. The adrenal glands are normal. There is an unchanged\n prominent left extrarenal pelvis.\n\n The patient is status post right middle lobe wedge resection, with stable\n postoperative appearance. There is bilateral pleural thickening and small\n effusions, which appears increased compared to prior study. There is\n extensive fibrotic change seen at the lung bases, with prominent honeycombing\n seen on the right and associated architectural distortion and bronchiectasis.\n The appearance is most compatible with fibrotic NSIP related to patient's\n scleroderma, though UIP could have a simlar appearance. There is a large\n lucent region in the paramediastinal right lower lobe which is unchanged from\n prior studies.\n\n However, new compared to prior study is extensive ground-glass opacity, most\n apparent at the right apex, though also scattered throughout the remainder of\n the right and left upper lobes, as well as superimposed upon basilar fibrotic\n change. This is most likely infectious in etiology, though there is likely\n also a component of mild pulmonary edema, as indicated by presence of mild\n smooth septal thickening.\n\n There are no osseous lesions identified concerning for malignancy.\n\n IMPRESSION:\n\n 1. Basilar-predominant pulmonary fibrosis, most compatible with fibrotic NSIP\n related to the patient's known diagnosis of scleroderma. Associated\n esophageal dilatation also related to scleroderma is also noted.\n\n 2. Extensive new ground-glass opacities seen throughout both lungs, most\n apparent at the right apex. This is most likely infectious in etiology.\n Given the history of HIV, PCP should be considered. Atypical infectious\n processes such as mycoplasma or viral pneumonias are also likely. Bacterial\n or fungal pneumonia is considered less likely given the radiographic\n appearance. Of note, the history of NSIP raises the additional possibility of\n acute interstitial pneumonia, though this would be a diagnosis of exclusion.\n (Over)\n\n 1:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Infectious cause overlying baseline interstitial disease? Pu\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. Septal thickening, suggesting mild interstitial edema.\n\n 4. Stable mediastinal adenopathy, likely reactive.\n\n 5. Prominence of the main pulmonary artery, suggesting pulmonary\n hypertension.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-19 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1190725,
"text": ", J. MED FA2 1:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Infectious cause overlying baseline interstitial disease? Pu\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cough, fever despite substantial antibiotic regimen.\n REASON FOR THIS EXAMINATION:\n Infectious cause overlying baseline interstitial disease? Pulmonary edema?\n Worsening interstitial disease?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Basilar-predominant bronchiectasis and fibrotic change, with conspicuous\n honeycombing at the right lung base. Findings are compatible with a fibrotic\n NSIP, though UIP could have a similar appearance, and are in keeping with the\n patient's known diagnosis of scleroderma. Associated esophageal dilatation is\n also noted.\n\n 2. New extensive ground-glass opacities throughout both lungs, most apparent\n at the right apex. Ground-glass opacity is also superimposed upon the basilar\n fibrosis, likely reflecting the same process seen in the upper lobes. This is\n most likely infectious in etiology, and given the history of HIV, PCP should\n be considered. Atypical infectious processes such as mycoplasma pneumonia, or\n viral pneumonias, should also be considered. Bacterial pneumonia is\n considered less likely given the radiographic appearance. Of note, given the\n history of NSIP, acute interstitial pneumonia could also be considered, though\n this would be a diagnosis of exclusion.\n\n 3. New mild septal thickening, suggesting mild interstitial edema.\n\n 4. Stable mediastinal adenopathy, likely reactive.\n\n 5. Dilated esophagus, in keeping with scleroderma.\n\n 6. Prominence of the main pulmonary artery, suggesting pulmonary\n hypertension.\n\n 7. Stable prominent left extrarenal pelvis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1190293,
"text": " 10:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with headache, fever, h/o HIV\n REASON FOR THIS EXAMINATION:\n Eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg FRI 10:51 PM\n neg acute\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: A 45-year-old HIV positive male with headache.\n\n COMPARISON: .\n\n TECHNIQUE: Axial images were acquired of the head without contrast and\n reformatted into coronal and sagittal planes.\n\n FINDINGS: There is no acute intracranial hemorrhage, extra-axial collection,\n or mass effect. The ventricles and sulci are normal in size and\n configuration. matter/white matter differentiation is preserved.\n\n The orbits are intact. There is minimal ethmoidal air cell mucosal\n thickening, the remainder of the visualized paranasal sinuses are otherwise\n clear. The mastoid air cells are clear bilaterally.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1190291,
"text": " 10:00 PM\n CHEST (PA & LAT) Clip # \n Reason: Eval PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with fever\n REASON FOR THIS EXAMINATION:\n Eval PNA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 45-year-old male with HIV. Evaluate for pneumonia.\n\n COMPARISON: , .\n\n FINDINGS: There are chronic reticular opacities in the bilateral bases with\n low lung volumes, compatible with known fibrotic lung disease. There is no\n consolidation. There is a small right pleural effusion. The heart is normal\n in size. The mediastinal contours are unremarkable.\n\n IMPRESSION: Chronic changes of fibrotic lung disease without significant\n interval change in appearance from prior radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190397,
"text": " 11:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Acute cardiopulm processes\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with HIV, Raynaud's who p/w cough, high fevers, now hypotensive\n REASON FOR THIS EXAMINATION:\n Acute cardiopulm processes\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH OF \n\n COMPARISON: Chest x-rays dating between and .\n Comparison is also made to a chest CT of .\n\n FINDINGS: Heart is mildly enlarged. Widening of the mediastinum is likely\n due to distended vascular structures and is accompanied by pulmonary vascular\n engorgement. Bilateral diffuse hazy opacities are present as well as more\n confluent consolidative opacities in the right mid and both lower lung\n regions. These findings are superimposed upon basilar predominant chronic\n interstitial fibrosis. Moderate right pleural effusion is present, possibly\n focusing with pleural thickening. Possible small left pleural effusion as\n well.\n\n IMPRESSION:\n 1. New ground-glass and consolidative opacities, which could represent\n pulmonary edema, opportunistic infection such as PCP, hemorrhage, or\n acute exacerbation of known interstitial lung disease.\n\n 2. Widened mediastinum is likely a combination of enlarged main pulmonary\n artery from pulmonary arterial hypertension and distended venous structures.\n However, attention to the mediastinum on standard PA and lateral chest x-ray\n would be helpful when the patient's condition permits.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-16 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1190374,
"text": " 4:57 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Any evidence of perforation, appendicitis, obstruction?\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with sudden onset intense abdominal pain and vomiting; can give\n IV contrast if necessary, patient cannot tolerate PO contrast at this time.\n REASON FOR THIS EXAMINATION:\n Any evidence of perforation, appendicitis, obstruction?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS\n\n INDICATION: Sudden onset of intense abdominal pain and vomiting. Query\n cause.\n\n COMPARISON: CT chest , CT virtual colonoscopy \n and CT abdomen and pelvis .\n\n TECHNIQUE: MDCT axially-acquired images from the lung bases to the pubic\n symphysis displayed with 5-mm slice thickness with oral and IV contrast.\n Coronal and sagittal reformations have been provided.\n\n FINDINGS:\n\n CT ABDOMEN:\n Again there is fibrosis, traction bronchiectasis and honeycombing noted within\n the lower lobes bilaterally consistent with known usual interstitial\n pneumonitis and systemic sclerosis, stable and unchanged when compared to\n prior imaging. There has been an increase in thickening of the pleura on the\n right side compared to CT chest in .\n No evidence for pneumoperitoneum. No focal liver lesions. No intra- or\n extra-hepatic biliary dilatation. Gallbladder, spleen and adrenal glands are\n unremarkable. There is a partially calcified 4.6 x 4.9 cm (series 2, image\n 38) complex parapelvic cyst in the left kidney, stable and unchanged when\n compared to prior imaging. Again small bilateral hypodensities in both\n kidneys consistent with simple hepatic cysts.\n There is again a low-density lesion identified within the tail of the pancreas\n measuring 5 mm (series 2, image 30) stable when compared to prior imaging.\n\n There are small volume retroperitoneal lymph nodes. These measure 12 mm\n posterior to the IVC (series 2, image 32), left paraaortic inferior to the\n renal vein measuring 11 mm (series 2, image 37) and aortocaval measuring 11 mm\n (series 2, image 50). These appear grossly stable when compared to prior\n studies.\n Incidental note is made of an umbilical hernia containing fat (series 2, image\n 52).\n In the right lower quadrant, the appendix wall is thickened measuring 16 mm in\n diameter. There is calcification noted which may be consistent with a small\n appendicolith (series 2, image 66) versus calcification in the wall. There is\n (Over)\n\n 4:57 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Any evidence of perforation, appendicitis, obstruction?\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n no luminal distention to suggest obstruction. No surrounding mesenteric\n stranding or periappendiceal fluid. Differential diagnosis includes mucocele,\n granulomatous process of the appendix such as TB, or primary neoplasm of the\n appendix or carcinoid tumor.\n No small or large bowel dilatation in the visualized upper abdomen.\n\n CT PELVIS:\n There is pelvic adenopathy. There is a right common iliac lymph node\n measuring 15 mm (series 2, image 59) and the left external iliac lymph node\n measuring 13 mm (series 2, image 76). Small volume inguinal lymph nodes are\n also identified.\n No free fluid.\n Visualized rectum, sigmoid colon, bladder and prostate gland are unremarkable.\n\n\n CT OSSEOUS SKELETON:\n No osseous destructive lesion.\n\n IMPRESSION:\n\n 1. Thickened appendiceal wall resulting in an appendix measuring 16mm in\n diameter. No luminal distention to suggest obstruction or features of acute\n appendicitis such as peri-appendceal stranding or fluid. Differential\n diagnosis includes appendiceal neoplasm (cystadenoma, adeocarcinoma,\n carcinoid), granulomatous process of the appendix such as TB, or possibly\n other unusual inflammatory processes (e.g. crohns, chronic appendicitis).\n However, clinical correlation is recommended.\n\n 2. Retroperitoneal and pelvic adenopathy, stable and unchanged when compared\n to prior CT, likely related to known systemic sclerosis / HIV.\n\n 3. Bibasilar fibrosis consistent with known UIP and systemic sclerosis. There\n has been an increase in thickening of the pleura on the right side since Chest\n CT .\n\n FINDINGS DISCUSSED VIA TELEPHONE WITH DR. AT 19:48HRS, .\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-15 00:00:00.000",
"description": "Report",
"row_id": 273725,
"text": "Sinus tachycardia with ventricular premature beats. Compared to the previous\ntracing of ventricular premature beats are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Report",
"row_id": 273723,
"text": "Sinus rhythm with borderline sinus tachycardia. Delayed R wave progression.\nModest low amplitude T wave changes. Findings are non-specific. Since the\nprevious tracing of the same date no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-23 00:00:00.000",
"description": "Report",
"row_id": 273724,
"text": "Sinus rhythm with borderline sinus tachycardia. Delayed R wave progression\nwith late precordial QRS transition. Modest low amplitude T wave changes.\nFindings are non-specific. Clinical correlation is suggested. Since the\nprevious tracing of sinus tachycardic rate is slower and ventricular\nectopy is not seen.\nTRACING #1\n\n"
}
] |
3,225 | 151,206 | Patient was initially admitted to the ICU for close monitoring of his alcohol withdrawal. He did require significant amounts of valium. On the second day of admission, the patient was felt to be safe for transfer to the medical floor. He was continued on his CIWA scale with valium. On the morning after transfer. The patient signed out AMA from the hospital. The medical team explained the risks of leaving the hospital, including death, or other injuries from withdrawal from alcohol. He voiced understanding of these risks and signed out AMA. DESPITE REQUESTS TO STAY FOR FURTHER EVALUATION, THIS PATIENT WAS NOT SEEN BY AN ATTENDING ON THE DAY OF DISCHARGE | NURSING NOTE 0700HRS - 1600HRSADMIT WITH ALCOHOL WITHDRWAL/STATUS POST FALL BUT HEAD CT NO ACUTE PROCESS..RECEIVED TOTAL 110MGS VALIUM IN ED THEREFORE BROUGHT HERE FOR MONITORING OF WITHDRAWL AS KNOWN SEIZURE WITH WITHDRAWLNEURO..VERY PLEASANT CO-OPERATIVE WITH CARE A/O X3..WAS RECEIVING IV VALIUM, HAS RECEIVED TOTAL OF 60MGS SINCE MN THEN SWITCHED TO PO @ 12MD..PATIENT NOW ON STANDING VALIUM 20MGS Q6 WITH PRN Q2 10-20MGS, HAS RECEIVED TOTAL 50MGS PO..CIWA CONTINUES HRLY AND IS TO RECEIVE VALIUM FOR CIWA > 10..NO COMPLAINTS OF PAIN..HAS BEEN OOB TO COMMODE, HE IS A LITTLE SHAKY ON LEGS AND NEEDS ASSIST X1 BUT ALSO USES HIS CANE..RESP...COUGH, BUT NON PRODUCTIVE, SATS >95%..LUNGS SOUND CLEAR, GUIFENSIN PRN..CVS...B/P 110-140 SYSTOLIC..HR 75-85 WHEN RESTING TO 120-130"S ON EXERTION [TEAM AWARE. He drinks daily and arrived with an elevated ETOH level.Lines: (1) #20.ID: Afebrile.Con't to monitor for withdrawal and administer valium as appropriate. Tolerating regular diet.GU: Voiding in adequate amts via urinal.F/E Receiving MVI/ folate/ and thiamine bag IV at 100cc'hr times one.Social: Pt is homeless and lives on the street . He has been requiring 10mg IVP valium q1-2 hr. His last drink was ~1hr before arriving in ED. Experiencing 2 episodes of diarrhea via commode. Therefore, he's requiring ICU observation for withdrawal.Systems:Neuro: A&O x's 3. Requesting cough medicine.CV: HR 80-90's SR with no ectopy. He was sober for 30 days once, that was 10 yrs ago. IS FOR TELEM WHEN D/C TO FLOOR]..K/MG REPLETE THIS AM AND PATIENT HAS COMPLETED A BANANA BAG TODAY..AFEBRILE..GI..EATING/TAKING FLUIDS VERY WELL...HAS STOOLED X2..GU..EXCELLENT U/O VIA BOTTLE..SKIN..INTACT..LINES..X1 ..SOCIAL..PATIENT IS HOMELESS AND LIVES , HE HAS ALL OF HIS BELONGINGS WITH HIM..SOCIAL TEAM TO SEE PATIENT..PSYCH CONSULT ALSO DONE AND AWAIT REVIEW..PLAN...CIWA Q1 AS TRANSITIONING TO PO..CALLED OUT TO FLOOR He presented to the ED with complaints that he fell, but unknown details. He began requiring large amts of valium, 115 mg. 120's with minimal activity.GI: +BS, abdomen soft non tender. He has had multiple attempts to detox, without success. Pt states he can feel himself getting shaky and he does get tremulous.Resp: LS course. Head CT negative. MICU Admission Note Pt is a 49 yo male, who was brought to the ED ~0100 on the 16th. Junky non productive cough. Pt has been drinking since the age of 14. Following CIWA scale. Please contact Social services in am. He refuses to go to a shelter, stating "It's not for him". | 2 | [
{
"category": "Nursing/other",
"chartdate": "2134-01-17 00:00:00.000",
"description": "Report",
"row_id": 1303694,
"text": "MICU Admission Note\n Pt is a 49 yo male, who was brought to the ED ~0100 on the 16th. He presented to the ED with complaints that he fell, but unknown details. Head CT negative. His last drink was ~1hr before arriving in ED. Pt has been drinking since the age of 14. He was sober for 30 days once, that was 10 yrs ago. He began requiring large amts of valium, 115 mg. Therefore, he's requiring ICU observation for withdrawal.\n\nSystems:\n\nNeuro: A&O x's 3. Pleasant and cooperative. Following CIWA scale. He has been requiring 10mg IVP valium q1-2 hr. Pt states he can feel himself getting shaky and he does get tremulous.\n\nResp: LS course. Junky non productive cough. Requesting cough medicine.\n\nCV: HR 80-90's SR with no ectopy. 120's with minimal activity.\n\nGI: +BS, abdomen soft non tender. Experiencing 2 episodes of diarrhea via commode. Tolerating regular diet.\n\nGU: Voiding in adequate amts via urinal.\n\nF/E Receiving MVI/ folate/ and thiamine bag IV at 100cc'hr times one.\n\nSocial: Pt is homeless and lives on the street . He refuses to go to a shelter, stating \"It's not for him\". He has had multiple attempts to detox, without success. He drinks daily and arrived with an elevated ETOH level.\n\nLines: (1) #20.\n\nID: Afebrile.\n\nCon't to monitor for withdrawal and administer valium as appropriate. Please contact Social services in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-01-17 00:00:00.000",
"description": "Report",
"row_id": 1303695,
"text": "NURSING NOTE 0700HRS - 1600HRS\n\nADMIT WITH ALCOHOL WITHDRWAL/STATUS POST FALL BUT HEAD CT NO ACUTE PROCESS..RECEIVED TOTAL 110MGS VALIUM IN ED THEREFORE BROUGHT HERE FOR MONITORING OF WITHDRAWL AS KNOWN SEIZURE WITH WITHDRAWL\n\n\nNEURO..VERY PLEASANT CO-OPERATIVE WITH CARE A/O X3..WAS RECEIVING IV VALIUM, HAS RECEIVED TOTAL OF 60MGS SINCE MN THEN SWITCHED TO PO @ 12MD..PATIENT NOW ON STANDING VALIUM 20MGS Q6 WITH PRN Q2 10-20MGS, HAS RECEIVED TOTAL 50MGS PO..CIWA CONTINUES HRLY AND IS TO RECEIVE VALIUM FOR CIWA > 10..NO COMPLAINTS OF PAIN..HAS BEEN OOB TO COMMODE, HE IS A LITTLE SHAKY ON LEGS AND NEEDS ASSIST X1 BUT ALSO USES HIS CANE..\n\n\nRESP...COUGH, BUT NON PRODUCTIVE, SATS >95%..LUNGS SOUND CLEAR, GUIFENSIN PRN..\n\nCVS...B/P 110-140 SYSTOLIC..HR 75-85 WHEN RESTING TO 120-130\"S ON EXERTION [TEAM AWARE. IS FOR TELEM WHEN D/C TO FLOOR]..\nK/MG REPLETE THIS AM AND PATIENT HAS COMPLETED A BANANA BAG TODAY..\nAFEBRILE..\n\n\nGI..EATING/TAKING FLUIDS VERY WELL...HAS STOOLED X2..\n\nGU..EXCELLENT U/O VIA BOTTLE..\n\nSKIN..INTACT..\n\nLINES..X1 ..\n\nSOCIAL..PATIENT IS HOMELESS AND LIVES , HE HAS ALL OF HIS BELONGINGS WITH HIM..SOCIAL TEAM TO SEE PATIENT..PSYCH CONSULT ALSO DONE AND AWAIT REVIEW..\n\n\n\nPLAN...CIWA Q1 AS TRANSITIONING TO PO..CALLED OUT TO FLOOR\n\n\n"
}
] |
21,445 | 179,205 | 1. Anemia: Unclear cause. Hct had been trending down over the past few weeks prior to admission. There was great concern for bleed with elevated INR, but CT showed no evidence of RP bleed. Throughout hospital course, all guaiacs negative. Pt seen by hematology oncology. Lab tests did not show any indication of mircoangiopatic hemolytic anemia on peripheral smear, nor was there any evidence of DIC. Hematocrit remained fairly stable, however, the elavated LDH and concurrent lactic acidosis was thought to be secondary to the rapid cell turnover. Bone marrow biopsy showed 2+ PMNs on the gram stain, but no orgs. Pt was given Fe supplementation during hosptial stay. 2. Thrombocytopenia/left shift: Platelet count low with concerning etiology of infection vs. malignancy. Peripheral smear "toxic" appearing but left shift resolving. Platelet counts followed closely with low threshold to transfuse. 3. INR elevation: Baselin INR 4. INR peaked in the hospital at 41. No evidence of bleed on CT. Guiac negative in ED. Fall precautions. Received 2 U FFP, and SC and IV vitamin K in ED. 4. Acidosis: gap: Multiple possible etiologies. Patient has had elevated glucose since , elevated now with decreased PO intake, however serum acetone was negative. Urine ketones, serum acitone negative. Serum ASA negative. Appeared to be lactic acidosis and probable renal failure contributing. Hypoalbumin may have masked size of anion gap. IN the MICU, pt continued to have high Lactate, with noted consolidation on CXR. Pt was started on broad spectrum antibiotics, with strict glycemic control. 4.5. Respiratory failure secondary to hypoxia. Increased A-a gradient. The differential diagnosis was broad upon admission to the MICU, including worsening PNA, viral or bacterial with special consideration of influenza, as the leading causes, not excluding TRALI. Given patient's hx and likely immunosuppression, pt remained on broad spectrum antibiotics. Pt became rapidly tachypnic and dyspnic on the floor, and was intubated secondary to respiratory failure. 5. : Normal cr is 0.6-0.9. Acute process most likely secondary to intravascular volume depletion in the setting of volume overload. . 6. Tachypnea: likely from anemia and a respiratory compensation to metabolic acidosis. . 7. Edema/anasarca: Bilat leg edema worsening over hospital course was not likely consistent with bilat DVT, but given hx may consider LENIs. CT showed increase size in pleural effusions, subcutaneous edema, free abdominal fluid and a new pericardial effusion that was not seen on . Albumen was low. 30 protein in the UA. There was Concern for malignancy though no mass noted on CT scans. . 8. Elevated LFTs: AST/ALT at baseline, has had elevated AST presumably realted to 6-MG since . LDH abnormally high in the 4000s. Unclear if this was related to process, hemolysis, cancer. Will recheck today . 9. Elevated blood glucose. QID FS, RISS . 10. Hypertension: changed long acting antihypertensives to metoprolol and Dilt QID dosing. . | Noechocardiographic signs of tamponade.GENERAL COMMENTS: Right pleural effusion.Conclusions:1. has coagulopathy. on vanco, levoflox, and zoysn. +pp by doppler. Known pleural effusions, now intubated.Height: (in) 63Weight (lb): 138BSA (m2): 1.65 m2BP (mm Hg): 120/65HR (bpm): 104Status: InpatientDate/Time: at 16:01Test: Portable TTE (Focused views)Doppler: No dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The effusionappears anterior, loculated. Effusion is loculated. infilltrate. **pt. Pt ABG in this state 7.38/30/99/18,thus Pt emergently intubated. Started on vanco, levo and pipercillin. Pt received 625mg/of Tylenol via ngt. Resp. Lytes pending.GI: NPO except meds. NGT in place. +BS. to obtain nasal aspirates this am.CV: HR 80-90 NSR. Currently gtt at 7.0units/hr, with sugars in 130's.Skin: dry, intact. has been getting boluses of the solution with D5W. Started on esmolol drip for hypertension-SBP 160's. LS coarse upper, bronchial lower.CV: Pt received on Esmolol gtt for increased Bp and hr. Post bronch pt with sats 89-93% CXR indicative of pleural effusions. On ct pt. Currently on 19cc/hr of Neo. RESP CAREPT PROGRESSIVELY BECAME HYPOXIC WITH SPO2 UPPER 80S/LOW 90S ON 100% AND WAS SUBSEQUENTLY INTUBATED THIS A.M. WITH #7.5 ETT SECURED AT 21CM AT THE LIP. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets.PERICARDIUM: Small to moderate pericardial effusion. PT CURRENTLY VENTED ON A/C 600X 12 PEEP 10 AND 100% WITH SPO2 IN THE LOW 90S. Pt. Pt. PLt. PATIENT/TEST INFORMATION:Indication: Recent cecompensation, tachycardia. No residuals.GU: Foley in place to gravity. On 100% pt. Troponin .06ID: afebrile but immunosuppressed from treatment for melanoma. Can titrate esmolol to keep HR less than 80. On droplet precautions for ? Pt placed on 100% fio2. NPN 7A-7P********Sig Events************ Pt moved to CMO.Nuero: Pt received this morning confused, AOx2. Lactate levels 6 from 7. stim tests completed.GI: NPO except for meds. has mild failure and ? NPN 7p-7a**All data for this pt. Blood cx sent. Sinus rhythm WITH atrial premature complexesFirst degree A-V delayLeft atrial abnormalityProminent/peaked T waves - are nonspecific and may be within normal limits butclinical correlation is suggested for possible hyperkalemiaSince previous tracing of , atrial ectopy present (goal cvp >10, goal MAP >65) Pt also placed on Neo gtt for sustained hypotension. Normal LV cavity size. INCREASE PEEP AS NEEDED IF PT HEMODYNAMICALLY STABLE. After acute respiratory compromise Pt intubated and Versed and Fentanyl initiated.Resp: Pt with increased wob this am, c/o sob, on 100% . Map >65 Pt with ionized Ca+ this am of 0.96 repleted 3grams of Calcium, bumped ionized Ca+ to 1.06 another 2.0grams given. Sats remained low, and ABG 7.40/31/79. PE was ruled out. blood cx pending. Receiving bicarb in IVF for bicarb level of 19. Asked pharmacy to switch base solution to NS (was in D5W). Pt initially placed on A/C 600/12/80/10 with sats >96%. After intubation hypotensive thus received several fluid boluses over course of day for inadequate SBP, minimal u/o and cvp <10. Evaluate for change in LV function, effusion. flu. Immunosuppressed from melanoma tx. . Did receive 0.5mg of ativan prior to line placement.Resp: was admitted to MICU with Pa02 of 50. HR in 80s. Receiving boluses of NS for inadequatd u/o, and low cvp.Endo: on insulin gtt for high sugars this am. Overallnormal LVEF (>55%).AORTIC VALVE: Normal aortic valve leaflets (3). ? Resp rate in 40's although pt. was admitted to MICU for resp distress and sepsis with lactate of 7.Neuro: Pt. Scant, yellow, urine output. Limited study2. yeast rash under breasts, and in groin area, aloe vesta skin protectant applied.ID: Tmax 100.2. Pt was noted to have sats decreasing to 92%, sxn for large amounts of bloody secretions, and large blood clot. No AS. The left ventricular cavitysize is normal. count 50's. Overall left ventricular systolic function is normal(LVEF>55%).3.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion.4.The mitral valve leaflets are mildly thickened. Mr met with myself, , DR. , and Dr. in setting of probable diagnosis and lack of available tx Mr. made decision to withdraw care. CVP 2 on admission-giving boluses of 250 until CVP 10. Started esmolol at 50mcg-increased to 100mcg with SBP 140. Pa02 is 90 with sats 93%. Will attempt to increase to 150mcg. Pt was lethargic, and speech garbled at times. Left ventricular wall thicknesses are normal. WBC increasing to 16 from 7. There are no echocardiographic signs of tamponadebut study are limited.Compared to the previous report of ,pleural effusion new. Bronch done, gross bright red blood visualized. ********Social: Pt husband in today, probable diagnosis is metatstatic malignant melanoma. Not requiring sedation now. BRONCHOSCOPY PROCEDURE DONE AND BAL SENT ALONG WITH CULTURES FOR PCP/AFB.PLAN: WILL SWITCH OVER TO HEATED CIRCUIT DUE TO THICK BLOODY CLOTS. No color doppler studiesdone to assess for MR .5.There is a small to moderate sized pericardial effusion. SXING FREQUENTLY FOR MOD AMTS OF THICK BLOODY CLOTS. addendum10u of insulin given for fingerstick of 447. states she is not short of breath. other labs pnd.GU: foley draining small amounts of concentrated urine.Social: no contact from family memebers overnight.Skin: intact. Breath sounds are clear with few bibasilar crackles. No stool, abd distended. No sputum. in carevue is electronically signed by but was actually entered by the nurse taking care of the pt. All of his questions and concerns were addressed, and emotional support provided. No stool. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2166-02-07 00:00:00.000",
"description": "Report",
"row_id": 1543901,
"text": "addendum\n10u of insulin given for fingerstick of 447. Asked pharmacy to switch base solution to NS (was in D5W). Pt. has been getting boluses of the solution with D5W. \n"
},
{
"category": "Nursing/other",
"chartdate": "2166-02-07 00:00:00.000",
"description": "Report",
"row_id": 1543902,
"text": "RESP CARE\nPT PROGRESSIVELY BECAME HYPOXIC WITH SPO2 UPPER 80S/LOW 90S ON 100% AND WAS SUBSEQUENTLY INTUBATED THIS A.M. WITH #7.5 ETT SECURED AT 21CM AT THE LIP. PT CURRENTLY VENTED ON A/C 600X 12 PEEP 10 AND 100% WITH SPO2 IN THE LOW 90S. SXING FREQUENTLY FOR MOD AMTS OF THICK BLOODY CLOTS. BRONCHOSCOPY PROCEDURE DONE AND BAL SENT ALONG WITH CULTURES FOR PCP/AFB.\nPLAN: WILL SWITCH OVER TO HEATED CIRCUIT DUE TO THICK BLOODY CLOTS. INCREASE PEEP AS NEEDED IF PT HEMODYNAMICALLY STABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-02-07 00:00:00.000",
"description": "Report",
"row_id": 1543903,
"text": "NPN 7A-7P\n********Sig Events************ Pt moved to CMO.\n\nNuero: Pt received this morning confused, AOx2. Pt was lethargic, and speech garbled at times. After acute respiratory compromise Pt intubated and Versed and Fentanyl initiated.\n\nResp: Pt with increased wob this am, c/o sob, on 100% . Pt ABG in this state 7.38/30/99/18,thus Pt emergently intubated. Pt initially placed on A/C 600/12/80/10 with sats >96%. Pt was noted to have sats decreasing to 92%, sxn for large amounts of bloody secretions, and large blood clot. Sats remained low, and ABG 7.40/31/79. Pt placed on 100% fio2. Bronch done, gross bright red blood visualized. Post bronch pt with sats 89-93% CXR indicative of pleural effusions. LS coarse upper, bronchial lower.\n\nCV: Pt received on Esmolol gtt for increased Bp and hr. After intubation hypotensive thus received several fluid boluses over course of day for inadequate SBP, minimal u/o and cvp <10. (goal cvp >10, goal MAP >65) Pt also placed on Neo gtt for sustained hypotension. +pp by doppler. Currently on 19cc/hr of Neo. Map >65 Pt with ionized Ca+ this am of 0.96 repleted 3grams of Calcium, bumped ionized Ca+ to 1.06 another 2.0grams given. Lytes pending.\n\nGI: NPO except meds. NGT in place. No stool, abd distended. +BS. No residuals.\nGU: Foley in place to gravity. Scant, yellow, urine output. Receiving boluses of NS for inadequatd u/o, and low cvp.\n\nEndo: on insulin gtt for high sugars this am. Currently gtt at 7.0units/hr, with sugars in 130's.\n\nSkin: dry, intact. ? yeast rash under breasts, and in groin area, aloe vesta skin protectant applied.\n\nID: Tmax 100.2. Pt received 625mg/of Tylenol via ngt. Immunosuppressed from melanoma tx. on vanco, levoflox, and zoysn. blood cx pending.\n\n********Social: Pt husband in today, probable diagnosis is metatstatic malignant melanoma. Mr met with myself, , DR. , and Dr. in setting of probable diagnosis and lack of available tx Mr. made decision to withdraw care. All of his questions and concerns were addressed, and emotional support provided.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-02-07 00:00:00.000",
"description": "Report",
"row_id": 1543900,
"text": "NPN 7p-7a\n**All data for this pt. in carevue is electronically signed by but was actually entered by the nurse taking care of the pt. .**\n\npt. was admitted to MICU for resp distress and sepsis with lactate of 7.\nNeuro: Pt. aware of where she is but seems slightly confused at times-calling out to family members but re-orients quickly. Not requiring sedation now. Did receive 0.5mg of ativan prior to line placement.\n\nResp: was admitted to MICU with Pa02 of 50. On 100% pt. Pa02 is 90 with sats 93%. PE was ruled out. On ct pt. has mild failure and ? infilltrate. Breath sounds are clear with few bibasilar crackles. No sputum. Resp rate in 40's although pt. states she is not short of breath. On droplet precautions for ? flu. Resp. to obtain nasal aspirates this am.\n\nCV: HR 80-90 NSR. Started on esmolol drip for hypertension-SBP 160's. Started esmolol at 50mcg-increased to 100mcg with SBP 140. HR in 80s. Can titrate esmolol to keep HR less than 80. Will attempt to increase to 150mcg. Receiving bicarb in IVF for bicarb level of 19. CVP 2 on admission-giving boluses of 250 until CVP 10. Troponin .06\n\nID: afebrile but immunosuppressed from treatment for melanoma. WBC increasing to 16 from 7. Started on vanco, levo and pipercillin. Blood cx sent. Lactate levels 6 from 7. stim tests completed.\n\nGI: NPO except for meds. No stool. Pt. has coagulopathy. PLt. count 50's. other labs pnd.\n\nGU: foley draining small amounts of concentrated urine.\n\nSocial: no contact from family memebers overnight.\n\nSkin: intact.\n\n"
},
{
"category": "Echo",
"chartdate": "2166-02-07 00:00:00.000",
"description": "Report",
"row_id": 102367,
"text": "PATIENT/TEST INFORMATION:\nIndication: Recent cecompensation, tachycardia. Evaluate for change in LV function, effusion. Known pleural effusions, now intubated.\nHeight: (in) 63\nWeight (lb): 138\nBSA (m2): 1.65 m2\nBP (mm Hg): 120/65\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 16:01\nTest: Portable TTE (Focused views)\nDoppler: No doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion is loculated. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Right pleural effusion.\n\nConclusions:\n1. Limited study\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%).\n3.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion.\n4.The mitral valve leaflets are mildly thickened. No color doppler studies\ndone to assess for MR .\n5.There is a small to moderate sized pericardial effusion. The effusion\nappears anterior, loculated. There are no echocardiographic signs of tamponade\nbut study are limited.\n\nCompared to the previous report of ,pleural effusion new.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2166-02-05 00:00:00.000",
"description": "Report",
"row_id": 292489,
"text": "Sinus rhythm WITH atrial premature complexes\nFirst degree A-V delay\nLeft atrial abnormality\nProminent/peaked T waves - are nonspecific and may be within normal limits but\nclinical correlation is suggested for possible hyperkalemia\nSince previous tracing of , atrial ectopy present\n\n"
}
] |
21,974 | 112,236 | The patient was admitted to the Neurosurgery service of Dr. on . After discussion with the family about the patient's poor prognosis and discussion of possible options, the patient was taken to the Angiography Suite. Prior to the onset of the procedure, the patient's ICP was found to be again elevated to 40 cmH2O. Accordingly a contralateral second ventricular drain was inserted prior to the beginning of the angiogram. The patient's ICP then stabilized to the around 20 cmH2O. The patient then underwent a diagnostic cerebral angiogram as well as coiling of a left pericallosal aneurysm. A small contrast leak was experienced during the deployment of the last coil which was treated with immediate coagulation reversal with protamine. The transient extravasation subsided spontaneously. There was no evidence of intracranial flow decrease and the ICP was noted to increase back to the low 40's. This was then followed by irrigation of the drains with saline and with one dose of tPA which improved CSF flow significantly. Postoperatively, the patient was returned to the Medical Intensive Care Unit. Overnight, both externalized ventriculostomy drains continued to work putting out a moderate amount of CSF overnight from postoperative day 0 to postoperative day one. The patient's intracranial pressures declined from mid-20's into the low teen's progressing further from postoperative day one to postoperative day two into the values of approximately . Neurologically postprocedure the patient demonstrated minimal improvement compared to his admission. He progressed to a point where he was able to open his eyes, but was not able to attend to examiner, follow commands, or be responsive to deep painful stimuli. Serial CAT scans demonstrated persistent interventricular clot despite multiple attempts to place intrathecal TPA. On with the patient demonstrating minimal neurologic improvement and after prolonged discussions with the family and Dr. , the family decided to withdraw support for the patient. On , the patient was extubated and his ventricular drains were clamped, and he expired approximately two hours later. The Organ Bank was , however, the family did not wish to pursue organ donation. On at approximately 11:58 p.m., the patient was found to have no spontaneous respirations, no pulse is measured either by telemetry or by palpation, and was subsequently pronounced dead. , M.D. Dictated By: MEDQUIST36 D: 00:07 T: 05:20 JOB#: | MANNITOL OVER/NOC. NIPRIDE GTT. ALSO ON NIMODIPINE TOL WELL. RECEIVED ON NIPRIDE GTT. ON DILANTIN. SPUTUM CX. NEED TO RELOAD AS YEST. NT SX. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. RLL. RLL. WHEN SX. AMTS. RECOMMENDED WE CONT. T/O SHIFT FOR MOD AMTS. X2 FOR MOD>COPIOUS AMTS. PAN CX. Was pan cx. SX. SX. ALSO NT SX. REMAINS ON NIPRIDE GTT. PT. PT. PT. PT. PT. PT. PT. PT. SPEC. ON Q6/HR MANNITOL; FOLLOWING OSM. REMAINS ON A/C .50/600X17 WITH SPONT RR 0-9/PEEP 10. SOFT, NTND, WITH +BS. RLA PIV IN PLACE; PATENT, SITE WNL. In process of weaning down 02. BOTH ZEROED @ 0 TO TRAGUS. RESP CARE NOTE:Pt cont intub omech vent as per Carevue. RESIDUALS CHECKED Q4HRS. ;PENDING.GI/GU - PT. sxn thk yel. TITRATED T/O SHIFT TO ATTAIN GOAL SBP <130 AND CPP 70'S. ADB. SENT YEST. AM LEVEL 9.2. LINE IN PLACE; PATENT WITH SHARP WAVE FORM; SITE WNL. RESTARTED @ .6 MCG AND TITRATED TO MAINTAIN GOAL SBP <130. PER. PERIPHERAL PULSES PALPABLE. PERIPHERAL PULSES PALPABLE. NPN 7a-7pNeuro: Pt. NPN 7a-7pNeuro: Pt. GTT. Will send for cx. PLAN IS TO CONT. Pt stable on present vent settings. COVERAGE.ACCESS - AS ABOVE PT. Dsg. AM OSM. REMAINS ON IV DILANTIN.C/V - HR 80'S-ONE-TEENS, NSR>ST, INC. WITH NOXIOUS STIMULI. YEST. CONDITION. ABD DISTENDED BUT SOFT WITH HYPOACTIVE BS. ON LEVOFLOX. T/O SHIFT FOR MOD. NOTED BLEED HAS HALTED. MOVEMENT OF EXTREM; THOUGH WELL SEDATED. RECEIVED WITH BILAT. Currently on 0.8mcg. WITH OGT IN PLACE; PATENT; PLACEMENT VERIFIED PER AUSCULTATION. TITRATED TO OFF @ 0100. LS COARSE T/O WITH DIMIN. LS COARSE T/O WITH DIMIN. CONT OF LEVOFLOX/ CEFTAZ.SKIN: NO ISSUES IN THIS AREA.ENDO: ON SSRI. MONITORING Q4/HR RESIDUALS WHICH HAVE BEEN MINIMAL. BREATHING SLIGHTLY OVER SET RATE ON VENT.RESP: PT CONT ON A/C WITH SOME SPONTANEOUS RESP NOTED. PLEASE SEE CAREVUE. NOTED TO HAVE REACTIVE (L)PUPIL AND NOW WITHDRAWING TO NAILBED PRESSURE WITH LUE & LLE. SECOND SET BLOOD CX. WITHDRAWING BILAT. (R) & (L)VENTRICULOSTOMY DRAINS PLACED. PLAN OF CARE AT THAT POINT. BS = bilat, slightly coarse R>L. TO NAILBED PRESSURE. Lung sounds coarse rhonchi clearing somewhat with suct mod th tan sput. SAME COURSE OF TX. plan: cont w/mech support. ABD. ON Q1/HR NEURO CHECKS. Cont mannitol last osm 310, hold mannitol for osm>315. ABGs stable on present settings. DR. DR. COVERAGE.GI/GU - OGT IN PLACE; PATENT, PLACEMENT VERIFIED PER AUSCULTATION. LINE IN PLACE; PATENT, WITH POSITIONAL SHARP WAVEFORM AT TIMES, UNABLE TO DRAW;NU (-)MAE. @ 1.0 MCG/KG/MIN. (R)RADIAL ART. (R)RADIAL ART. b/s coarse. See Caruvue flowsheet. ? GOAL CPP 70. HCT THIS AM 31.4.RESP - NO VENT CHANGES OVER/NOC. FIO2 decreased today. Lung sounds coarse rhonchi improve with suct mod-lge amt th tan sput. WITH NON-THERAPEUTIC LEVEL. TO GOAL 70/HR. RR 0-8/PEEP 5/O2SATS. MINIMAL RESIDUALS NOTED. LOWER EXTREM. WITH (R) AND (L) VENTRICULOSTOMY DRAINS; BOTH PATENT; VERY POOR WAVEFORM NOTED AT START OF SHIFT. (L) AND (R) VENTRICULOSTOMY DRAINS REMAIN;ZEROED TO 8CM @ THE TRAGUS. 2) There has been interval decompression of the right lateral ventricle. Comparisons: Single view AP from Single AP Chest View: The endotracheal tube and right subclavian central venous line are in good position. At this point, angiographic run was performed which revealed small seepage of contrast beyond the confines of the aneurysm dome. The enormous hemorrhage within the ventricles and to a lesser extent within the subarachnoid space, most notably the left sylvian fissure is redemonstrated. Left sphenoid air cell is nearly completely opacified. In comparison with the outside CT, there has been interval placement of a right frontal approach ventricular catheter. At this point, a decision was made to proceed with treatment of the ruptured site was felt to be the left pericallosal artery aneurysm. TECHNIQUE: Non-contrast head CT scan was obtained. TECHNIQUE: Noncontrast head CT. HEAD CT W/O IV CONTRAST: There is diffuse subarachnoid blood. )**Post sedation med's Nipride gtt turned off, cont's to meet goal SBP.ROS:Neuro: q 1hr neuro checks, however started on sedation med's, and currently receiving Fentanyl and Propofol. IMPRESSION: Multiple intracranial aneurysm with a left ruptured pericallosal artery aneurysm treated successfully using GDC coils. There is diffuse cerebral edema with loss of the normal sulcation pattern. Within the anterior portion of the left temporal lobe there is a small area of subarachnoid hemorrhage. At this point, the microcatheter was then withdrawn gently advanced over the microwire into the aneurysm. At this point, a series of GDC coils were used with success to fill the aneurysm. During the multiple angiographic runs were performed in between coils which revealed the decreased of flow into the aneurysm and decreased filling. Right vent drain level at 0 to tragus, bloody drainage, drain flushed by neuro resident, ICP 24-30, mannitol 25gm Q6. The pulmonary vascularity shows mild perihilar haziness . Moderate bilateral ethmoid sinus mucosal thickening is seen within a small air fluid level seen within the left frontal air cell. Status post GDC coil embolization of the left pericallosal artery aneurysm. Immediately prior to the beginning of the procedure, he was noted to have elevated intracranial pressure and accordingly he underwent placement of an additional left frontal ventricular catheter. FINDINGS: Bifrontal ventricular catheters remain in place. There has been decrease in prominence of the right ventricle. We bypassed the anterior communicating artery aneurysm and proceeded to the left A2 segment with the micro and the microcatheter. Next a diagnostic catheter was used to selectively catheterize the following vessels over a guidewire in succession: (Over) 1:59 PM CAROT/CEREB Clip # Reason: ANEURYSM Admitting Diagnosis: HEAD BLEED Contrast: OPTIRAY Amt: 280 FINAL REPORT (Cont) Right common carotid, right internal carotid artery, left common carotid artery, left internal carotid artery and then through the microcatheter left intracranial anterior cerebral artery and then left intracranial pericallosal artery. | 25 | [
{
"category": "Nursing/other",
"chartdate": "2101-10-04 00:00:00.000",
"description": "Report",
"row_id": 1550449,
"text": "NPN 7a-7p\nNeuro: Pt. remains unresponsive to most stimuli. Have not been able to get a response to nail bed pressure but will have some flexion with sx. ? grimaces to pain-bites when orally sx or moving et tube. L pupil reactive but slow. Remains on propofol and fentanyl drip. Propofol increased to 35mcg because he was biting his tongue. Went for head ct this afternoon-results pnd. ICP has been ranging for both L and R, draining 0-25 cc/hr. Drainage increased for the first 2 hours after TPA injected into drains by neurosurgery, now back down to 10cc/hr. Dsg. has not been changed, neurosurg will change but would like to minimize opening dsg.\nCV: On Nipride at 0.8 to keep BP at goal of 130-140. HR 85-110 no ectopy. Does have intermittent episodes of increased BP when he is suctioned.\nResp: Sx for small to moderate amounts of thick, foul smellng, white/yellow sputum. Less than yesterday. Breath sounds rhonchorous which improves after suctioning.\nID: Tmax 101-comes down to 100 with Tylenol. Was pan cx. yesterday. Remains on Levo and ceftaz.\nSkin: Intact. Drains intact and draining bloody drainage, not as bloody as yesterday.\nF&E: Received 40K for a K of 3.4 this am, has a K pnd. NS infusing at 125/hr.\nGI: Tube feeds increased to 30cc/hr with minimal residuals, attempting to get to goal of 60cc/hr.\nGU: foley draining well-75-100cc/hr.\nSocial: Family in visiting. Updated by neurosurgery, they have placed a call to Dr. for response. Would like to speak with social services, I left a voice mail to see pt. tomorrow.\nA/P: Remains intubated and sedated with minimal neurological responses.\n-continue to monitor ICP and drainage\n-replace K as needed\n-have social services contact family\n-due for serum osm. at 22.\n-continue to support family and pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-04 00:00:00.000",
"description": "Report",
"row_id": 1550450,
"text": "Respiratory Care Note:\n Patient remains intubated and sedated and on full vent support. FIO2 decreased today. See Caruvue flowsheet. BS = bilat, slightly coarse R>L. Suctioned for thick tannish-yellow sputum. Noted foul smelling oral secretions. Patient transported to head CT this afternoon on vent without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-05 00:00:00.000",
"description": "Report",
"row_id": 1550451,
"text": "Resp Care Note:\n\nPt cont ess unresponsive intub on mech vent as per Carevue. Lung sounds coarse suct for sm th yellow sput. No vent changes made overnoc. Pt stable on present vent settings. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-02 00:00:00.000",
"description": "Report",
"row_id": 1550440,
"text": "Resp Care Note:\n\nPt returned from IR S/P Aneurysm coiling and return to mech vent. Pt significantly over breathing vent decision made to sedate and control vent with good result (refer to Carevue). Lung sounds rhonchi somewhat improved with suct mod-lge amt th pale yellow sput. ABGs stable on present settings. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-02 00:00:00.000",
"description": "Report",
"row_id": 1550441,
"text": "resp care\npt remains intubated and mech ventilated. no vent changes this shift. b/s coarse. sxn thk yel. plan: cont w/mech support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-02 00:00:00.000",
"description": "Report",
"row_id": 1550442,
"text": "MICU NPN 0700-1900\n\nMr. 54yo man with large SAH, s/p coiling , right and left ventriculostomy drains intact\n\nNEURO: sedation off 6am, opens eyes spontaneously, inattentive, pupils 2mm nonreactive, increase RR 20's, does not follow commands, no sponataneous movement, move head with nasal and oral suctioning, +gag, +cough. left vent drain intact flushed with TPA by neurosurg, draining bloody fluid 10-15cc/hr, ICP trending downward started the day at 20's currently . right vent drain also with bloody drainage 10-15cc/hr. CPP goal 70. No seizures, dilantin level 3.4, reloaded with 750mg x1. Cont mannitol last osm 310, hold mannitol for osm>315. Drains level at 0 at the tragus.\n\nCV: BP goal 100-130's, nipride for BP >130 currently at 1mcg/kg/min, cont nimodipine Q4, HR 70's SR no VEA. Increased BP with stimulation from family and noise in room.\n\nRESP: remains intubated and vented with unchanged vent setting, sedation resumed after am wake to suppress respiratory drive. Breath sounds coarse, suctioning for thick yellow foul smelling secretions, sputum culture sent, also draining large amts fouls smelling yellow liquid from nares.\n\nGI ABD soft +BS, no BM, OGT intact, tube feeds promote with fiber initiated at 10cc/hr due not advance, cont to check residuals Q4.\n\nHEME: am plt ct 89, transfuse with 1 bag plts, post plt ct 90, transfused with second bag of plts post ct 123\n\nGU: foley intact with clear yellow urine\n\nSKIN: intact\n\nACCESS: right SC TL, right rad , 2 peripheral IV's. Right femoral sheath d/c by neuro , -hematoma,-ooze\n\nSOCIAL: brother and significant other met with Neurosurg and NSicu teams for update on status and plan of care, family has met amongst themselves and stated would not want to live if he were vent dependent, Neuro described the extent of stroke and injury and the gravity of his prognosis, but would cont to monitor for 24-48 hrs. Large extended family here throughout the day, coming in/out at 2 at a time to decrease stimulation in the room\n\nPLAN: cont to monitor Q1 neuro checks, follow ICP, goal ICP< 20, goal BP 100-130, nipride or neo titrate to effect, currently on nipride, follow sputum cx\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-03 00:00:00.000",
"description": "Report",
"row_id": 1550443,
"text": "RESP CARE NOTE:\n\nPt cont intub omech vent as per Carevue. Lung sounds coarse rhonchi improve with suct mod-lge amt th tan sput. No vent changes made overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-03 00:00:00.000",
"description": "Report",
"row_id": 1550444,
"text": "MICU-B NPN 1900-0700\nPLEASE SEE FHP FOR FURTHER DETAILS.\n\nNEURO - PT. S/P WITNESSED SEIZURE @ HOME, ADMIT TO WITH HEAD CT + FOR INTERVENTRICULAR SAH, 2 ANEURYSMS, S/P COILING - REPEAT CT WITH WORSENING BLEED; MRA SHOWED 6MM SEPTAL DEVIATION. (R) & (L)VENTRICULOSTOMY DRAINS PLACED. VERY POOR PROGNOSIS. FAMILY AWARE. PT. REMAINS INTUBATED AND SEDATED ON FENT. GTT. @ 50MCG/HR & PROPOFOL GTT. @ 20MCG/KG/MIN. ON Q1/HR NEURO CHECKS. PT. NON-RESPONSIVE. (-)MAE. RECEIVED WITH BILAT. PUPILS 2MM/2MM NR. NOT WITHDRAWING ANY EXTREM. TO NAILBED PRESSURE. LAST TWO HOURS PT. NOTED TO HAVE REACTIVE (L)PUPIL AND NOW WITHDRAWING TO NAILBED PRESSURE WITH LUE & LLE. WILL OPEN EYES SPONT. WHEN SX. +COUGH/+GAG/+CORNEAL REFLEXES NOTED. NO SEIZURE ACTIVITY. ON DILANTIN. AM LEVEL 9.2. NEED TO RELOAD AS YEST. WITH NON-THERAPEUTIC LEVEL. (L) & (R) VENTRICULOSTOMY DRAINS REMAIN IN PLACE; PATENT, GOAL ICP 20. BOTH ZEROED @ 0 TO TRAGUS.(R) ICP 8-11, WITH BLOODY DRAINAGE 9-17/HR AND GREATER THAN THE LEFT. (L) ICP 6-8, WITH BLOODY DRAINAGE 5-10/HR. CPP 40'S-70'S. GOAL CPP 70. ON Q6/HR MANNITOL; FOLLOWING OSM. TO BE HELD FOR OSM >315. AM OSM. 310.\n\nC/V - HR 70'S-104, NSR>ST WITH NO ECTOPY NOTED. ABP 90'S-140'S/40'S-80'S. PT. RECEIVED ON NIPRIDE GTT. @ 1.0 MCG/KG/MIN. MD OFF @ 2300 WITH 250CC FLUID BOLUS FOR CPP 48; SBP 100'S-ONE-TEENS. PT. WITH RESULTANT HYPERTENSIVE EPISODE AND NOTABLE PUPIL CHANGE; (L) PUPIL 4-5MM NR. NIPRIDE GTT. RESTARTED @ .6 MCG AND TITRATED TO MAINTAIN GOAL SBP <130. PLEASE SEE CAREVUE. TITRATED TO OFF @ 0100. PERIPHERAL PULSES PALPABLE. NO EDEMA NOTED TO EXTREM.\n\nHEME - PT. WITH PLT COUNT THIS AM 101; S/P TRANSFUSION 2U PLT YESTERDAY FOR AM PLT COUNT 89, WITH POST 2U PLT COUNT 123. HCT THIS AM 31.4.\n\nRESP - NO VENT CHANGES OVER/NOC. PT. REMAINS INTUBATED AND SEDATED ON A/C .50/600 X 17 WITH SPONT. RR 0-8/PEEP 5/O2SATS. 97-100%. LS COARSE T/O WITH DIMIN. RLL. SX. T/O SHIFT FOR MOD. AMTS. THICK, TAN, FOUL SMELLING SECRETIONS. ALSO NT SX. X2 FOR MOD>COPIOUS AMTS. THICK, TAN, FOUL SMELLING SECRETIONS. SPEC. SENT YEST.;PENDING.\n\nGI/GU - PT. WITH OGT IN PLACE; PATENT; PLACEMENT VERIFIED PER AUSCULTATION. TF (PROMOTE WITH FIBER) INITIATED YEST @ 10CC/HR WITH NO GOAL FOR ADVANCEMENT. MONITORING Q4/HR RESIDUALS WHICH HAVE BEEN MINIMAL. ABD. SOFT, NTND, WITH +BS. NO STOOL THIS SHIFT. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. CLEAR, YELLOW URINE OUT OVER/NOC.\n\nID - TMAX 100.9; TCURRENT 100.1. SPUTUM CX. PENDING. ON LEVOFLOX. AND CEFAZOLIN FOR ABX. COVERAGE.\n\nACCESS - AS ABOVE PT. WITH (R) AND (L) VENTRICULOSTOMY DRAINS; BOTH PATENT; VERY POOR WAVEFORM NOTED AT START OF SHIFT. PER HO WAVEFORM UNCHANGED FROM PREVIOUS SHIFTS; CONSIDERED ACCURATE READINGS. TRIPLE-LUMEN RSC IN PLACE; DISTAL PORT UNABLE TO FLUSH SINCE YEST. TEAM AWARE ( CHANGE TODAY). OTHER TWO PORTS PATENT; GOOD DRAW. RLA PIV IN PLACE; PATENT, SITE WNL. LLA PIV 18 GAUGE; PATENT, SITE WNL. (R)RADIAL ART. LINE IN PLACE; PATENT, WITH POSITIONAL SHARP WAVEFORM AT TIMES, UNABLE TO DRAW;NU\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-03 00:00:00.000",
"description": "Report",
"row_id": 1550445,
"text": "MICU-B NPN 1900-0700\n(Continued)\nMEROUS ATTEMPTS MADE, DOES FLUSH, ALL EQUIPMENT CHECKED FOR PATENCY.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/NOC. TEAM HAS SPOKEN WITH FAMILY PER GRIM PT. PROGNOSIS. PT. FAMILY VERY POSITIVE PT. WOULD NOT WANT TO BE SUSTAINED ON VENT. SUPPORT. PLAN IS TO CONT. CURRENT TREATMENT REGIME OVER COARSE OF 24-48 HOURS AND RE-EVALUATE CONT. PLAN OF CARE AT THAT POINT. DAUGHTER AND PT'S. GIRLFRIENDS NAME BOTH .\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-03 00:00:00.000",
"description": "Report",
"row_id": 1550446,
"text": "NPN 7a-7p\nNeuro: Pt. remains unresponsive. Has occasional posturing to pain-nail bed. Pupils 2mm and non reactive. Does have cough reflex. ICP pressures both R and L. Drain repositioned by NSICU to be leveled at 8cm at tragus (was 0 at tragus) Draining 5-10cc/hr bloody drainage out of both drains. Manitol has been changed to prn to be given to keep ICP less than 20 and serum osm. less than 315. Went for head ct today-bleed reportedly slightly less but still extensive.\nCV: Has been on and off Nipride for labile BP. Attempting to keep SBP 130, has been ranging 110-170. Currently on 0.8mcg. HR 110 ST no ectopy.\nResp: Had an episode of sats dropping to 88% on 50% At the same time was hypertensive to 160-170 and HR-122. Increased 02 to 100% -took about 5-10min for sats to come up to 100% ABG came back with pa02-218,ph-7.45. In process of weaning down 02. Was suctioned for large amounts of very foul smelling sputum. Will send for cx. Breath sound rhonchi bilaterally.\nID: tmax 101. will draw blood cx.\nGI: Tolerating tube feeds at 10cc/hr with minimal residuals. Will increase to 20cc/hr to try to get to goal 70/hr.\nGU: Foley draining well\nSocial: Many family members in visiting throughout day.\nA/P:\n-neuro status unchanged\n-continue to wean 02\n-? source of fever neuro vs. infection\n-family waiting to hear re: ct scan to help guide future decisions re: status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-04 00:00:00.000",
"description": "Report",
"row_id": 1550447,
"text": "Resp Care Note:\n\nPt cont ess unresponsive intub on mech vent as per carevue. Lung sounds coarse rhonchi clearing somewhat with suct mod th tan sput. No vent changes made overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-04 00:00:00.000",
"description": "Report",
"row_id": 1550448,
"text": "MICU-B NPN 1900-0700\n PT. REMAINS INTUBATED AND SEDATED ON PROPOFOL GTT. @ 30 MCG/KG/MIN) TITRATED UP FROM START OD SHIFT TO ATTAIN ADEQUATE SEDATION) AND FENT. @ 50MCG/HR. PT. WITHDRAWING BILAT. LOWER EXTREM. & RUE TO NAIL BED PRESSURE; NO SPONT. MOVEMENT OF EXTREM; THOUGH WELL SEDATED. PUPILS 2-3MM WITH (R)NR AND (L)WITH BRISK RESPONSE TO LIGHT. MOVING HEAD WITH SUCTIONING. OPENING EYES AT TIMES TO NOXIOUS STIMULI. (L) AND (R) VENTRICULOSTOMY DRAINS REMAIN;ZEROED TO 8CM @ THE TRAGUS. ICP 6-9 T/O SHIFT; CPP 60'S> 100; WITH 0-10CC BLOODY DRAINAGE OUT FROM (R) AND 8-45CC BLOODY(THOUGH CLEARING A BIT) DRAINAGE OUT FROM (L). NO PRN. MANNITOL OVER/NOC. PER. DR. , CT SCAN YEST. NOTED BLEED HAS HALTED. NO SEIZURE ACTIVITY NOTED. REMAINS ON IV DILANTIN.\n\nC/V - HR 80'S-ONE-TEENS, NSR>ST, INC. WITH NOXIOUS STIMULI. REMAINS ON NIPRIDE GTT. TITRATED T/O SHIFT TO ATTAIN GOAL SBP <130 AND CPP 70'S. CURRENTLY RUNNING @ .6 MCG/KG/MIN. ABP 100'S-160'S/50'S-80'S. PERIPHERAL PULSES PALPABLE. NO EDEMA NOTED TO EXTREM.\n\nHEME - HCT STABLE @ 32.0; PLT 113 THIS AM.\n\nRESP - AS ABOVE REMAINS INTUBATED. NO VENT CHANGES OVER/NOC. REMAINS ON A/C .50/600X17 WITH SPONT RR 0-9/PEEP 10. O2SATS 98-100%. LS COARSE T/O WITH DIMIN. RLL. SX. T/O SHIFT FOR MOD AMTS. THICK, TAN, FOUL SMELLING SECRETIONS. NT SX. X2 FOR MOD > COPIOUS AMTS THICK, YELLOW, FOUL SMELLING SECRETIONS.\n\nID - TMAX 101.5. PAN CX. YEST. SECOND SET BLOOD CX. OBTAINED LAST EVE; RESULTS PENDING. REMAINS ON CEFAZOLIN AND LEVOFLOXACIN FOR ABX. COVERAGE.\n\nGI/GU - OGT IN PLACE; PATENT, PLACEMENT VERIFIED PER AUSCULTATION. TF (PROMOTE WITH FIBER) @ 30CC/HR TO BE ADVANCED AS TOL. TO GOAL 70/HR. MINIMAL RESIDUALS NOTED. ADB. SOFT, ND WITH +BS; NO STOOL THIS SHIFT. INDWELLING FOLEY REMAINS; PATENT WITH GOOD AMTS, AMBER, CLEAR URINE OUT THIS SHIFT.\n\nACCESS - RSC TRIPLE LUMEN IN PLACE; ALL PORTS PATENT, GOOD DRAW, SITE WNL. (R)RADIAL ART. LINE IN PLACE; PATENT WITH SHARP WAVE FORM; SITE WNL. LLA PIV 18 GAUGE IN PLACE; PATENT, SITE WNL.\n\nSOCIAL - FAMILY ALL IN AT START OF SHIFT. DR. CAME TO SPEAK WITH THEM AND UPDATE THEM ON PT. CONDITION. IT WAS EXPRESSED THAT THE PT'S CONDITION REMAINS GRAVE, BUT THAT THERE IS ALWAYS A SMALL CHANCE THAT HE IMPROVE; HIS BLEED HAS STOPPED; THE COILING WAS SUCCESSFUL; HIS ICP REMAINS LOW, HIS INC. IN RESPONSE TO NOXIOUS STIMULI. DR. RECOMMENDED WE CONT. SAME COURSE OF TX. FOR A COUPLE OF WEEKS BECAUSE IT IS TOO SOON TO DETERMINE OUTCOMES AT THIS POINT. PT. REMAINS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-05 00:00:00.000",
"description": "Report",
"row_id": 1550452,
"text": "NURSING PROGRESS NOTE:\nPT REMAINS /VENT ON AC/40% 600 X 17 5 PEEP. PT REMAINS ON PROPOFOL AND FENTANYL DRIPS FOR SEDATION. PT UNRESPONSIVE TO NOXIOUS STIMULI. PUPILS BOTH 2MM RIGHT PUPIL NONREACTIVE/LEFT PUPIL REACTS SLIGHTLY. NO SPONTANEOUS MOVEMENTS OF ALL EXTREMETIES. WHEN SX PT BLINKED EYES EVER SO SLIGHTLY. NO CORNEAL REFLEXES NOTED. ICP DRAINS INTACT OPEN AND DRAINING BLOODY DRAINAGE. LEFT MORE THAN THE RIGHT AND ICP MEASURMENTS HAVE BEEN . ONLY RESPONSE NOTED TO STIMULATION IS A RISE IN BP AND HEART RATE.\nCV: PT REMAINS ON NIPRIDE TO KEEP BP 120-140, NIPRIDE TITRATED ACCORDINGLY. ALSO ON NIMODIPINE TOL WELL. HR NSR NO ECTOPY RATE 80-LOW 100. BREATHING SLIGHTLY OVER SET RATE ON VENT.\nRESP: PT CONT ON A/C WITH SOME SPONTANEOUS RESP NOTED. SX FOR MOD AMT'S OF FOUL SMELLING THICK YELLOW SECRETIONS. NASOPHARYNX SX FOR LRG AMT'S OF BLOODY MATERIAL. MOUTH DRAINING LRG AMT'S OF ORAL SECRETIONS MIXED WITH BLOOD. TONGUE APPEARS LACERATED. LUNG SOUNDS COARSE THROUGHOUT AND DIMINISHED AT THE BASES. O2SAT'S IN HIGH 90'S. NO ABG'S CHECKED OVERNIGHT.\nGI: PT RECEIVING PROMOTE WITH FIBER AT 30/HR VIA OGT. RESIDUALS CHECKED Q4HRS. 80CC AT MIDNIGHT AND TUBE FEEDS TURNED OFF FOR 2HRS. RESTARTE AND RESIDUALS HAVE DECREASED. WILL RECHECK AT 0600. ABD DISTENDED BUT SOFT WITH HYPOACTIVE BS. NO STOOL AT THIS TIME.\nGU: FOLEY CATH PATENT DRAINING MOD AMT'S OF CLEAR YELLOW/AMBER URINE. IV FLUID CONT AT 125/HR.\nID: TEMP MAX 101.3 PO, RECEIVED TYLENOL X ONE DURING THE NIGHT. CONT OF LEVOFLOX/ CEFTAZ.\nSKIN: NO ISSUES IN THIS AREA.\nENDO: ON SSRI. BS CHECKED Q 6/HRS.\nFAMILY IN TO VISIT EARLIER IN THE NIGHT. REQUESTING TO SPEAK TO DR. . SUGGESTED THEY CALL ANSWERING SERVICE AND LEAVE MESSAGE TO CALL BACK.\nPT REMAINS FULL CODE AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-05 00:00:00.000",
"description": "Report",
"row_id": 1550453,
"text": "nursing note: 7a-7p\nneuro- pt remains sedated on propofol at 40mcg/kg/min and fentanyl 50mcg/h unresponsive to everything but suctioning on these doses.\nicp 5-9. left vent drain with bloody drainage and more ouptut than right which has now been more serous in drainage. pt had a repeat head ct scan today, results pending.\n\nresp- pt remains intubated on ac support. no vent changes today. ls coarse and diminished. secrestions continue to be foul smelling and in moderate amounts.\n\ncv- hr 80-100 sr no ectopy noted. sbp 120-160 continues on nipride gtt now at 1.8mcg/kg/min. goal sbp 120-140's requiring increasing doses of nipride to maintaine that goal.\n\ngi- abd soft +bs no stool. ogt with tf promote with fiber now at40cc/h, goal 60cc/h. residuals 30-60cc.\n\ngu- foley patent for amber urine in adequate amounts. ivf ns at 125cc/h maintained.\n\naccess- tlcl rsc intact wnl and r radial aline intact wnl also with one piv.\n\nsocial- daughter and brother are designated spokespersons for the family and the primary/secondary decisionmakers. family asked information to be given to them only, and they will communicate it to other members. family met with sw today. dr and dr both updated family today. many family members present for the entire day. asked about possibility of transfer back to when able, nsurg team felt he still needed to be managed here. family expressed pt's desire to not be maintained on life support for extended period of time and that he wanted to be an organ donor but had been unsure if he would be able to due to hep c. organ bank notified by sw with family's knowlegde in order to evaluate if he would be a candidate if it came to brain death or withdrawal of care.\n\ndispo- remains in micu, full code. continue to support on vent, control bp with nipride and follow neurological exam. continue to offer support to family and keep updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-01 00:00:00.000",
"description": "Report",
"row_id": 1550438,
"text": "micu npn 0700-1900\n\nMr. large SAH with 2 aneurysms, R vent drain, to IR for angio and potential coiling.\n\nNeuro: awake, eyes open spontaneously, does not make eye contact, pupils 2mm nonreactive, no spontaneous movement, no seizure activity, cont dilantin. Right vent drain level at 0 to tragus, bloody drainage, drain flushed by neuro resident, ICP 24-30, mannitol 25gm Q6. In IR ICP 40's a left vent drain placed ICP done to 20's, also given 25gm mannitol, coiling 1 aneurysm.\n\nCV: pre-procedure goal BP 100-130, neo d/c, labetalol titrate to effect, also receiving nimodipine BP decrease 20pts after nimodipine, HR 70's SR no ectopy.\n\nRESP: remains intubated with A/C 14/600/40%/5peep SRR 0-8 above vent, breath sounds coarse, sxn for scant sercetions, copious oral secretions foul smelling\n\nGI: ABd soft +BS, +flatus, OGT intact, NPO except meds\n\nGU: foley intact\n\nSKIN: intact\n\nID: afebrile\n\nACCESS: R SC TL, R PIV, L #18 PIV, R rad aline\n\nSOCIAL: many family members present in waiting\n\nPLAN: awaiting return from IR, follow neuro checks Q1hr, follow neuro recommendations for BP parameters post procedure\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-02 00:00:00.000",
"description": "Report",
"row_id": 1550439,
"text": "NPN 19:00-07:00 MICU (pt followed by N/SICU)\n*Please see Carevue for additional patient information\n*Full Code\n\nShift Events:\nReport from IR showing pt to have had Aneurysm x2, ICP increasing to 40 in IR, L ventricular drain placed, ICP's down to 20, now L&R drain ICP 12-25 (highest of 25, x1). R ventricular drain site wnl.\n\nAt begining of shift pt opening eyes mid-shift, however not following commands, no mvmt of extremities noted. PERL 2mm-3mm, non-reactive. D/t pt's Co2 levels being <35 (goal 35-40 to enhance cerebral perfusion), pt was placed on sedation med's in effort for pt not to breath over vent (Propofol 30mcg/hr and Fentanyl at 35mcg/hr). Currently sedated on both med's. Vent settings A/C 600x17/peep5/Fio2 50%(changed from CPAP+PS),pndg ABG. O2 sat's high 90's-100%. Ventricular 0/Tragus, drain site wnl, both R and L drain output bloody, ~6-8cc/hr. CV: Nipride gtt 1.0 mcg/kg/min started for goal SBP<130 (Labetolol turned off.)**Post sedation med's Nipride gtt turned off, cont's to meet goal SBP.\n\nROS:\n\nNeuro: q 1hr neuro checks, however started on sedation med's, and currently receiving Fentanyl and Propofol. No mvmt of extremities, no w/drawal to pressure on nail bed. No seizure activity. PERL 2mm, NR. *Per Dr. will turn off sedation at 06:15, for team to assess Neuro status.\n\nCV: HR 84-99, NSR no ectopy. SBP <130 (now off Nipride gtt). Afebrile, however slightly diaphoretic at times. Pulses palpable 3+.\n\nResp: Please see above: vent settings. O2 sat's 100%, LS coarse throughout, sxn'd for moderate-copious amounts of thick,yellow secretions. Goal pCO2 35-40.\n\nGI/GU: +bs, no bm, OGT in place, NPO except med's. U/O wnl, foley in place.\n\nAccess: Please see Carevue.\nEndo: RISS\n\nPlan:\nGoals:\n-SBP <130, ICP<25, pCo2 35-40.\n-Mannitol osmo's to be checked q6hr\n\nSocial: Brother and pt's girlfriend in waiting room o/n. Very appropriate, updated on pt's status/critical condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2101-10-01 00:00:00.000",
"description": "Report",
"row_id": 1550437,
"text": "Resp Care Note:\n\nPt received from OSH via LifeFlight direct admit to MICU B intub placed on mech vent as per Carevue. Lung sounds dim R otherwise clear. Pt intub with #8.0 23 @ lip. Cont mech vent support.\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805286,
"text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm ETT placement\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man intubated, SAH\n REASON FOR THIS EXAMINATION:\n confirm ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Recently intubated. confirm position.\n\n CHEST, AP PORTABLE: The ET tube is in satisfactory position. The heart is\n enlarged. Some widening of the aorta is present. No failure is seen.\n\n IMPRESSION: ET tube in satisfactory position.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805496,
"text": " 3:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumothorax\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with\n REASON FOR THIS EXAMINATION:\n pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54 year old male with pneumothorax.\n\n Comparisons: Single view AP from \n\n Single AP Chest View: The endotracheal tube and right subclavian central\n venous line are in good position. The right subclavian line tip lies within\n the proximal SVC. The aorta is tortuous. There is no evidence of pulmonary\n infiltrate. The right costophrenic angle is cut off, however there are no\n effusions. There is no pneumothorax. The NG tube is seen lying in the stomach.\n\n IMPRESSION: No evidence of infiltrate. No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 805283,
"text": " 5:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ventricular size; outside films in ICU\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with subarachnoid hemorrhage, hydrocephalus\n REASON FOR THIS EXAMINATION:\n ventricular size; outside films in ICU\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Subarachnoid hemorrhage, hydrocephalus.\n\n Comparison is made to the CT examination dated from \n Hospital.\n\n HEAD CT W/O IV CONTRAST: There is diffuse subarachnoid blood. Blood nearly\n fills the ventricular system. The ventricles are abnormally dilated. In\n comparison with the outside CT, there has been interval placement of a right\n frontal approach ventricular catheter. There has been decrease in prominence\n of the right ventricle. There is a lobulated focus of hemorrhage anterior to\n the third ventricle which appears to communicate with the ventricular system.\n There is low attenuation surrounding this region of hemorrhage. Within the\n anterior portion of the left temporal lobe there is a small area of\n subarachnoid hemorrhage. There is low attenuation anterior to this likely\n representing fluid within the subdural space. There is no significant shift\n of the normally midline structures. There is narrowing of the basal cisternal\n spaces. The -white matter differentiation is preserved. There is diffuse\n cerebral edema with loss of the normal sulcation pattern.\n\n There are no fractures identified. Fluid layers within the maxillary sinuses\n and sphenoid sinus. There is a small amount of fluid within the ethmoid air\n cells. The frontal sinuses appear clear. The patient is intubated.\n\n IMPRESSION:\n 1) There has been no significant change in the previously noted diffuse\n subarachnoid hemorrhage and intraventricular hemorrhage.\n\n 2) There has been interval decompression of the right lateral ventricle. The\n remainder of the ventricles are not significantly changed in size compared\n with the outside exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 805590,
"text": " 1:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 54 year old man with subarachnoid hemorrhage, hydrocephalus\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with subarachnoid hemorrhage, hydrocephalus\n\n REASON FOR THIS EXAMINATION:\n 54 year old man with subarachnoid hemorrhage, hydrocephalus evaluate s/p\n coiling/ placement of second EVD.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow up study. Status post subarachnoid and intraventricular\n hemorrhage with coiling of an anterior communicating artery aneurysm and\n placement of a ventricular drainage catheter.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There has been little change in the extent of intraventricular and\n subarachnoid hemorrhage, compared with the prior day's study. There is\n continued evolution of what is likely infarction within the gyrus rectus on\n both sides as well as in the area of the cingulate gyrus bilaterally. These\n infarcts would be in the distribution of the anterior cerebral arteries. There\n is a probable additional area of infarction within the left frontal lobe. No\n other significant intracranial alterations have occurred. There is continued\n complete loss of the visualized paranasal sinuses, which presumably represent\n the effects of intubation.\n\n CONCLUSION: Relatively unaltered markedly abnormal study as noted above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 805462,
"text": " 11:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate s/p coiling/ placement of second EVD\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with subarachnoid hemorrhage, hydrocephalus\n\n REASON FOR THIS EXAMINATION:\n evaluate s/p coiling/ placement of second EVD\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN:\n\n HISTORY: Subarachnoid hemorrhage and hydrocephalus, evaluate brain following\n coiling.\n\n TECHNIQUE: Non-contrast head CT scan was obtained.\n\n FINDINGS: Comparison with the prior study of reveals interval placement\n of coiling material within the anterior communicating artery region. The\n enormous hemorrhage within the ventricles and to a lesser extent within the\n subarachnoid space, most notably the left sylvian fissure is redemonstrated.\n Bilateral lateral ventricular drainage catheters are seen.\n\n There is no shift of normally midline structures. There is no new major\n vascular territorial infarction, although there is persistent low density in\n the region of the gyrus rectus on both sides, worrisome for ischemia. There\n is extensive opacification of the sphenoid sinus, likely by a mixture of\n hemorrhagic and non-hemorrhagic material. Left sphenoid air cell is nearly\n completely opacified. Moderate bilateral ethmoid sinus mucosal thickening is\n seen within a small air fluid level seen within the left frontal air cell.\n\n CONCLUSION: Residual extensive intraventricular as well as subarachnoid\n blood, the latter particularly noticeable near the vertex portion of the\n skull, as noted above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805718,
"text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pnuemonia\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with massive SAH and spiking temperatures.....\n\n REASON FOR THIS EXAMINATION:\n evaluate for pnuemonia\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: 54-year-old man with massive subarachnoid hemorrhage and spiking\n fever.\n\n CHEST, AP PORTABLE: Comparison is made to the prior study obtained on\n . The patient is rotated. Again noted is right-sided subclavian\n line, ET tube and NG tube, all of which remain stable in location. The\n patient is rotated. The aorta is tortuous. The pulmonary vascularity shows\n mild perihilar haziness . There is no definite focal consolidation.\n\n IMPRESSION: Findings are consistent with mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-01 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 805317,
"text": " 1:59 PM\n CAROT/CEREB Clip # \n Reason: ANEURYSM\n Admitting Diagnosis: HEAD BLEED\n Contrast: OPTIRAY Amt: 280\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL BILAT C1769 GUID WIRES INFU/PERF *\n * C1769 GUID WIRES INFU/PERF C1769 GUID WIRES INFU/PERF *\n * C1887 CATH GUIDING INFUS/PERF C1887 CATH GUIDING INFUS/PERF *\n * C1894 INT/SHTH NOT/GUID EP NON-LASER C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Subarachnoid hemorrhage grade 5 and evidence of an\n anterior communicating artery and anterior cerebral artery aneurysm by MR\n imaging.\n\n POSTOPERATIVE DIAGNOSIS: Same. Status post GDC coil embolization of the left\n pericallosal artery aneurysm.\n\n ANESTHESIA: General endotracheal anesthesia.\n\n INDICATION: Mr. is a 54 year old man who presented with subarachnoid\n hemorrhage at an outside hospital. He had very dense intraventricular blood.\n He subsequently underwent ventricular drain placement at the referring\n institiution and was transferred. Immediately prior to the beginning of the\n procedure, he was noted to have elevated intracranial pressure and accordingly\n he underwent placement of an additional left frontal ventricular catheter.\n This resulted in decrease of the intracranial pressure to below 20 cm of\n water. He is undergoing this procedure in order to prevent recurrent\n hemorrhage. His current neurological grade is a Hunt grade 5. Prior to\n the procedure, he has shown no neurological improvement despite ventricular\n drainage.\n\n CONSENT: The patient's family was given a full and complete explanation of\n the procedure. Specifically, the indications, risks, benefits and\n alternatives to the procedure were explained in detail. In addition the\n possible complications such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death were outlined. The\n patient understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought in the endovascular suite was\n placed on the table in supine position. The right groin area was prepped and\n draped in the usual sterile fashion. A 19 gauge single wall needle was then\n used to puncture the right femoral artery and upon the return of brisk\n arterial blood a 6 FR vascular sheath was inserted over a guidewire and kept\n on a heparinized saline drip. Next a diagnostic catheter was used to\n selectively catheterize the following vessels over a guidewire in succession:\n (Over)\n\n 1:59 PM\n CAROT/CEREB Clip # \n Reason: ANEURYSM\n Admitting Diagnosis: HEAD BLEED\n Contrast: OPTIRAY Amt: 280\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Right common carotid, right internal carotid artery, left common carotid\n artery, left internal carotid artery and then through the microcatheter left\n intracranial anterior cerebral artery and then left intracranial pericallosal\n artery.\n\n RESULTS: Injection of the right and left common carotid arteries revealed no\n evidence of cervical atherosclerosis or carotid disease. However, injection\n of both common carotid arteries reveal that the internal carotid artery at the\n high cervical region in the C2 segment harbored a 360 degree loop was\n symmetric and present bilaterally. Injection of the right internal carotid\n artery revealed a patent A1 segment of the anterior cerebral artery and also\n showed the presence of a 1 mm aneurysm at the origin of the right anterior\n temporal artery. There was no evidence of intracranial aneurysm on the right\n side. Injection of the left internal carotid artery revealed again the\n presence of the tortuous anatomy in the cervical region. It showed the\n presence of an aneurysm measuring 2 mm at the anterior communicating artery\n and more importantly an aneurysm in the pericallosal junction of the left\n anterior cerebral artery which measured approximately 4 mm in its greatest\n extent by 3 mm with a narrow neck of approximately a mm in a half. In\n addition was visualized a small infundibulum at the origin of the left\n posterior communicating artery. The remainder of the vessels were patent\n intracranial. At this point, a decision was made to proceed with treatment of\n the ruptured site was felt to be the left pericallosal artery aneurysm. To\n that end a SL 10 microcatheter was steam-shaped gently and used in conjunction\n with a microwire. After trying a multitude of wires including a Transcend 14\n microwire followed by Agility 14 microwire without success. The Synchro wire\n enabled us to characterize the left A1 segment of the anterior cerebral artery\n and very carefully enable us to thread the microcatheter into the left A1. We\n bypassed the anterior communicating artery aneurysm and proceeded to the left\n A2 segment with the micro and the microcatheter. Carefully the microcatheter\n was used to go beyond the origin of the aneurysm. At this point, the\n microcatheter was then withdrawn gently advanced over the microwire into the\n aneurysm. With the microcatheter in the aneurysm, an angiographic run was\n performed and used to confirm the position of the microcatheter. At this\n point, a series of GDC coils were used with success to fill the aneurysm.\n During the multiple angiographic runs were performed in between coils which\n revealed the decreased of flow into the aneurysm and decreased filling. The\n last coil which was a 1 cm Ultrasoft GDC coil while being repositioned was\n noted to have gone beyond the confines of the previous coil mass. Accordingly,\n a decision was made to administered Protamine to reverse the heparinization.\n At this point, angiographic run was performed which revealed small seepage of\n contrast beyond the confines of the aneurysm dome. This was a very slow\n progress and there was a slight increase in the patient's intracranial\n pressure of approximately 10 to 15 cm of water. A repeat angiographic run was\n performed which showed that there was no further opacification beyond the\n (Over)\n\n 1:59 PM\n CAROT/CEREB Clip # \n Reason: ANEURYSM\n Admitting Diagnosis: HEAD BLEED\n Contrast: OPTIRAY Amt: 280\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aneurysm and excellent flow throughout all the major intracranial vessels. At\n this point, the drains were lowered to the ground and after approximate period\n of 20 minutes to half an hour, the patient's intracranial pressure after\n flushing of the ventricular drains was noted to return back to preoperative\n value. Following the coiling, a three-dimensional angiographic run was\n performed which showed no further filling of the aneurysm and no evidence of\n intracranial vasospasm.\n\n IMPRESSION: Multiple intracranial aneurysm with a left ruptured pericallosal\n artery aneurysm treated successfully using GDC coils.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2101-10-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 805677,
"text": " 11:58 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: KNOWN SAH.EVAL FOR INTERVAL CHANGES\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with\n REASON FOR THIS EXAMINATION:\n SAH with ACOM and ACA aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for interval changes in a patient s/p aneurysm rupture\n with subarachnoid hemorrhage.\n\n TECHNIQUE: Axial non-contrast CT scan of the brain were obtained.\n\n Comparison is made to the previous CT of .\n\n FINDINGS:\n\n Bifrontal ventricular catheters remain in place. The ventricles are not\n generally dilated, but there is mild expansion of the temporal of the\n left lateral ventricle. This is unchanged since the previous study.\n Hypodensity is again noted in the inferior frontal lobes, and extending along\n the cingulate gyri in the distribution of the anterior cerebral artery\n territories bilaterally. Foci of decreased attenuation are also present in the\n left frontal lobe white matter. None of these findings are changed since the\n previous study. No new areas of abnormal attenuation are identified within the\n brain.\n\n There continues to be opacification of paranasal sinuses and portions of\n mastoid air cells.\n\n IMPRESSION: Stable appearance of brain and ventricular size since the previous\n day's scan.\n\n"
}
] |
12,828 | 192,255 | This was a 58-year-old gentleman with no significant hypercoagulable risk factors who presented with bilateral large clot burden pulmonary emboli initially admitted to the Medical Intensive Care Unit. 1. Bilateral pulmonary emboli with lower extremity deep venous thromboses with RV dysfunction status post syncope: Patient was continued on his Heparin drip, made therapeutic after a bolus in the Emergency Room. Continued on Heparin, and patient was considered a candidate for lysis if he became hemodynamically unstable. However, he refused lysis and eventually was just continued on his Heparin drip and transitioned to Coumadin and goal INR of 2 to 3. Initial inpatient hypercoagulable workup including anticardiolipin, antiphospholipid, and homocystine levels were negative. Rest of hypercoagulable workup can be done as an outpatient. Overall, patient's oxygenation improved and patient was transferred to the floor, did fairly well, and stayed while waiting for his INR to become therapeutic to be discharged on his regimen. Patient had three sets of negative CKs and troponins and otherwise remained hemodynamically stable. Two days follow admission patient had resolution of his right bundle branch block and was otherwise stable and discharged to the floor with continued INR and PTT monitoring. His Heparin drip was within therapeutic range, and we are waiting for his INR to be greater than 2.2 for discharge. Overall, pulmonary emboli status and deep venous thrombosis status patient was stable on his regimen of Coumadin, and patient understood risks and benefits of anticoagulation therapy and will have rest of his hypercoagulable workup as an outpatient. 2. Depression/paranoid personality disorder: During the course of his hospitalization patient refused to take his psychiatric medicines because of a mistrust of the system. Patient said he would restart at home, where he trusts his medicines, and otherwise remained stable throughout course. 3. Chronic renal insufficiency: Per baseline through trends on the computer system, creatinine runs from 1.2 to 1.6, and since this was chronic, no further workup was done at this time. Patient did have previous ultrasounds and CTs with otherwise normal renal functioning on imaging in . 4. Hypertension: He was normotensive and did not require any further medications for his hypertension. His glaucoma was stable. 5. Glaucoma: Stable on his Timolol drops. | Non-occlusive thombus in the main right PA. PEs in the RUL and RML branches, and some segmental RLL branches. Noaortic regurgitation is seen.MITRAL VALVE: Trivial mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. Slightly +1 edema in RLE, weak/palpable pulses appreciated in LE's. Mild tricuspid [1+]regurgitation is seen. NSR c no ectopy noted. Left main PA occluded. Pt denied CP/palpitations. Thepulmonary artery is not well visualized.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: The patient is tachycardic (HR>100bpm).Conclusions:Suboptimal images. Denies any chest pain or discomfort.Resp: LS diminished throughout. HO notified of pts recalcitrant stance and was also unable to persuade the pt for the necessity of his compliance.CV: Hemodynamically stable, afebrile. Trivial mitral regurgitation is seen.The pulmonaryartery is not well visualized. Right bundle-branch block is no longer recorded. PATIENT/TEST INFORMATION:Indication: Pulmonary embolus.BP (mm Hg): 122/92HR (bpm): 131Status: InpatientDate/Time: at 12:05Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: The left ventricular cavity size is normal. IMPRESSION: Occlusive thrombus within the right popliteal vein. TECHNIQUE: Helically acquired contiguous axial images of the chest were obtained without contrast. IMPRESSION: No acute intracranial hemorrhage. Very diminished BS throughout. HISTORY: Shortness of breath. 96.7 oral. Gi/Gu: Abdomen soft with + bs. DENIES SOB.GI/GU: ABD SOFT W/+BS. No bm this shift. DENIES PAIN WHEN ASKED. There is abnormal septalmotion/position consistent with right ventricular pressure/volume overload.AORTIC VALVE: The number of aortic valve leaflets cannot be determined. Nbp 100's to 110's systolic. Denies any pain or discomfort.CV: NSR to ST, no ectopy noted. Denies any SOB but appears to DOE.GI: Abd soft, +bs, +lg hard BM. There is severeglobal right ventricular free wall hypokinesis. Univ Iso prec in place. No cough, dyspnea w/ any exertion.CARDIAC: tackycardia to 130's no vea. pt refused lytics. CHEST CT WITH AND WITHOUT CONTRAST: There is minimal atelectasis at both lung bases. Cv: Sinus rhythm with no ectopy noted, rate 70's to 80's. FINDINGS: Allowing for technique, there has been no significant change in the cardiac and mediastinal contours. The calvarium, mastoid air cells, and visualized paranasal sinuses are unremarkable. IMPRESSION: Normal portable chest. + flatus. LS DIMINISHED T/O. There is an anterior space which most likelyrepresents a fat pad, though a loculated anterior pericardial effusion cannotbe excluded. IMPRESSION: No pneumonia or CHF. No change from . No signs of active bleeding, has evidence of old nose bleed.LINES: #18R antecub, functioning well.SOCIAL; Son states he is next of . Selectively cooperative w/ care.GU: voids, unclear if voided in EWGI: Taking cardiac diet well.HEME: heparin gtt 800u/hr, PTT sent 1700 and pnd. However, there isnew T wave inversion in leads III and aVF, as well as new recording of T waveinversion in leads VI-V3 with biphasic T wave in lead V4. Temp. Arrived to unit , stable, on heparin gtt. There is severe global right ventricular free wallhypokinesis. The estimated pulmonary artery systolic pressure isnormal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen. NBP 89-117/56-62. The right ventricularcavity is dilated. Deneis discomfort. COMPARISON: No prior studies. Noted to be similiar on admission to unit. TECHNIQUE: Axial images of the head were obtained from the occiput to the vertex without IV contrast. Pts feelings were validated, unfortunately he still would not take his Coumadin. Ivf heparin at 1550 units hr, unchanged. No edema. Tolerating po's well. FINAL REPORT *ABNORMAL! NO SIGNS OF BLEEDING.RESP: CONTINUES ON 100%NRB WITH SATS 95-100% WITH RR 15-18. COMPARISON: Head CT . No evidence of acute injury. HEAD CT: Ther is no acute intra- or extra-axial hemorrhage. MD AWARE. The left ventricular cavity size is normal. Active antero-apicalischemic process cannot be excluded. Sinus tachycardia with slowing of the rate compared to the previous tracingof . VOIDS VIA URINAL, AMBER AND CLEAR.ID: TMAX 98, NO CURRENT ID ISSUES.SKIN: INTACT.ACCESS: RAC PIV.SOCIAL/DISPO: FULL CODE. The visualized osseous structures are unremarkable. FINDINGS: Occlusive thrombus is present within the right popliteal vein. Pt reports RLE is sore to palpation. BP 97-116/55-74. No c/o chest pain or pressure. MICU NPN 7P-7ANEURO: AAOX3. The estimated pulmonary artery systolic pressure is normal, butmay be underestimated (the interventricular septum is flattened on someviews). Good pulses all extrem. Right bundle-branch block. The lungs are clear with no effusions or focal consolidation. MOVING INDEPENDANTLY IN BED.CARDIAC: HR 117-91 ST/SR WITH NO ECTOPY. The ventricles, cisterns, and -white matter differentiation are unremarkable. Within the remainder of the exam there is evidence of normal compressibility, waveform, and color flow within the right common femoral vein and superficial femoral vein. The airways are patent to the level of segmental bronchi. No change from one day prior. BEHAVIOR HAS BEEN APPROPIATE. PLAN FOR GOAL PTT 70-90, F/U ON AM LABS...WEAN O2 AS TOLERATED. NO OUTBURSTS. No aorticregurgitation is seen. Pt agreed to wear NRB. HR 92-103. There is no pleural or pericardial effusion. Sagittal and coronal reconstructions were performed. Sinus tachycardia. The pulmonary vasculature is normal. Denies CP.NEURO/MENTAL STATUS: Documented explosive personality as demonstrated in EW as well. Adeq UO.MS: This pt has been seamingly pleasant and cooperative when engaged in subject matter that does not focus on PO medication and his PE's. Normal color flow, waveform, compressibility, and augmentation is seen within the left common femoral vein, superficial femoral vein, and popliteal vein. 113/70. Fall (syncopal episode)-> EW. Has been cooperative but still not forthcoming with care. +palp pedal pulses. MICU NSG ADMISSSION NOTE: 180058 y.o. CAN HAVE CARDIAC DIET BUT TOOK NO PO'S DURING THE NOC. Overall leftventricular systolic function is normal (LVEF>55%).RIGHT VENTRICLE: The right ventricular cavity is dilated. today to see primary. The number of aortic valve leaflets cannot be determined. RECEIVED ON 800U/HR OF HEPARIN. INDICATION: Right calf pain. Nursing Progress Note.COAG: Pt currently c a nearly therapeutic Heparin gtt rate of 1550U/hr c an AM PTT of 69.6 (therapeutic goal 70-90). | 13 | [
{
"category": "Radiology",
"chartdate": "2142-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 814966,
"text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia, chf, pneumothorax, etc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with\n REASON FOR THIS EXAMINATION:\n r/o pneumonia, chf, pneumothorax, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Back pain.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH:\n\n Comparison is made to one day prior.\n\n FINDINGS: Allowing for technique, there has been no significant change in the\n cardiac and mediastinal contours. The lungs are clear with no effusions or\n focal consolidation. The pulmonary vasculature is normal.\n\n IMPRESSION: No pneumonia or CHF. No change from one day prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-02-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 814978,
"text": " 10:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with s/p fall\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:53 AM\n No acute hemorrhage. No evidence of acute injury.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall.\n\n TECHNIQUE: Axial images of the head were obtained from the occiput to the\n vertex without IV contrast.\n\n COMPARISON: Head CT .\n\n HEAD CT: Ther is no acute intra- or extra-axial hemorrhage. The ventricles,\n cisterns, and -white matter differentiation are unremarkable. There is no\n mass effect and no shift of normally midline structures. The calvarium,\n mastoid air cells, and visualized paranasal sinuses are unremarkable.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage. No change from .\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-02-22 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 814990,
"text": " 12:35 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: RT CALF PAIN, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with right calf pain\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: 1:27 PM\n thrombus in right popliteal vein\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Right calf pain.\n\n FINDINGS: Occlusive thrombus is present within the right popliteal vein.\n Within the remainder of the exam there is evidence of normal compressibility,\n waveform, and color flow within the right common femoral vein and superficial\n femoral vein. Normal color flow, waveform, compressibility, and augmentation\n is seen within the left common femoral vein, superficial femoral vein, and\n popliteal vein.\n\n IMPRESSION: Occlusive thrombus within the right popliteal vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-02-22 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 814974,
"text": " 10:33 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with SOB\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:19 AM\n Multiple PEs. Left main PA occluded.\n Non-occlusive thombus in the main right PA. PEs in the RUL and RML branches,\n and some segmental RLL branches.\n\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: Shortness of breath.\n\n COMPARISON: No prior studies.\n\n TECHNIQUE: Helically acquired contiguous axial images of the chest were\n obtained without contrast. Pulmonary CTA was performed with 100 cc of\n intravenous Optiray. Sagittal and coronal reconstructions were performed.\n\n PULMONARY CT ANGIOGRAM: There is a large saddle embolus occluding the left\n main pulmonary artery and partially extending into the main right pulmonary\n artery. The central left embolus extends into the lobar pulmonary arterial\n branches. In the right lung, emboli are occluding the upper and middle lobar\n arterial branches, as well as some of the segmental lower lobe branches.\n\n CHEST CT WITH AND WITHOUT CONTRAST: There is minimal atelectasis at both lung\n bases. There is no mediastinal, hilar or axillary lymphadenopathy. There is no\n pleural or pericardial effusion. The airways are patent to the level of\n segmental bronchi.\n\n The visualized portions of the liver, gallbladder, spleen, pancreas, adrenal\n glands and kidneys are unremarkable. The visualized osseous structures are\n unremarkable.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reconstructions confirm the presence\n of a saddle pulmonary embolus as described above.\n\n IMPRESSION: Saddle pulmonary embolus with a large thrombotic burden.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-02-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815055,
"text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: PULMONARY EMBOLISM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with saddle pulmonary embolus, on heparin drip currently.\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST @ 8 A.M. on :\n\n The heart is normal in size and the lungs are clear and fully expanded.\n\n IMPRESSION: Normal portable chest.\n\n"
},
{
"category": "Echo",
"chartdate": "2142-02-22 00:00:00.000",
"description": "Report",
"row_id": 61990,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary embolus.\nBP (mm Hg): 122/92\nHR (bpm): 131\nStatus: Inpatient\nDate/Time: at 12:05\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. There is severe\nglobal right ventricular free wall hypokinesis. There is abnormal septal\nmotion/position consistent with right ventricular pressure/volume overload.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. No\naortic regurgitation is seen.\n\nMITRAL VALVE: Trivial mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nnormal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen. The\npulmonary artery is not well visualized.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: The patient is tachycardic (HR>100bpm).\n\nConclusions:\nSuboptimal images. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is dilated. There is severe global right ventricular free wall\nhypokinesis. The estimated pulmonary artery systolic pressure is normal, but\nmay be underestimated (the interventricular septum is flattened on some\nviews). The number of aortic valve leaflets cannot be determined. No aortic\nregurgitation is seen. Trivial mitral regurgitation is seen.The pulmonary\nartery is not well visualized. There is an anterior space which most likely\nrepresents a fat pad, though a loculated anterior pericardial effusion cannot\nbe excluded.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2142-02-22 00:00:00.000",
"description": "Report",
"row_id": 114574,
"text": "Sinus tachycardia. Right bundle-branch block. Compared to the previous tracing\nof the rate has increased and right bundle-branch block has appeared.\nFollowup and clinical correlation are suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2142-02-23 00:00:00.000",
"description": "Report",
"row_id": 114573,
"text": "Sinus tachycardia with slowing of the rate compared to the previous tracing\nof . Right bundle-branch block is no longer recorded. However, there is\nnew T wave inversion in leads III and aVF, as well as new recording of T wave\ninversion in leads VI-V3 with biphasic T wave in lead V4. Active antero-apical\nischemic process cannot be excluded. Followup and clinical correlation are\nsuggested.\nTRACING #2\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-02-23 00:00:00.000",
"description": "Report",
"row_id": 1430855,
"text": "MICU NPN 7P-7A\nNEURO: AAOX3. BEHAVIOR HAS BEEN APPROPIATE. NO OUTBURSTS. COOPERATIVE WITH BLOOD DRAWS, BUT REFUSED ALL MEDS. MD AWARE. DENIES PAIN WHEN ASKED. MOVING INDEPENDANTLY IN BED.\n\nCARDIAC: HR 117-91 ST/SR WITH NO ECTOPY. BP 97-116/55-74. RECEIVED ON 800U/HR OF HEPARIN. PTT 28.6 SO WAS BOLUSED WITH 2800U AND INCREASED GTT RO 1100U/HR. NEXT PTT 46.7, BOLUSED WITH 1400U AND INCREASED GTT TO 1250U/HR. LABS SENT @0615, PENDING. NO SIGNS OF BLEEDING.\n\nRESP: CONTINUES ON 100%NRB WITH SATS 95-100% WITH RR 15-18. WHEN MASK FALLS OFF SATS DROP TO MID 80'S. LS DIMINISHED T/O. DENIES SOB.\n\nGI/GU: ABD SOFT W/+BS. NO STOOL. CAN HAVE CARDIAC DIET BUT TOOK NO PO'S DURING THE NOC. VOIDS VIA URINAL, AMBER AND CLEAR.\n\nID: TMAX 98, NO CURRENT ID ISSUES.\n\nSKIN: INTACT.\n\nACCESS: RAC PIV.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM SON. PLAN FOR GOAL PTT 70-90, F/U ON AM LABS...WEAN O2 AS TOLERATED. COULD BE CALLED OUT IF O2 REQUIREMENTS DECREASE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-02-23 00:00:00.000",
"description": "Report",
"row_id": 1430856,
"text": "Nursing Progress Note MICU A\n\nNeuro: Alert and oriented x3. Pleasant and cooperative. Follows all commands. Moves all extremities. Denies any pain or discomfort.\n\nCV: NSR to ST, no ectopy noted. HR 92-103. NBP 89-117/56-62. +palp pedal pulses. No edema. On heparin gtt @ 1550units/hr. PTT 60.6. Goal PTT to be 70-90. Denies any chest pain or discomfort.\n\nResp: LS diminished throughout. O2 sats 90-99% on 3L NC. Denies any SOB but appears to DOE.\n\nGI: Abd soft, +bs, +lg hard BM. Colace and Senna given this evening.\n\nGU: Voiding clear yellow uring QS in urinal.\n\nAccess: 1 PIV in Left FA.\n\nSocial: Wife and son in to visit with patient, updated on pts condition.\n\nPlan: Called out to floor. Transfer note written. Continue on Heparin gtt, goal for PTT to be 70-90.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-02-24 00:00:00.000",
"description": "Report",
"row_id": 1430857,
"text": "Nursing Progress Note.\n\nCOAG: Pt currently c a nearly therapeutic Heparin gtt rate of 1550U/hr c an AM PTT of 69.6 (therapeutic goal 70-90). Pt refused his 5mg Coumadin PO dose last evening despite the logical rationale for the use of this med. Pt would consistently cut me off mid sentence, stating \"I no take pill now, only when I go home\". HO notified of pts recalcitrant stance and was also unable to persuade the pt for the necessity of his compliance.\n\nCV: Hemodynamically stable, afebrile. NSR c no ectopy noted. Slightly +1 edema in RLE, weak/palpable pulses appreciated in LE's. Pt reports RLE is sore to palpation. AM Heme and electrolyte labs WNL. Pt denied CP/palpitations. Adeq UO.\n\nMS: This pt has been seamingly pleasant and cooperative when engaged in subject matter that does not focus on PO medication and his PE's. The pt is compliant and openly participates c VS recordings, IV Heparin therapy, bathing, lab draws, and small-talk conversation. However, pt appears to become fairly angry when pressed about taking his PO Coumadin and/or prescribed psych meds. Pt verbalized that he is distraught that his DVT was missed by his PCP earlier this week. Pts feelings were validated, unfortunately he still would not take his Coumadin. Pt also indicated that he may or may not be alive in the near future (one or two weeks . . . maybe more?).\n\nRESP: 3LNCO2 c nl sats/RR.\n\nGI: Sipping bottled water @ BS.\n\nSOCIAL: No calls/visitors overnight. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Univ Iso prec in place. Pt currently awaiting transfer to a regular med unit today, D/C Transfer Note completed in CareVure.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-02-24 00:00:00.000",
"description": "Report",
"row_id": 1430858,
"text": "MICU NURSING PROGRESS NOTE. 7AM TO 7PM.\n SEE CAREVIEW FOR OBJECTIVE DATA..\n\n Events: Calmly refusing to take any more medications or ivf other than what he is already recieving. Did agree to take coumadin 5mg po this am but that was all. Instructed on bleeding precautions with coumadin but did not appear to fully comprehend the instructions so will require repeat instructions prior to d/c. Has been cooperative but still not forthcoming with care.\n\n Neuro: Alert and oriented x 3. Speach is broken english but is understandable and is able to make needs known verbally. MAE. Good pulses all extrem. Temp. max. 96.7 oral. Deneis discomfort.\n\n Respiratory: Lung sounds are clear in upper fields, diminished in lower fields. RR 16-24 non-labored but does report that he does have occn periods where he notes harder breathing, but not more so than he has already felt. O2 sat 94-99% on 3l nc.\n\n Cv: Sinus rhythm with no ectopy noted, rate 70's to 80's. Nbp 100's to 110's systolic. Ivf heparin at 1550 units hr, unchanged. No c/o chest pain or pressure. Iv in lt wrist wnl.\n\n Gi/Gu: Abdomen soft with + bs. Tolerating po's well. No bm this shift. + flatus. Voiding clear amber strong smelling urine.\n\n Social: No calls made.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-02-22 00:00:00.000",
"description": "Report",
"row_id": 1430854,
"text": "MICU NSG ADMISSSION NOTE: 1800\n58 y.o. Russian male admitted via ew w/ large PE. Arrived to unit , stable, on heparin gtt. pt refused lytics.(R popliteal DVT)\n\nHPI: CP and SOB x one week. today to see primary. Fall (syncopal episode)-> EW. Bloody nose, RA sats 85%, HR 130 ST, 140/100.\nExplosive behavior, difficulty w/ management reported in EW. Heparin gtt, NRB, Labs-> MICU 1530.\n\nALLERGIES: unknown\n\nROS:\n\nRESP: NRB W/ SATS 95%, he complained about the mask, attempted NC@6L but sats 88% w/ increased hr. Pt agreed to wear NRB. Very diminished BS throughout. No cough, dyspnea w/ any exertion.\n\nCARDIAC: tackycardia to 130's no vea. 113/70. Denies CP.\n\nNEURO/MENTAL STATUS: Documented explosive personality as demonstrated in EW as well. Noted to be similiar on admission to unit. Son also demonstrated explosive nature as well. Unpredictable. Both the patient and son are notable more receptive and appropriate engaging w/ men.\nIs alert and oriented. MAE. Selectively cooperative w/ care.\n\nGU: voids, unclear if voided in EW\n\nGI: Taking cardiac diet well.\n\nHEME: heparin gtt 800u/hr, PTT sent 1700 and pnd. No signs of active bleeding, has evidence of old nose bleed.\n\nLINES: #18R antecub, functioning well.\n\nSOCIAL; Son states he is next of . His number is on board in room as well as on front of blue book.\n\nASSESs: High oxygen requirements, poor activity tolerance, altered behavior patterns, tackycardia\n\nPLAN: follow PTT, limit interactions of unknown personell, secure male nurse to care for pt, monitor for bleeding, bedrest, social service.\n"
}
] |
13,067 | 155,846 | 1. Respiratory: The infant has remained on room air since admission to the NICU and did have a couple episodes of desaturation with apnea on the newborn day which were very brief and transient. The infant has had no further apnea spells or desaturation spells and has been stable on room air since that initial newborn period. 1. Cardiovascular: The infant has maintained a normal cardiovascular status with no murmur, normal heart rate and normal blood pressures, pink and well perfused. 1. Fluids, electrolytes and nutrition: IV fluid was initiated on the newborn day due to the transient respiratory distress. D-sticks have remained stable. Enteral feedings were initiated on the newborn day. The infant had increased irritability and poor feeding initially and some spits. The feedings have improved since day 1 of life and the infant is now ad lib p.o. feeding, Neo Sure 24 cal per oz and taking approximately 120 ml per kg per day. Most recent weight is 1775 grams. Electrolytes were measured on . Sodium of 133; potassium of 8.6, hemolyzed; chloride 104 and C02 16. 1. Hematology: Hematocrit was measured at birth and the hematocrit was 52. Platelet count of 300. No further hematocrits have been measured. No blood product transfusions have been given. No blood typing has been done on this infant. 1. Infectious disease: CBC and blood culture were screened on admission. CBC remained within normal limits. Blood culture also had no growth. The infant was never started on antibiotics. 1. Neurology: The infant has had subtle neurologic symptoms including jitteriness, occasional poor feeding, and increased tone. Otherwise, maintains a normal neurologic exam for gestational age. It has been felt that those neurologic symptoms are most likely related to the maternal medications during pregnancy for Mom's bipolar disorder. 1. Sensory: A hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears. 1. Psychosocial: social worker has been in contact with the family. There are no active issues at this time of concern. If a social worker needs to be reached, the phone number to reach the NICU social worker is . | Primary pedi will be at in . hips stable.Labs:d/s 89wbc 12.4 (44p, 2b), Hct 52, Plt 300Bld cx pendingImpression:1. P: Continue to monitor DSclosely and eval need for NG placement.G&D O/A: Temps stable, swaddled in OAC. Mildsubcostal retractions noted. P: Cont to supp and update. Sepsis evaluationPlan:-- TTN resolving on its own w/o support. Also of note periodic breathing with desaturations. G1P0 now 1 mother. Updated.Would like to visit latertoday.#4 Resp-Remains in RA.RR- 30-60. Nursing Progress Note 0700-1900Resp O/A: Remains in RA. Temp stable. Updates given. Pt voiding and stooling, guiacneg. P: Continue to monitor.FEN O/A: Received on 80cc/k/d D10 with 2+1 via PIV. Mild sc retractions. Mild subcostal retractions. Voiding qs, transitionalstools. NeonatologyDoing well. will make an Early Intervention referral, as well.I will remain avial. Mother w/o PIH/preeclampsia or placental insufficiency. P: Cont to supp dev needs.Parents: Parents in this am and were updated. Onespit this am. NPN DAYSFEN: TF 80cc/k/d. Mild retractions. P: Cont tomonitor resp status and monitor A's/B's. P: Cont w/ current feeding plan.#2G/D: Temps remain stable, pt swaddled in OAC. RR deferred. Cont to monitor.-- Now that tachypnea has generally resolved will allow to PO feed. BP mean stable-see flow sheet for further details. Hep B consent obtained. Lungs CTA, fair to good aeration, =. RR now mainly in the normal range with minimal retractions and absence and flaring and grunting. Will wean maintenance IVFs as po abilities improve. Abd soft, +BS. Continue to update and support.Resp: RA,lungs are clear and equal, mild SC retractions attimes, mild tachypnea during cares up to 80's, RR at rest40-60's. Periodic breathing5. IV off this am. Neonatology NP NotePEswaddled in open cribAFOf, sutures approximatedcomfortable respirations in room air, lungs clear/=RRR, no murmur, pink and well perfusedabdomen soft, nontender and nondistended, active bowel sounds, cord on/dryactive, irritable but consolablegenerally mildly hypertonic, arches with feeds, mildly jitteryfamily meeting held with both , and , SW.Discussed Cristianna'a discharge criteria. Active/alert withcares. Will continue to offer po feedings, andplan to wean IVF if taking improved amts, and does not spitafter feeding.G/D: Temps are stable in crib, swaddled with hat on.Infant is active and alert for brief periods, thensleepy/drowsy. Back to sleepbrochure given. Seeflowsheet. to arrange to visit her and baby . A: AGA. is in a stable and supportive rela. stability prenatally, and has consistently demonstrated intact judgment and insight re: the importance of having close support.Mo. Remains in RA. Transitional tachypnea of the newborn4. Awaiting documented maturation of resp control ands ability to maintain adequate po intake. Wean IV as tol if infant po adequate amount.ID: CBC and blood culture sent. Fetal growth restriction & Small for gestational age3. CV RRR, no murmur, 2+FP. A: Infant blood glucose stable. is also followed by Fraktman, RNC, Ph.D., maternal-child psych RN, who is aware of baby's birth and will call mo. during baby's NICU stay. Lungs c/=. Baby meds given. Abdomen issoft, pink, active bowel sounds, no loops, AG stable.Voiding and Stooling meconium stool. toencourage po feeds.#2 DEVELOPMENT: Temps stable swaddled in oac. Wakingq4h. HEENT WNL. NeonatologyODing well. Pedi aptFriday. Cor nl s1s2 w/o murmurs. Tolerating feeds at ad lib volumes.Abdomen benign.HBV to be given.Continue as at present. NPN#1 TF 80cc/k/d. V/S. Nospells/desats so far this shift. swaddled in OAC. Skin w/o leisons. Wakes Q3-4hrsto feed. Neuro non-focal and age appropriate. A: Infant coordinated with bottlingand taking adequate volume. DS stable. NeonatologyDOing well. NeonatologyDOing well. Wt. Expect is related to maternal medication withdrawal.Continue as at present. Chest clear, mild retractions. Voidingand stooling heme neg. A:AGA. Neonatology ExamPink active non-dysmorphic. Pt. AGA. AGA. Wt 1820(+10gms).#2 Infant alert with cares. Abdominal exam benign. HAving moderate amoutn of jitteriness. DS 98. Remains in RA. Remains in RA. REmains in RA. Nospits. Nospits. BS in good range. Tolerating feeds ad lib. BW 1810gms. UO1.6cc/k/hr x20 hrs. Notably jittery, tone mildly increased, mild clonus. Took 107cc/k last 24 hrs.One smallspit. Day of spell countdown.Wt 1745 no change. Cont. Cont. Trace mec stool. BS clear. TF=min100cc/k of Neosure24.Taking all po's. Mildretractions.Occ desats to the 80's QSR.Pale pink. Tags werechecked. Lungs clear.A bdomen benign. Comfortable appearing.WT 1775 up 30. soft, pink, no noted loops, active bowel sounds.Voiding and stooling each care. Abdomen benign. P: Cont to monitor. Well saturated and perfused in RA. Rehab/OTInfant seen today for OT screen at d/c. AFOF. BS have been in normal range. Abd soft, +BS, no loops. Abdomen round,pink, and soft w/active bowel sounds and no loops. Warmer temp weaned x1and then infant was swaddled on off warmer--with re-checktemp with warmer off. Intake at 110 cc/k/d, Said to be vigorous with feeds. Abd. Day count. RR 30-60's.LSC/=. NNP aware ofincreased fuassiness and of jitteriness. Plan to supportdev. MAE. NPN#1 F/N- Abd soft,+bs, no loops. Awaiting doucmneted maturation of resp contorl and feeds. Now in day spell countdown. needs.#3Parents. Stable. Referral to Early Intervention made. NPN/1900-0700#1 FEN: Wt 1745gms, no change. RR 20-50'swith mild SCR. Current weight 1775grams. NPN 1900-0700#1FEN. Dstik 98.ID: CBC benign, blood cx NGTD, not on amp/gent.DEV: Transitioned to crib this am.NEURO: Noted to be irritable, jittery overnight.EXAM: Small infant, active, responsive to exam. BS clear and equal. Reported that will not be visitingtomorrow d/t transportation issues but will be in onThursday.#4 RESP: Breathing room air w/ sats >97%. In RA, RR 30-50, sat 97 and above, no drifts orbradys. Rec'g IVF D10W at 80cc/k/d=6.0cc/hr. A: Momplanning for discharge. Moving all 4ext. Lung sounds cl/= with no increased work ofbreathing. Loves pacifier. Infant calms with tight proprioceptive input and low stim environment. Voiding, stooling. Lung sounds clear and equal and no retractions. Overall comfortable, mild intermittent retractions. to monitor. Infant is pink andwell perfused with normal pulses and brisk cap refill. Discussed infant needs with and nursing. Updated.#4 Resp- Remains in RA w/ o2 sats 95-100%. Recommend EI and to monitor developmental progress.I Having some non-bilious spits.Temp stable in crib. Awake from until 2300,crying at times, calmed with being held. | 26 | [
{
"category": "Nursing/other",
"chartdate": "2157-11-12 00:00:00.000",
"description": "Report",
"row_id": 1863790,
"text": "Neonatology Attending Admission Note\n\nInfant is a 36 1/7 weeks gestation, 1810 gram female newborn who was admitted to the NICu for respiratory distress.\n\nInfant was born to a 24 y.o. G1P0 now 1 mother. Prenatal screens: A+, antibody negative, HBsAg negative, RPR NR, RI, GBS unknown. medical history of bipolar disorder and HSV. Maternal medications include prozac, ativan, trazadone, ziprasidone. Also mother reports ppd tobacco.\n\nThis pregnancy complicated by fetal growth restriction (12&ile) and low amniotic fluid index. Mother presented in spontaneous labor. No perinatal sepsis risk factors: no maternal fever, ROM x ~11 hrs PTD, clear fluid, maternal intrapartum chemoprophylaxis > 4hrs PTD for unknown GBS colonization.\n\nVaginal delivery. Apgars 8,8. In DR, infant noted to have tachypnea, retractions and grunting. Otherwise, ROS not applicable.\n\nPhysical exam:\nGrowth: Wt 1810 gms = <10%, HC 29.5 cm <10%, L 39.25 cm = <10%\nVS on admission: T98.1r, HR 137, RR36, BP 75/44, 56\nO2 sat 92 in RA\nPink, nondysmorphic, comfortable in RA. AFAF. RR deferred. Ears nl set w/o anomalies. palate intact. Neck supple, intact clavicles. Lungs CTA, fair to good aeration, =. Mild retractions. Also of note periodic breathing with desaturations. CV RRR, no murmur, 2+FP. Abd soft, +BS. GU nl preterm female. Patent anus. No sacral anomalies. hips stable.\n\nLabs:\nd/s 89\nwbc 12.4 (44p, 2b), Hct 52, Plt 300\nBld cx pending\n\nImpression:\n1. Preterm female newborn\n2. Fetal growth restriction & Small for gestational age\n3. Transitional tachypnea of the newborn\n4. Periodic breathing\n5. Sepsis evaluation\n\nPlan:\n-- TTN resolving on its own w/o support. RR now mainly in the normal range with minimal retractions and absence and flaring and grunting. Cont to monitor.\n-- Demonstrating some periodic breathing, question contribution from maternal medications (will check resources), is though at risk for this due to GA; but this would be early for apnea of prematurity. Cont to monitor.\n-- Now that tachypnea has generally resolved will allow to PO feed. Will wean maintenance IVFs as po abilities improve. Glucose monitoring per hypoglycemia protocol.\n-- Unclear etiology to growth restriction. Mother w/o PIH/preeclampsia or placental insufficiency. Exam and presentation not c/w dysmorphology or congenital viral infections.\n-- Due to early signs of respiratory distress, infant evaluated for possible sepsis. CBC reassuring. No antibiotics at this time.\n\nMother updated at the bedside.\n\nOB: Dr. \nPedi: mother undecided\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-12 00:00:00.000",
"description": "Report",
"row_id": 1863791,
"text": "Admission Note\nNPN Admission Note\n\nSee attending note for history. Infant is 36 and and admitted from L+D for IUGR and monitoring.\n\nResp: Infant in room air since birth. Initially tachypneic w/occasional drifts in sat to 80s and two desats requring BBO2. Infant current resp rate 20s-40s and sat 92-96%. Lung sounds initially coarse and equal but now clear and equal. Mild subcostal retractions. No spells so far this shift. A: Infant stable in room air. P: Cont to monitor closely.\n\nCV: Infant has no murmur. HR 110s-130s. Infant is pink and well perfused w/normal pulses and brisk capillary refill. BP mean stable-see flow sheet for further details. 72/32 (47).\n\nFEN: BW 1810 grams. Infant currently npo and receiving D10W via PIV @ 80 cc/kg. DS 89, 74, 58, 95. Abdomen pink and soft w/active bowel sounds and no loops. AG 23 cm. Void 11 cc @ 1300 cares. No stool so far this shift. A: Infant blood glucose stable. P: Cont to monitor DS and plan to bottle infant when eager- SC 20. Wean IV as tol if infant po adequate amount.\n\nID: CBC and blood culture sent. Blood culture pending. A: No signs/symptoms of sepsis. P: No antibiotics ordered at this time.\n\nDev: Infant nested on open warmer. Temp stable. Alert and active w/cares and sleeps well in between. Baby meds given. Bruising noted on back. A: AGA. P: Cont to supp dev needs.\n\nParents: Parents in this am and were updated. Mom in w/grandmother and visitors x 2. Mom took temp and changed diaper. A: Mom appropriate and caring. P: Cont to supp and update.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-12 00:00:00.000",
"description": "Report",
"row_id": 1863792,
"text": "1 FEN\n2 G/D\n3 Parents\n4 Term Respiratory Distress\n5 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 FEN; added\n Start date: \n 2 G/D; added\n Start date: \n 3 Parents; added\n Start date: \n 4 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 5 Infant with Potential Sepsis; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-15 00:00:00.000",
"description": "Report",
"row_id": 1863803,
"text": "Neonatology\nDoing well. Remains in RA. No spells. Comfortable appearing. Will monitor for 5 spell free days.\n\nWt 1745 down 55 Tolerating feeds of Neosure 22 at full volume. TF at 80 cc/k/d. IV off this am. Will increase to 24 cal and monitor tolerance. WIll advance TF to 100 cc/k/d. Provide gavage as needed. Abdomen benign.\n\nTemp stable in open crib.\n\nRemains sl jittery BS in 60s.\n\nBili not an issue.\n\nFamily meeting for this afternoon.\n\nContinue as at present. Awaiting documented maturation of resp control ands ability to maintain adequate po intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-15 00:00:00.000",
"description": "Report",
"row_id": 1863804,
"text": "NPN 0700-1900\n\n\n#1FEN: TF min of 100cc/kg/day of Neosure 24. Pt waking Q 3\nhrs and taking full volume PO. Pt is eager but poorly\ncoordinated with bottling. Frequent burps while feeding.\nTolerating feedings well, one small spit, AG stable. Abd\nsoft and flat, no loops, +BS. Pt voiding and stooling, guiac\nneg. DS= 86 @ 0900. P: Cont w/ current feeding plan.\n\n#2G/D: Temps remain stable, pt swaddled in OAC. Alert and\nactive with cares. Pt is jittery at times, but settles well\nwith pacifier. MAE. AFSF. P: Cont to support dev needs.\n\n#3PAR: No contact from so far this shift. Family mtg\nwas scheduled for 1300 today, mom did not show up or call.\nMtg to be re-scheduled. P: Cont to support and update\n.\n\n#4RESP: Pt breathing comfortably in RA, sats >98%. RR\n30s-50's. Lung sounds clear and equal bilaterally. Mild\nsubcostal retractions noted. No spells or desats so far this\nshift. Pt is now 3 of 5 day spell countdown. P: Cont to\nmonitor resp status and monitor A's/B's.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-15 00:00:00.000",
"description": "Report",
"row_id": 1863805,
"text": "Correction to above note\n are undecided regarding pediatrician.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-15 00:00:00.000",
"description": "Report",
"row_id": 1863806,
"text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOf, sutures approximated\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds, cord on/dry\nactive, irritable but consolable\ngenerally mildly hypertonic, arches with feeds, mildly jittery\n\nfamily meeting held with both , and , SW.\nDiscussed Cristianna'a discharge criteria. Mother describes both her as strong support. Gave mom prescription for for powder. Primary pedi will be at in .\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-15 00:00:00.000",
"description": "Report",
"row_id": 1863807,
"text": "NPN Addendum\n\n\n#2G/D: Pt noted arching back while feeding, excessive\nsucking on pacifier, and unconsollable at times. Calms with\nswaddling and pacifier.\n\n#3PAR: Both arrived late for family meeting at 1400.\nFamily meeting took place at this time with NNP and social\nworker. Updates given. Hep B consent obtained. Back to sleep\nbrochure given. Mom to bring carseat Thursday afternoon.\n will not be in tomorrow, because they cannot get a\nride. Mom stated she was going to \"meet with\" a pediatrician\nbefore choosing one. Dad asked for a paternity test during\nfamily mtg.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-14 00:00:00.000",
"description": "Report",
"row_id": 1863799,
"text": "Social Work\nBaby mo. known to me from one session psychosocial assessment early in the pregnancy. Mo. is a 24 y.o. affianced unemployed Caucasian HS grad who receives disability benefits for bipolar and anxiety disorders, for which she takes multiple meds and has been pscyh hospitalized in the past. She has been excited and highly motivated re: parenting, has maintained psych. stability prenatally, and has consistently demonstrated intact judgment and insight re: the importance of having close support.\n\nMo. is in a stable and supportive rela. w/ fa., also psychiatrically disabled, w/ whom she lives in . Mo.'s live in and are high functioning, very inv'd, and much appreciated by mo.\n\nMo. is followed wkly by a psychotherapist and monthly by a psychopharm, w/ whom the plan is to readjust her meds once she is stably post-partum. Mo. is also followed by Fraktman, RNC, Ph.D., maternal-child psych RN, who is aware of baby's birth and will call mo. to arrange to visit her and baby . and ongoingly. will make an Early Intervention referral, as well.\n\nI will remain avial. during baby's NICU stay. Please page me when family mtg. is to take place: #.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-14 00:00:00.000",
"description": "Report",
"row_id": 1863800,
"text": "Nursing Progress Note 0700-1900\n\n\nResp O/A: Remains in RA. Lungs c/=. Mild sc retractions. No\nspells or drifts. P: Continue to monitor.\n\nFEN O/A: Received on 80cc/k/d D10 with 2+1 via PIV. IV\nweaned throughout day per team, DS 62 and 59 (2 hrs after IV\nheplocked). Feeding >80cc/k/d volume of Neosure 22, bottling\n25-30cc q4h. Abdomen benign. Voiding qs, transitional\nstools. Spits with each feeding. P: Continue to monitor DS\nclosely and eval need for NG placement.\n\nG&D O/A: Temps stable, swaddled in OAC. Active/alert with\ncares. AGA. MAE. Font s/f. Sucks pacifier. P: Check bili and\nstate screen in a.m.\n\n O/A: Mom at bedside x2 this shift. Discharged home\nfrom hospital today - fam meeting to be done tomorrow per\n' request so that both may be present.\nUpdated by this RN and team. P: Continue to update, educate,\nand support NICU family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-14 00:00:00.000",
"description": "Report",
"row_id": 1863801,
"text": "5 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 5 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-15 00:00:00.000",
"description": "Report",
"row_id": 1863802,
"text": "NPN\n\n\n#1 F/N- Abd soft,+bs, no loops. Bottles slowly 25cc of\nNeosure 22 cals w/sm spits.Wakes to eat q 3 hrs.Voiding+\nstooling in adeq amts.Wt down 55gms.TF min of 80cc/kg/day.\n#2 Dev- Alert+ active.Wakes for feeds q 3 hrs.Very\njittery.Temp stable swaddled in open crib.\n#3 -Mom called x1. Updated.Would like to visit later\ntoday.\n#4 Resp-Remains in RA.RR- 30-60. BS clear.Mild\nretractions.No A's or B's or desats yet tonight. See\nflowsheet.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-13 00:00:00.000",
"description": "Report",
"row_id": 1863795,
"text": "NPN DAYS\n\n\nFEN: TF 80cc/k/d. Offered bottle with each care today,\ntaking minimal amts 6-8cc per feeding. Infant sucks eagerly\nfor a few minutes then stops and sleeps. IVF D10W inusing\nat 80cc/k/d (6.0cc/hour) via PIV in left hand. Abdomen is\nsoft, pink, active bowel sounds, no loops, AG stable.\nVoiding and Stooling meconium stool. DS 110 and 86. One\nspit this am. Infant gagging at times while sleeping, no\nfurther spits. lytes this afternoon - 138/4.7/103/21. Taking\nminimal PO feeds. Will continue to offer po feedings, and\nplan to wean IVF if taking improved amts, and does not spit\nafter feeding.\n\nG/D: Temps are stable in crib, swaddled with hat on.\nInfant is active and alert for brief periods, then\nsleepy/drowsy. Infant moving all extremities, jittery\nmovements intermittently. Occasionally will suck on\npacifier. likely some of sleepiness/jitters from maternal\nmedicines taken during pregnancy, will continue to monitor\nclosely.\n\n: Mother and grandmother in to visit infant. Mother\nassisted with temp taking, diapering, and feeding/burping\ninfant. Back to sleep brochure given and reviewed, as well\nas car seat safetly. Discussed need for infant to be\nmonitored for 5day countdown d/t desats w/ needing BBO2 on\nday of delivery. Mother understanding on need, plans to see\nif she may stay in family room after DC. Likely she is to\nbe discharged monday. Loving and caring mother, will\ncontinue to encourage parenting skills/involvement in cares\nand plans. Continue to update and support.\n\nResp: RA,lungs are clear and equal, mild SC retractions at\ntimes, mild tachypnea during cares up to 80's, RR at rest\n40-60's. No desats or bradycardias. Day day countdown.\n\nPot sepsis: BC pending. No signs or symptoms of infection.\nwill continue to monitor closely.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-14 00:00:00.000",
"description": "Report",
"row_id": 1863796,
"text": "NPN\n\n\n#1 F/N- Abd soft,+bs, no loops. Bottles poorly taking 5-10cc\nof Sc20 cals q 4 hrs w/sm spit x1.D/S=83.PIV patent LH\ninfusing at 80cc/kg/day.Voiding in adeq amts.Sm mec stool.Wt\ndown 20gms.\n#2 Dev- Alert+ active w/cares.Temp stable swaddled in open\ncrib.\n#3 Mom here to visit x2. Updated.\n#4 Resp- Remains in RA w/ o2 sats 95-100%. BS clear. Mild\nretractions.Occ desats to the 80's QSR.Pale pink.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-14 00:00:00.000",
"description": "Report",
"row_id": 1863797,
"text": "Neonatology\nDOing well. REmains in RA. No spells. Comfortable apeparing.\nOccasional destas overnight.\n\nWt 1800 down 20. Tolerating feeds. Abdomen benign. Having some non-bilious spits.\n\nTemp stable in crib. HAving moderate amoutn of jitteriness. BS in good range. Expect is related to maternal medication withdrawal.\n\nContinue as at present. Awaiting documented maturation of resp contorl and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-14 00:00:00.000",
"description": "Report",
"row_id": 1863798,
"text": "NNP Physical Exam\nPE: pink, mild facial jaundice, AFOF, breath sounds clear/equal with easy wob, no murmur, abd soft, + bowel sounds, sleeping, reactive to exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-13 00:00:00.000",
"description": "Report",
"row_id": 1863793,
"text": "NPN\n\n\n#1 TF 80cc/k/d. Attempted to PO feed infant x2 and she\nonly took 5-7cc SC20. Infant choking, gagging, and arching\nafter feeds--small spit x1. Abd soft, +BS, no loops. Ag\n21-22cm. Rec'g IVF D10W at 80cc/k/d=6.0cc/hr. DS 98. UO\n1.6cc/k/hr x20 hrs. Trace mec stool. Wt 1820(+10gms).\n\n#2 Infant alert with cares. AFSF. Warmer temp weaned x1\nand then infant was swaddled on off warmer--with re-check\ntemp with warmer off. Infant sucks on pacifier.\n\n#3 No contact from this shift.\n\n#4 Infant remains in RA with O2 sats 97-100%. RR 20-50's\nwith mild SCR. BS clear and equal. No bradys or desats so\nfar this shift.\n\n#5 Blood cultures pending. No signs/symptoms of sepsis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-13 00:00:00.000",
"description": "Report",
"row_id": 1863794,
"text": "Neonatology\nDOL #1, CGA 36 wks.\n\nCVR: Remains in RA, O2sats 97-100%, no desats/bradys overnight - apneas noted yesterday day needing blow-by oxygen and stim. Overall comfortable, mild intermittent retractions. Hemodynamically stable, no murmur. HR 100-120s.\n\nFEN: BW 1810, weight overnight 1820. TF 80 cc/kg/day D10W via PIV. Attempting PO feeding but minimal intake with frequent spits. Voiding, stooling. Dstik 98.\n\nID: CBC benign, blood cx NGTD, not on amp/gent.\n\nDEV: Transitioned to crib this am.\n\nNEURO: Noted to be irritable, jittery overnight.\n\nEXAM: Small infant, active, responsive to exam. Notably jittery, tone mildly increased, mild clonus. Fontanelles soft and flat. Skin clear, pink. Chest clear, mild retractions. Cardiac RRR, no m. Abdomen soft, no HSM, no mass. Femoral pulses 2+.\n\nIMP: 36+ wk infant, growth restricted, in utero exposure to multiple psychiatric meds, with immature respiratory control, immature feeding patterns. Spells appear to have improved from admission. Jitteriness and intolerance of feeds may be consistent with in-utero exposures.\n\nPLANS:\n- Continue monitoring in NICU.\n- Monitor for spells.\n- Advance PO feeding as able, wean IVF as able.\n- Lytes/bili sent this am.\n- Monitor off abx.\n- Monitor neurologic exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-17 00:00:00.000",
"description": "Report",
"row_id": 1863815,
"text": "Rehab/OT\n\nInfant seen today for OT screen at d/c. Please refer to chart for full medical hx. Infant exposed to various drugs in utero. Questionalble withdrawal from drug exposure. No pharmacological intervention initiated.\n\nUnable to do full assessment. Infant presenting in state 6 (irritable), difficult to calm. Arching her back, eyes hyperalert, difficult to calm.\n\nInfant did calm with tight swaddle, hands to face, and firm touch for holding.\n\nAttempted prone positioning with immediate escalation to state 6. Infant rolling from prone to supine due to increased tone.\n\nA/P: Infant presenting with marked irritabliltiy and decreased state regulation. Tone is increased throughout. Infant calms with tight proprioceptive input and low stim environment. Discussed infant needs with and nursing. Infant is at risk for developmental delay due to drug exposure, marked irritability, and increased tone. Recommend EI and to monitor developmental progress.\n\nI\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-17 00:00:00.000",
"description": "Report",
"row_id": 1863812,
"text": "NPN 1900-0700\n\n\n#1FEN. Wt. 1775gms, up 30gms. BW 1810gms. On TF minimum of\n100cc/k/day of 24, minimum of 30ccq4hrs, has bottled\nx3, 35, 35, and 25cc. Took 107cc/k last 24 hrs.One small\nspit. Abd. soft, pink, no noted loops, active bowel sounds.\nVoiding and stooling each care. Stool guaic negative,\ndesitin applied to reddened diaper area. Plan to continue\ncurrent feeding schedule.\n\n#3G/D. Pt. swaddled in OAC. Awake from until 2300,\ncrying at times, calmed with being held. Very jittery. Pt.\nfell asleep in car seat, passed car seat test. NNP aware of\nincreased fuassiness and of jitteriness. Plan to support\ndev. needs.\n\n#3Parents. Mom called x1, plans to call in am to see if\ninfant passed carseat test.Plan to continue discharge\nteaching with .\n\n#4Resp. In RA, RR 30-50, sat 97 and above, no drifts or\nbradys. Now in day spell countdown.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-17 00:00:00.000",
"description": "Report",
"row_id": 1863813,
"text": "Neonatology\nDOing well. Remains in RA. No spells. Comfortable appearing.\n\nWT 1775 up 30. Tolerating feeds ad lib. Intake at 110 cc/k/d, Said to be vigorous with feeds. Will suggest 35 cc/feed min.. On 24 cal.\n\nPassed car seat test.\nREceived HBV\nCar seat test passed.\nFU appointment arranged for tomorrow.\n\nReady for dc\nDC prep time 35 minutes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-17 00:00:00.000",
"description": "Report",
"row_id": 1863814,
"text": "NPN 7a-7p\n\n\nDischarge Note\n\nInfant is a former 36 and is currently DOL 5 corrected\nat 36 6/7 weeks gestation. Infant admitted to NICU for IUGR\nand respiratory distress. Infant now stable and ready to be\ndischarged to home with .\n\nResp: Infant in room air with resp rate 20s-60s and sat\n99-100%. Lung sounds cl/= with no increased work of\nbreathing. Infant completed 5 day spell countdown.\n\nCV: Infant has no murmur. HR 110s-140s. Infant is pink and\nwell perfused with normal pulses and brisk cap refill. BP\nstable-most recent BP 78/37 (51).\n\nFEN: Infant birthweight 1810 grams. Current weight 1775\ngrams. Infant TF min 100 cc/kg of 24 (30 cc q4h). No\nspits. Infant bottling adequate volume 28-35 cc q3-4h.\nAbdomen pink and soft with active bowel sounds and no loops.\nVoiding sufficiently and stooling heme negative.\n\nDev: Infant swaddled in an open crib, temp stable. Alert and\nactive/sl jittery during cares and sleeps well in between.\nSettles well with boundaries and pacifier. AGA.\n\n: in @ 1200 to prep for discharge. This RN\nreviewed formula prep with and Mom demonstrated\nproper preparation of 24-recipe given. Car seat\ninstruction and safety reviewed. Mom demonstrated\nsafely/securely positioning infant in car seat. Mom took\ntemp, changed diaper, dressed, and bottled infant. Reviewed\nw/ to bottle infant q3-4h and goal for infant\nbottling minimum 35 cc q4h. plan to return Saturday\n @ 1400 for CPR class. visit for Monday. Pedi apt\nFriday. Referral to Early Intervention made. See discharge\ndocuments in chart for further details. appropriate\nwith infant and have adequate family support. Tags were\nchecked.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-16 00:00:00.000",
"description": "Report",
"row_id": 1863808,
"text": "NPN/1900-0700\n\n\n#1 FEN: Wt 1745gms, no change. TF=min100cc/k of Neosure24.\nTaking all po's. Bottled 118cc/k in previous 24hrs. No\nspits. Abdominal exam benign. V/S. DS stable. Cont. to\nencourage po feeds.\n#2 DEVELOPMENT: Temps stable swaddled in oac. Wakes Q3-4hrs\nto feed. Loves pacifier. AFOF. MAE. Noted to be jittery\non days, noted mildy over night. AGA. Support\ndevelopmental needs.\n#3 : Mom called x1 and updated. No further contact\nthis shift. Reported that will not be visiting\ntomorrow d/t transportation issues but will be in on\nThursday.\n#4 RESP: Breathing room air w/ sats >97%. RR 30-60's.\nLSC/=. No bradys or desats. Stable. Cont. to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-16 00:00:00.000",
"description": "Report",
"row_id": 1863809,
"text": "Neonatology\nODing well. Remains in RA. No spells. Continues to be sl jittery. BS have been in normal range. Day of spell countdown.\n\nWt 1745 no change. Tolerating feeds at ad lib volumes.\nAbdomen benign.\n\nHBV to be given.\n\nContinue as at present. Awaiting doucmneted maturation of resp contorl and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-16 00:00:00.000",
"description": "Report",
"row_id": 1863810,
"text": "NPN 7a-7p\n\n\n#1 FEN: TF min 100 cc/kg of 24 (30 cc q4h, 23 cc\nq3h). Infant bottling 30-35 cc q4h. No spits. Abdomen round,\npink, and soft w/active bowel sounds and no loops. Voiding\nand stooling heme neg. A: Infant coordinated with bottling\nand taking adequate volume. P: Cont w/current plan.\n\n#2 Dev: Infant swaddled in an open crib, temp stable. Alert\nand active during cares and sleeps well in between. Waking\nq4h. Hep B vaccine given. Infant passed hearing screen. A:\nAGA. P: Cont to supp dev needs.\n\n#3 : Mom originally unable to come in today, but this\nnurse and social work to arrange for\ntransportation for discharge teaching as infant most likely\nto be d/c tomorrow. Mom arranged transportation with family\nmember and plans to visit @ 1600-1700 for discharge\nteaching. Mom plans to bring car seat tomorrow. A: Mom\nplanning for discharge. P: Plan to provide discharge\nteaching and bath for Mom. form started, infant\npassed hearing screen, and hep B vaccine given. Plan to call\nEarly Intervention and to confirm pedi with Mom.\n\n#4 Resp: Infant in room air with resp rate 30s-60s and sat\n>97%. Lung sounds clear and equal and no retractions. No\nspells/desats so far this shift. Day count. A: Infant\nstable in room air w/no spells. P: Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2157-11-16 00:00:00.000",
"description": "Report",
"row_id": 1863811,
"text": "Neonatology Exam\nPink active non-dysmorphic. Well saturated and perfused in RA. Skin w/o leisons. HEENT WNL. Cor nl s1s2 w/o murmurs. Lungs clear.A bdomen benign. Moving all 4ext. Neuro non-focal and age appropriate.\n"
}
] |
11,404 | 119,701 | 1. Hypoxic Respiratory Distress. Patient initially developed hypoxic respiratory distress, likely secondary to pulmonary edema from volume overload with acute renal failure. Initial patient echo showed poor EF of 20-25%. His oxygen requirements were monitored closely, and did not increase. Patient was fluid restricted to 1500cc a day initially, which was d/c'd once patient's renal function recovered and patient was able to diurese. On discharge, he had oxygen saturations in the high 90s on room air. . 2. Rhabdomyolosis. Patient was in rhabdomyolysis on admission. He had creatinine kinases elevated into the 100,000s on admission, likely secondary to being found unconscious for several days per outside report. Patient was aggressively hydrated with fluids. However he went into pulmonary edema with fluid rescuscitation and was placed on hemodialysis for renal failure and volume overload. His CKs have been trending downward, but continue to remain mildly elevated. . 3. Acute renal failure. Patient developed acute renal failure likely secondary to rhabdomyolysis. He has had gradual improvement in urine output through the past several days. He was initiated on hemodialysis initially on MWF. His electrolytes were monitored carefully. He was placed on nephrocaps, sevelamer, and calcium acetate for electrolyte abnormalities associated with renal failure. His hemodialysis was terminated one week prior to discharge for improvement in renal function with good diuresis and improving creatinine. His tunneled catheter was removed. Patient is to have weekly checks of his creatinine and BUN to be followed by his PCP to assess for continued recovery of renal function. His sevelamer, calcium, and nephrocaps were all d/c'd prior to discharge due to continued improvement of his renal function. . 4. Compartment syndrome. Patient had bilateral lower extremity swelling on admission. Bilateral LENIs were negative. Orthopedics was consulted, and felt that the swelling was likely secondary to edema. After fluid removal during dialysis, patient had persistent swelling, tenderness, and limited range of motion in his left leg, and concern was raised for compartment syndrome. Patient was taken to the OR on for evacuation of anterior fasciotomy, and repeat washout was performed on for anterior fasciotomy with removal of large amounts of necrotic tissue. Patient was placed on a wound vac with large amounts of serosanguineous drainage. He was then taken to the OR again on for primary closure of the lateral fasciotomy. He had decreased drainage of his medial fasciotomy throughout his hospital course, and his wound vac was d/c'd prior to discharge. He is to have wet-to-dry dressings over the site, and a 10 day course of prophylactic antibiotics. No further surgery is anticipated. Patient is to be seen by orthopedics in weeks for follow-up. His leg exam was monitored throughout his stay. He had diminished DP pulses and weakness with dorsiflexion in his left toe, as well as decreased sensation to light touch. He had intensive physical therapy during his stay, as well as occupational therapy. He had a multipodus boot fitted, and he will need to maintain his foot in a neutral position to prevent contracture. He will need continued aggressive physical therapy at rehab to help with recovery of his muscle strength. . 5. Leukocytosis. Patient had persistent leukocytosis and fever on admission, with negative cultures. Patient's CXR and UA were negative for infection. His sputum cultures were positive for GPR and GPCP, and patient was initiated on empiric treatment for aspiration pneumonia with vancomycin, levofloxacin, and metronidazole. His final sputum, blood, and urine cultures were negative. His stool cultures for C. difficile was negative. He was continued on vancomycin due to continued leukocytosis and concern for cellulitis overlying the fasciotomy site. The vancomycin was stopped after patient's final surgery. A PICC was placed for delivery of long-term antibiotics, which remained in place. Patient is to go to rehabilitation on a 10 day course of oral cephalexin. . 6. Anemia. Patient's hematocrit decreased from 38 to 23, with no obvious source of bleeding, likely secondary to erythropoietin deficiency from renal failure, with component of acute blood loss during orthopedic procedures for fasciotomies. Patient received multiple blood transfusions to maintain his hematocrit above 30 in the context of cardiomyopathy with low EF. Due to concern for continued bleeding, patient had a CT abdomen which was negative for a retroperitoneal bleed. He continued to have serosanguineous drainage through his wound vac. Patient received IV iron and erythropoietin during dialysis, and was continued on erythropoietin until full recovery of his renal function. He will need to have his renal function monitored closely at rehab, and his erythropoietin may be d/c'd once renal function recovers and anemia resolves. . 7. Cardiomyopathy - Patient had LBBB on EKG and global hypokinesis on echo with an EF of 20-25%. Patient also had elevated CK and CK-MB, but in context of rhabdomyolysis, as well as persistent tachycardia. It was unclear whether patient had acute ischemia or dilated cardiomyopathy from chronic alcohol use. Cardiology was consulted, and felt that the patient did not have an acute ischemic event. Patient was placed on digoxin, aspirin, and metoprolol. His digoxin was subsequently d/c'd secondary to adequate rate control with metoprolol. Patient continued to have TWI on EKG, with deepening of T waves during surgeries. His EKG remained unchanged, however, and he was maintained on his beta-blocker and his ASA. He was transfused to hematocrit >30 prior to OR procedures. He had a repeat echocardiogram which showed complete recovery of ejection fraction, with only trace MR. The initial global hypokinesis was thought to be secondary to stunned myocardium in the context of being acutely ill. . 8. EtOH abuse. After sedation was removed, patient became delirious with active hallucinations, requiring high doses of valium. He improved over the next several days. Addictions and psychology were consulted. Psychiatry felt that patient was not actively suicidal and overdose was not a suicide attempt. Patient will likely need substance abuse counseling as an outpatient. . 9. Bullae. Patient had a bullae on his thenar eminence which dermatology was consulted for. They felt that it was a pressure-induced bullae. The bullae popped spontaneously, and patient applied bactroban lotion to the site daily. It appeared well-healed. . 10. Pain. Patient has a history of substance abuse, and had a period of withdrawal from heroin, methadone, and alcohol. In the past, he has used Percocet, Tylenol #3, occasionally oxycontin. Patient was placed on a fentanyl patch, with dilaudid for breakthrough pain. He was on a dilaudid PCA post-operatively for better pain control. Pain team was consulted for evaluation. His PCA was d/c'd, and he was transitioned to fentanyl 250mcg patch q72h, with dilaudid 8 mg q3-4 hours for breakthrough pain, which was an adequate regimen for his pain control. . 11. SW and addiction consults for coping, substance abuse, resources. Patient was seen by social work and by psychiatry for his substance abuse needs. . 12. Hypercalcemia. Patient developed gradual increase in calcium, likely secondary to muscle recovery after severe rhabdomylosis. Patient received aggressive fluid resuscitation, as well as multiple doses of calcitonin. He was started on pamidronate 30 mg IV, and he was placed on telemetry for continuous cardiac monitoring. His EKGs did not show interval prolongation, and he had no events on telemetry. He did develop nausea and vomiting, thought to be a side effect from the calcitonin and pamidronate injections, which was relieved by dolasetron. His LFTs, amylase, and lipase were checked and were all normal, and he had a benign abdominal exam. His calcium normalized over the course of several days. He will need to have his calcium level checked every other day at rehabilitation to assess for worsening of his hypercalcemia. . 13. Hypertension. Patient had hypertension, controlled with metoprolol 150 mg TID, amlodipine 10 mg QD, as well as isordil and hydralazine. His amlodipine may be stopped as an outpatient as his calcium improves. His metoprolol was decreased to 150 on discharge. . 14. Constipation. Patient had severe constipation, likely related to immobility and high doses of narcotics. He was given enemas with relief. He was initiated on standing colace. . 15. Communication: Mother . 16. Access. Patient has left PICC line for access. This may be removed if no longer needed at rehabilitation. His tunneled catheter for hemodialysis was removed prior to discharge. | No aortic regurgitation is seen.6.The mitral valve leaflets are mildly thickened. Again, seen moderate diffuse interstitial edema, unchanged. The heart size and mediastinal contours appear unchanged. Cardiac and mediastinal contours are unchanged. Cardiac and mediastinal contours are unchanged. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Moderately dilated aortic root. Trivial mitral regurgitationis seen.7.There is no pericardial effusion. Mild (1+)mitral regurgitation is seen. The estimated pulmonary artery systolic pressureis normal. No AR.MITRAL VALVE: Normal mitral valve leaflets. IMPRESSION: No significant interval change in moderate pulmonary edema. There is severe global left ventricular hypokinesis.Systolic function of apical segments and the base is relatively preserved.Overall left ventricular systolic function is severely depressed.3.Right ventricular chamber size is normal. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.PERICARDIUM: No pericardial effusion.Conclusions:1. No large hematoma, Right subclavian central venous catheter has its tip at the brachiocephalic SVC junction. Normal RVsystolic function.AORTA: Moderately dilated aortic root.AORTIC VALVE: Normal aortic valve leaflets (3). The ventricles are symmetric, and there is no shift of normally midline structures. Mild (1+) MR. Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Limited abdomen and pelvis CT without intravenous or oral contrast. STUDY: CT chest, abdomen, and pelvis without contrast. Stable congestive heart failure. Severelydepressed LVEF.RIGHT VENTRICLE: Normal RV wall thickness. TECHNIQUE: Noncontrast head CT. CT HEAD WITHOUT IV CONTRAST: Motion artifact limits evaluation. The upper mediastinum appears within normal limits with treatment of the congestive heart failure. The osseous structures appear unchanged. Right subclavian central venous catheter remains in stable position within the mid SVC. The right subclavian IV catheter terminates in the superior vena cava. There is no pericardial effusion.Compared with the findings of the prior study (tape reviewed) of , the left ventricular ejection fraction is markedly increased. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Mild atelectatic changes are noted at the lung bases. Sinus rhythmLeft ventricular hypertrophy with ST-T abnormalitiesCannot exclude in part anterolateral ischemiaSince previous tracing of , no significant change Anterolateral T wave changes may be due to myocardial ischemia.Compared to the previous tracing of no significant change.TRACING #2 Sinus rhythmSeptal ST elevation - repeat if myocardial injury is suspectedLateral T wave changes are nonspecificSince previous tracing, no significant change Sinus tachycardia.Anterolateral T wave abnormalities 0 are nonspecific but cannot exclude in partischemia - clinical correlation is suggestedSince previous tracing of , T wave changes more prominent The right subclavian IV catheter terminates in the SVC. Sinus tachycardiaAnterolateral T wave abnormalities - are nonspecific but cannot exclude in partischemia - clinical correlation is suggestedSince previous tracing of , sinus tachycardia rate slower Compared to theprevious tracing of anterolateral ST-T wave abnormalities are lessmarked.TRACING #1 TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the pubic symphysis were acquired without IV contrast. Sinus rhythmAcute anterior myocardial infarctionLateral T wave changes may be due to myocardial ischemiaSince previous tracing, abterior ST segment elevation persist - consider leftventricular aneurysm CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is seen within the bladder, which is collapsed. IMPRESSION: Unremarkable radiographs of the left tibia and fibula. This likely represents subacute hematoma. The pelvic loops of bowel, seminal vesicles, and prostate are otherwise unremarkable. Within the left medial thigh musculature, lateral to the left superior pubic ramus, there is an approximately 3.0 x 8.1 cm rim-calcified fluid collection, most likely representing a subacute hematoma. REASON FOR THIS EXAMINATION: Please REMOVE tunneled catheter for HD. Sinus tachycardia.Lateral T wave changes are nonspecific, more pronounced than previousConsider ischemia REASON FOR THIS EXAMINATION: Please evaluate for thrombus FINAL REPORT INDICATION: Left arm swelling with PICC in place. pt placed on sbt and tolertated well with abg of 7.38/39/191. BY EMS PT GIVEN NARCAN, ABLE TO AROUSE. CXR WITH POSSIBLE ASPIRATION OR PNEUMONITIS AND PULM EDEMA.GI/GU: ABD SOFT AND DISTENDED WITH +BS. LYTES PER CAREVUE. LYTES PER CAREVUE. PT STARTED ON VANCO, FLAGYL, LEVAQUIN. RIGHT SUBCLAVIAN TLC, RIGHT ALINE. R sc tlc. +perrla noted. Combivent MDI Q vent check. BC SENT IN EW. PT TO EW. Pt currently sedated and vented on A/C see current settings in flow sheet. CONTINUES ON VANCO, LEVO, AND FLAGYL. A 0.018 guidewire was advanced under fluoroscopy into the superior vena cava. FLUIDS GIVEN FOR RHABDO. Resp. ABG 7.36/39/139. BY THIS AM ABLE TO WEAN DONW FIO2. ON 10PEEP ABG 7.41/37/194/24. Pulse is dopplarable in Lt. leg. Bs course to clear. ABG 7.43/35/85/24. was AA0x2, but very anxiou. PULSES BY DOPPLER. Abgs WNL. IONIZED CA+ .78, 3GMS CA+ GIVEN. PT R/I FOR AWMI.GI/GU: ABD SOFT, DISTENDED. Plan to wean to extubate in am with anesthesia present. PT DID WAKE W/ HD LINE PLACEMENT. Pneumothorax is identified. DECREASED PEEP TO 8 WITH ABG 7.46/31/214/23. on , will cont. REMAINS ON VANCO, LEVO, FLAGYL. Placed on SBT with good ABG, RR variable and TV>1.0L at times. LACTATE 2.5. TO MICU.NKDA. SC TLC, Rt. , RRT Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt. REPEAT K+ 5.3. PT GIVEN 80MG IV LASIX IN EW W/ NO RESULT. sputum sent. RESEDATED.RESP: ON ADMIT TO UNIT ABG 7.22/50/91 ON 100% FIO2. BP 140-150.access: R radial aline that is positional. A final fluoroscopic spot image of the chest demonstrates the tip to be in the superior vena cava. sxn for mod amt thick tan tenacious secretions via ett. BS + and belly is soft and distended. repeat LENI.resp: Currently on cool neb mask with sats 100%. Positional air leak noted. ANASARCA. REMAINS NPO.ID: TMAX 100.4 WITH WBC 15.9. Sxn for tannish secretions, specimen sent. adm. hx, flowsheet and previous notes. BP 132-158/83-97. TMAX 102.2. | 48 | [
{
"category": "Echo",
"chartdate": "2103-09-21 00:00:00.000",
"description": "Report",
"row_id": 79552,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG.\nHeight: (in) 70\nWeight (lb): 200\nBSA (m2): 2.09 m2\nBP (mm Hg): 112/90\nHR (bpm): 117\nStatus: Inpatient\nDate/Time: at 13:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Severe\nglobal LV hypokinesis. Relatively preserved apical LV contraction. Severely\ndepressed LVEF.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Moderately dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis moderately dilated. There is severe global left ventricular hypokinesis.\nSystolic function of apical segments and the base is relatively preserved.\nOverall left ventricular systolic function is severely depressed.\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic root is moderately dilated.\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen.\n6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n7.There is no pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2103-10-11 00:00:00.000",
"description": "Report",
"row_id": 79490,
"text": "PATIENT/TEST INFORMATION:\nIndication: Murmur.\nHeight: (in) 75\nWeight (lb): 210\nBSA (m2): 2.24 m2\nBP (mm Hg): 154/74\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 16:24\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Overall\nnormal LVEF (>55%). No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Normal mitral valve\nsupporting structures. Mild (1+) MR. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is moderately dilated. Overall left ventricular systolic function is\nnormal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic root is moderately dilated. The ascending aorta\nis mildly dilated. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the left ventricular ejection fraction is markedly increased.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-19 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 884829,
"text": " 8:58 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with inc wbc, rhabdo,\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Increasing white count and rhabdo, status post line placement.\n\n COMPARISON: at hours.\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: Since the previous examination, there has been placement of a right\n subclavian venous access catheter, which crosses the midline with tip directed\n in a leftward position. The tip of the catheter may possibly be located\n within the left brachiocephalic vein, within a persistent left-sided SVC, or\n the catheter may be intraarterial. Clinical correlation is required. The\n heart size and mediastinal contours appear unchanged. There is continued\n prominence of the pulmonary vascularity and interstitial markings consistent\n with congestive heart failure. No pneumothorax.\n\n The osseous structures appear unchanged.\n\n IMPRESSION:\n\n 1. Right subclavian venous access catheter possibly terminates within the\n left brachiocephalic vein or within a left-sided SVC; intraarterial course is\n felt less likely.\n\n 2. Stable congestive heart failure.\n\n 3. No pneumothorax.\n\n Initial results discussed with the ED resident caring for the patient at 9:30\n p.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885154,
"text": " 11:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with hypoxic respiratory failure to pulmonary edema\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia.\n\n Single upright portable chest radiograph demonstrates an endotracheal tube\n with its tip at the clavicular heads. A right subclavian central venous\n catheter is present with its tip in the SVC. Cardiac silhouette is now better\n defined along the right heart border. Changes in mediastinal contour are\n attributable to differences in ankle projection and phase of respiration. The\n bibasilar opacities have markedly improved. No pneumothorax. Trachea is\n midline.\n\n IMPRESSION:\n\n Marked interval improvement in pulmonary edema. Support lines as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885328,
"text": " 11:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 44M w/ volume overload, recently extubated, now w/ CP, SOB\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with hypoxic respiratory failure to pulmonary edema\n\n REASON FOR THIS EXAMINATION:\n 44M w/ volume overload, recently extubated, now w/ CP, SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxic respiratory failure, now with chest pain and shortness of\n breath.\n\n PORTABLE AP CHEST: Comparison is made to study dated .\n\n FINDINGS: The patient has been extubated. Right subclavian central venous\n catheter remains in stable, satisfactory position within the proximal SVC.\n Cardiac and mediastinal contours are unchanged. In the interval, there is\n increased hilar fullness, interstitial prominence, and subpleural Kerley B\n lines, consistent with pulmonary edema. The are no pleural effusions. Left\n retrocardiac density has increased in the interval, consistent with worsening\n atelectasis.\n\n IMPRESSION:\n 1. Worsening interstitial edema.\n 2. Increased left lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-22 00:00:00.000",
"description": "LP UNILAT LOWER EXT VEINS LEFT PORT",
"row_id": 885221,
"text": " 9:08 PM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: r/o DVT\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with LLE swelling, and erythema. Had LENI yesterday which was\n negative but leg has become swollen and tight, want repeat to r/o DVT\n\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lower extremity swelling and erythema.\n\n COMPARISON: .\n\n LEFT LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler son of\n left common femoral, left superficial femoral, and left popliteal veins were\n performed. Normal waveforms, compressibility, augmentation, and color flow\n were demonstrated in all these veins. No intraluminal thrombus was noted.\n\n IMPRESSION: No evidence of deep venous thrombosis in the left lower\n extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-20 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 884889,
"text": " 4:24 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: found down, r/o head bleed or c-spine fx\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man found down, confused\n REASON FOR THIS EXAMINATION:\n found down, r/o head bleed or c-spine fx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of fall, evaluate for C-spine fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial images of the cervical spine were obtained with multiplanar\n reconstructions.\n\n CT C-SPINE: No fracture or malalignment is identified. No prevertebral soft\n tissues swelling is seen. While CT is not good at evaluating soft tissues\n within the spinal canal, no gross abnormalities identified. The patient is\n intubated. In the visualized portions of the lung apices, no pleural effusion\n or pneumothorax are identified, but there is a bleb on the right.\n\n IMPRESSION: No evidence of fracture or malalignment.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-20 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 884890,
"text": " 4:24 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o PNA\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n Field of view: 42\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with wbc and bandemia\n REASON FOR THIS EXAMINATION:\n r/o PNA\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 44-year-old man with leukocytosis and bandemia, renal\n failure, intubated and altered consciousness.\n\n STUDY: CT chest, abdomen, and pelvis without contrast.\n\n TECHNIQUE: Multidetector CT of the chest, abdomen and pelvis was performed\n with 5 mm axial images displayed on PACs. 5 mm coronal and sagittal reformats\n of the chest, abdomen and pelvis were also made. No intravenous or oral\n contrast was administered.\n\n FINDINGS:\n CHEST:\n There is soft tissue stranding within the subcutaneous tissues superficial to\n the right pectoralis muscles along with enlargement of the right pectoralis\n muscles and some fat stranding around the right subclavian vein, likely\n related to right subclavian central venous catheter placement. No large\n hematoma, Right subclavian central venous catheter has its tip at the\n brachiocephalic SVC junction. No pneumothorax.\n\n There are hazy patchy ground-glass opacities within the mid and upper lungs\n bilaterally to a mild degree, possibly representing a small amount of\n pneumonitis or aspiration. There is no focal lobar pneumonia and there is not\n extensive opacities to suggest diffuse pulmonary infection. There is\n bilateral lower lobe atelectasis in a dependent position with small bilateral\n pleural effusions layering. No evidence of loculated effusion. No enlarged\n mediastinal lymph nodes by CT size criteria. No masses. Incidental note is\n made of ductus calcifications and a small amount of aortic atherosclerosis. No\n pericardial effusion. Heart size is within normal limits.\n\n The endotracheal tube tip is just beyond the thoracic inlet in the expected\n position.\n\n No acute fractures or other concerning bone abnormalities within the thorax.\n\n ABDOMEN AND PELVIS CT:\n Evaluation of the abdomen and pelvis is limited without intravenous contrast\n or significant oral contrast. There is minimal oral contrast within the\n (Over)\n\n 4:24 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST; CT RECONSTRUCTION\n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o PNA\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n Field of view: 42\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n stomach with some tablets, which may be related to medication intake. This is\n a nonspecific finding. There is a moderate amount of fat stranding within the\n anterior and posterior pararenal spaces bilaterally, along the paracolic\n gutters, and into the pelvis. There is a small amount of free fluid within\n the paracolic gutters bilaterally as well as moderate free fluid within the\n pelvis. There is bilateral subcutaneous fat stranding as well. This all\n likely reflects fluid overload, along with the bilateral pleural effusions.\n\n There is a normal noncontrast CT appearance of the liver, bilateral kidneys,\n spleen, pancreas, bilateral adrenal glands, and large and small bowel. There\n is subtle increased density layering dependently within the gallbladder,\n possibly representing sludge. Bile ducts are not dilated, and there is no\n other findings to suggest acute cholecystitis. No lymphadenopathy within the\n abdomen, pelvis, or retroperitoneum. No abscess within the muscles about the\n abdomen or pelvis or within the subcutaneous tissues. There is a right\n femoral venous catheter with its tip in the right common femoral vein. There\n are phleboliths in the pelvis. No ureteral calculi or renal collecting system\n dilatation. Incidental note is made of a small left inguinal hernia\n containing only fat and no bowel. No acute bony abnormalities or concerning\n bony lesions within the abdomen or pelvis.\n\n IMPRESSION:\n 1. Minimal patchy upper lung ground-glass opacity could represent a small\n amount of pneumonitis or aspiration. There is no lobar pneumonia or diffuse\n pulmonary abnormality to suggest diffuse pulmonary infection.\n\n 2. Limited abdomen and pelvis CT without intravenous or oral contrast.\n Bilateral retroperitoneal fat stranding, small amount of ascites within the\n paracolic gutters and pelvis, subcutaneous fat stranding, and bilateral\n pleural effusions likely reflect fluid overload.\n\n 3. Right pectoralis and chest wall edema likely from right subclavian central\n venous catheter placement. No large hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-23 00:00:00.000",
"description": "L KNEE (AP, LAT & OBLIQUE) LEFT",
"row_id": 885269,
"text": " 11:19 AM\n KNEE (AP, LAT & OBLIQUE) LEFT; ANKLE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: r/o acute process\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with LLE swelling\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old man with left lower leg swelling.\n\n COMMENTS: Three views of the left ankle and AP and lateral radiographs of the\n left knee are reviewed. There is extensive swelling around the left ankle.\n No evidence of fracture or dislocation is seen. There is probably a small\n joint effusion.\n\n There is also small effusion in the suprapatellar bursa. No evident fracture\n or dislocation is seen in the left knee joint.\n\n IMPRESSION: Small effusion in the left ankle and left knee joint. The\n possibility of septic arthritis cannot be excluded in the proper clinical\n setting. No evidence for fracture or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 884888,
"text": " 4:23 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed, mass\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man found down with likely heroin overdose; ?infxn; also has rhabdo\n and ARF; MAE, nonfocal exam\n REASON FOR THIS EXAMINATION:\n r/o bleed, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of fall, evaluate for intracranial hemorrhage or mass.\n\n COMPARISON: None.\n\n TECHNIQUE: Noncontrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: Motion artifact limits evaluation. No\n intracranial hemorrhages identified. The ventricles are symmetric, and there\n is no shift of normally midline structures. The -white matter\n differentiation is preserved. The density of the brain parenchyma is within\n normal limits. The paranasal sinuses are well aerated. Soft tissue\n abnormalities are identified. The osseous structures are normal.\n\n IMPRESSION: Motion limited. No intracranial hemorrhage or mass effect\n identified.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-21 00:00:00.000",
"description": "LP UNILAT LOWER EXT VEINS LEFT PORT",
"row_id": 884979,
"text": " 10:07 AM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: eval for DVT\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with LLE pain/swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old man with left lower extremity pain and swelling.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler examination of the deep veins of the\n left thigh and posterior knee demonstrate normal compressibility, color flow,\n respiratory variation, and augmentation. There is no sign of intraluminal\n thrombus.\n\n IMPRESSION: No DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-25 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 885490,
"text": " 7:22 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please place tunnelled IJ line\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1750 CATH,HEMO/PERTI DIALYSIS LONG C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with acute renal failure on HD, femoral line clotted, please\n place tunnelled IJ line\n REASON FOR THIS EXAMINATION:\n please place tunnelled IJ line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 44-year-old man with acute renal failure on\n hemodialysis, needs tunneled dialysis catheter placement on the left side.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr. .\n Dr. , the attending radiologist, was present and supervising throughout\n the procedure.\n\n After the risks and benefits were explained to the patient, written informed\n consent was obtained. The patient was placed supine on the angiographic\n table. Preprocedure timeout was performed to confirm the patient's name,\n procedure and side. The left neck and upper chest were prepped and draped in\n the standard sterile fashion. Ultrasound confirmed the left internal jugular\n vein was patent and compressible. Under ultrasonographic guidance, a 21-gauge\n needle was used to access the left internal jugular vein. A 0.018 guidewire\n was placed through the needle under fluoroscopic guidance. The needle was\n exchanged for a 4-French sheath.\n\n A tunneled track was created in the subcutaneous tissue extending from the\n left upper chest to the primary left internal jugular vein puncture site. The\n dialysis catheter was then advanced through the track using tunneled device.\n The left internal jugular venous entrance site was then progressively dilated\n with multiple dilators. A 14.5-French sheath was then advanced over the wire\n and the inner dilator was then exchanged for the hemodialysis catheter. A\n final film confirmed the tip of the catheter is within the right atrium. Two\n lumens were flushed and the catheter was secured with skin by sutures.\n\n The patient tolerated the procedure well, and there were no immediate\n complications.\n\n IMPRESSION: Successful placement of a tunneled dialysis catheter through left\n internal jugular vein with the tip in the right atrium. The catheter is ready\n to use.\n\n (Over)\n\n 7:22 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: please place tunnelled IJ line\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885361,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for progression of pulmonary edema\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with hypoxic respiratory failure to pulmonary edema\n\n REASON FOR THIS EXAMINATION:\n please evaluate for progression of pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxic respiratory failure.\n\n PORTABLE AP CHEST: Comparison is made to study performed 8 hours earlier.\n Right subclavian central venous catheter remains in stable position within the\n mid SVC. Cardiac and mediastinal contours are unchanged. Again, seen\n moderate diffuse interstitial edema, unchanged. Dense left retrocardiac\n density is consistent with atelectasis. There may be small bilateral pleural\n effusions.\n\n IMPRESSION: No significant interval change in moderate pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 884879,
"text": " 3:01 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate ETT\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with hypercarbic respiratory failure s/p ETT change due to air\n leak\n REASON FOR THIS EXAMINATION:\n evaluate ETT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 44-year-old man with respiratory failure, ET tube placement.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study at 1:17 a.m.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n right subclavian IV catheter terminates in the superior vena cava. No\n pneumothorax is identified.\n\n The previously identified pulmonary edema has been improving. The heart is\n normal in size. There is left lower lobe patchy atelectasis. There are small\n bilateral pleural effusions. No evidence of pneumothorax is identified. The\n upper mediastinum appears within normal limits with treatment of the\n congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 884825,
"text": " 7:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with inc wbc, ?anterior mi\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leukocytosis, anterior myocardial infarction, drug abuse.\n\n COMPARISONS: None.\n\n SINGLE VIEW CHEST, AP: There are diffuse interstitial and alveolar opacities\n bilaterally in a perihilar distribution consistent with pulmonary edema. The\n contour of the superior mediastinum is enlarged. There is no pneumothorax.\n The osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Diffuse marked interstitial and alveolar opacities consistent with\n pulmonary edema.\n 2. Widening of the superior mediastinum which likely represents vascular\n engorgement. However, followup radiographs are recommended.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-10-12 00:00:00.000",
"description": "Report",
"row_id": 202726,
"text": "Normal sinus rhythm, rate 82. Non-specific lateral repolarization changes\nconsistent with ischemia. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-22 00:00:00.000",
"description": "Report",
"row_id": 202976,
"text": "Sinus tachycardia.\nLateral T wave changes are nonspecific, more pronounced than previous\nConsider ischemia\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-20 00:00:00.000",
"description": "Report",
"row_id": 202977,
"text": "Sinus tachycardia. Probable left bundle-branch block. Compared to the previous\ntracing of the rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-19 00:00:00.000",
"description": "Report",
"row_id": 202978,
"text": "Sinus tachycardia\nLeft bundle branch block\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2103-10-11 00:00:00.000",
"description": "Report",
"row_id": 202968,
"text": "Sinus rhythm\nLeft ventricular hypertrophy with ST-T abnormalities\nCannot exclude in part anterolateral ischemia\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2103-10-05 00:00:00.000",
"description": "Report",
"row_id": 202969,
"text": "Sinus rhythm\nAcute anterior myocardial infarction\nLateral T wave changes may be due to myocardial ischemia\nSince previous tracing, abterior ST segment elevation persist - consider left\nventricular aneurysm\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-29 00:00:00.000",
"description": "Report",
"row_id": 202970,
"text": "Sinus rhythm\nAnterolateral T wave changes may be due to myocardial ischemia\nAnterolateral T wave changes more widespread than previos\nAnteroseptal ST segment elevation consider acute anteroseptal myocardial\ninfarction\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-30 00:00:00.000",
"description": "Report",
"row_id": 202971,
"text": "Sinus rhythm\nSeptal ST elevation - repeat if myocardial injury is suspected\nLateral T wave changes are nonspecific\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-28 00:00:00.000",
"description": "Report",
"row_id": 202972,
"text": "Sinus rhythm. Anterolateral T wave changes may be due to myocardial ischemia.\nCompared to the previous tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-27 00:00:00.000",
"description": "Report",
"row_id": 202973,
"text": "Sinus rhythm. Anterolateral T wave changes are non-specific. Compared to the\nprevious tracing of anterolateral ST-T wave abnormalities are less\nmarked.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-25 00:00:00.000",
"description": "Report",
"row_id": 202974,
"text": "Sinus tachycardia\nAnterolateral T wave abnormalities - are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia rate slower\n\n"
},
{
"category": "ECG",
"chartdate": "2103-09-23 00:00:00.000",
"description": "Report",
"row_id": 202975,
"text": "Sinus tachycardia.\nAnterolateral T wave abnormalities 0 are nonspecific but cannot exclude in part\nischemia - clinical correlation is suggested\nSince previous tracing of , T wave changes more prominent\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-15 00:00:00.000",
"description": "TUNNELED CENTRAL W/O PORT",
"row_id": 888225,
"text": " 7:21 AM\n DIALYSIS REMOVE Clip # \n Reason: Please REMOVE tunneled catheter for HD. Patient no longer ne\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ********************************* CPT Codes ********************************\n * TUNNELED CENTRAL W/O PORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with tunneled catheter in place. Needs to be removed by IR.\n REASON FOR THIS EXAMINATION:\n Please REMOVE tunneled catheter for HD. Patient no longer needs HD.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: The patient no longer requires hemodialysis catheter.\n\n PROCEDURE: The procedure was performed by Drs. , \n and with Dr. , the attending radiologist,\n supervising during the entire procedure.\n\n Standard sterile prep and drape of the left upper chest and base of the neck\n and the in situ catheter. A preprocedure timeout was performed to confirm\n patient, procedure, and site. Local anesthesia with 8 cc of 1% lidocaine\n around the tunnel entry site and catheter cuff. With minimal manual\n manipulation the catheter was removed easily. Hemostasis was ensured with\n direct manual compression at the base of the neck at the internal jugular vein\n puncture site and over the subcutaneous tunnel. There were no immediate\n complications. A sterile dressing was applied over the tunnel entry site. This\n dressing can removed in 48 hours. The patient may shower making sure to keep\n this area covered with plastic such as a plastic bag taped over the area. The\n patient should not bathe or submerse this area in water for at least ten days.\n\n IMPRESSION: Successful removal of a left internal jugular vein tunnelled\n hemodialysis catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-03 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 886682,
"text": " 6:24 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: DIFFUSE ABD.PAIN. DROPPING HCT. ?RP BLEED\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with wbc and bandemia c/o diffuse abd pain, now with dropping\n hct despite PRBC and asymmetrical LLE edema\n REASON FOR THIS EXAMINATION:\n Please r/o RP bleed\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure/on HD\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: White count, bandemia, complaints of diffuse abdominal pain and\n dropping hematocrit.\n\n COMPARISON: CT from .\n\n TECHNIQUE: MDCT acquired contiguous axial images from the lung bases to the\n pubic symphysis were acquired without IV contrast.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Mild atelectatic changes are noted at\n the lung bases.\n\n The superior aspect of the liver is excluded from the study. Imaged portion\n of the liver otherwise appears unremarkable without evidence of intrahepatic\n biliary duct dilatation or focal masses. The gallbladder, pancreas, spleen,\n adrenal glands, kidneys, ureters, stomach, and loops of large and small bowel\n are all within normal limits. The abdominal aorta is normal in caliber. There\n is no free air or free fluid. There is no evidence of retroperitoneal\n hematoma. No pathologically enlarged mesenteric or retroperitoneal lymph\n nodes are seen.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is seen within the\n bladder, which is collapsed. The pelvic loops of bowel, seminal vesicles, and\n prostate are otherwise unremarkable. There is no free fluid. There is no\n pelvic or inguinal lymphadenopathy.\n\n Within the left medial thigh musculature, lateral to the left superior pubic\n ramus, there is an approximately 3.0 x 8.1 cm rim-calcified fluid collection,\n most likely representing a subacute hematoma. Additionally, fluid is seen\n within the fascial planes of the left thigh as well as extensive subcutaneous\n fat stranding. No high-density fluid collection is present to suggest an\n acute hematoma.\n\n Additionally seen within the lateral musculature of the right thigh, there are\n linear areas of calcification seen, which may represent heterotopic/dystrophic\n calcification secondary to prior trauma injury. Small amount of fluis and fat\n stranding is also seen within the fascial planes of the right lateral thigh\n musculature. Irregular calcification is also noted posterior to the sacrum\n within the paraspinal musculature.\n (Over)\n\n 6:24 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: DIFFUSE ABD.PAIN. DROPPING HCT. ?RP BLEED\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No fractures are noted. No suspicious lytic or sclerotic\n lesions are present.\n\n IMPRESSION:\n 1. No evidence of retroperitoneal hematoma.\n 2. Rim-calcified fluid collection within the medial left thigh. This likely\n represents subacute hematoma. Additionally, there is fat stranding and fluid\n surrounding the musculature and fascial planes of the left thigh, particularly\n laterally.\n 3. Small amount of fluid also demonstrated within the right thigh musculature\n laterally, without a focal fluid collection seen.\n 4. Irregular areas of ossification noted within the sacral paraspinal muscles\n as well as within the lateral right thigh musculature, likely representing\n heterotopic/dystrophic calcification secondary to trauma.\n\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-10 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 887636,
"text": " 1:32 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: LT EDEMA, PLEASE EVAL FOR THROMBUS IN ARM WITH PICC LINE\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left arm swelling with PICC line in place.\n REASON FOR THIS EXAMINATION:\n Please evaluate for thrombus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left arm swelling with PICC in place.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler examination of the IJ, subclavian,\n axillary, brachial, basilic, encephalic veins demonstrate normal\n compressibility, color flow, respiratory variation, and augmentation. There\n is no sign of intraluminal thrombus. A PICC is present in the basilic vein.\n\n IMPRESSION: No DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 884837,
"text": " 12:58 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please assess line placement\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 4 year old man with inc wbc, rhabdo, intubated, central line pulled back 4 cm\n REASON FOR THIS EXAMINATION:\n please assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 44-year-old man with increased WBC.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of yesterday.\n\n The tip of the endotracheal tube is identified just above the thoracic inlet.\n The right subclavian IV catheter terminates in the SVC. No pneumothorax is\n identified.\n\n The previously identified pulmonary edema has been improving. There is\n continued mild congestive heart failure with cardiomegaly.\n\n Note is made of prominent upper mediastinum, which indicate vascular\n engorgement versus mediastinal lymphadenopathy. Please evaluate with chest\n x-ray when the pulmonary edema is treated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-22 00:00:00.000",
"description": "LP ANKLE (AP, MORTISE & LAT) LEFT PORT",
"row_id": 885139,
"text": " 8:31 AM\n ANKLE (AP, MORTISE & LAT) LEFT PORT; TIB/FIB (AP & LAT) LEFT PORTClip # \n Reason: r/o effusion or fx\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left ankle swelling and pain\n REASON FOR THIS EXAMINATION:\n r/o effusion or fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Ankle pain.\n\n Three radiographs of the left tibia and fibula demonstrate no fracture. Soft\n tissues are unremarkable. Limited assessment of the ankle and knee joints is\n unremarkable.\n\n IMPRESSION:\n\n Unremarkable radiographs of the left tibia and fibula.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 884833,
"text": " 10:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval tube placement, also ?ptx from line\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with inc wbc, rhabdo, intubated\n REASON FOR THIS EXAMINATION:\n eval tube placement, also ?ptx from line\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 44-year-old man with increased WBC.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study at 9:11 p.m.\n\n The patient has been intubated. The tip of the endotracheal tube is\n identified at the thoracic inlet. The right subclavian IV catheter remains in\n the left innominate vein. No pneumothorax is identified.\n\n There is marked progression of the pulmonary edema probably due to congestive\n heart failure. There is continued cardiomegaly. Pneumothorax is identified.\n There is continued prominence of the upper mediastinum, which indicates the\n possibility of mediastinal lymphadenopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-09-28 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 885910,
"text": " 7:40 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC for IV antibiotics; bedside PICC failed\n Admitting Diagnosis: RHABDOMYALASIS;TELEMETRY\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with ARF on HD, rhabdomyolysis, s/p LLE fasciotomy\n REASON FOR THIS EXAMINATION:\n please place PICC for IV antibiotics; bedside PICC failed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infection requiring IV antibiotics. IV nurse unable to advance a\n PICC line at bedside.\n\n PHYSICIANS: The procedure was performed by Dr. and Dr. \n , with Dr. , the attending radiologist, present and\n supervising.\n\n PROCEDURE AND FINDINGS: The patient was placed supine on the angiography\n table. The patient's left upper arm was prepped and draped in sterile fashion.\n Since no suitable superficial veins were visible, ultrasound was used for\n localization of a suitable vein. The left basilic vein was patent and\n compressible. After local anesthesia with 8 cc of 1% lidocaine, the left\n basilic vein was entered under ultrasonographic guidance with a 21-gauge\n needle. A 0.018 guidewire was advanced under fluoroscopy into the superior\n vena cava. Based on the markers on the guide wire, it was determined that a\n length of 48 cm would be suitable. The PICC line was trimmed to length and\n advanced over a 4 French introducer sheath under fluoroscopic guidance into\n the superior vena cava. The sheath was removed. The catheter was flushed. A\n final fluoroscopic spot image of the chest demonstrates the tip to be in the\n superior vena cava. The line is ready for use. A StatLock was applied and the\n line was heplocked.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful placement of a 48-cm long, 4 French, single-lumen PICC\n line with tip in the superior vena cava. The catheter is ready for use.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-20 00:00:00.000",
"description": "Report",
"row_id": 1412300,
"text": "RESPIRATORY CARE NOTE\n\nPt received from ED intubated with a 7.5 LMA ETT. Positional air leak noted. BLBS are coarse and with crackles. Dialysis at bedside this AM. Albuterol MDI given for wheezing. ABG shows adequate ventilation and oxygenation.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-20 00:00:00.000",
"description": "Report",
"row_id": 1412301,
"text": "NURSING MICU ADMIT NOTE 7P-7A\n\nPT FOUND IN MOTEL EVENING BY MAID UNRESPONSIVE. BY EMS PT GIVEN NARCAN, ABLE TO AROUSE. IN OSH, PT TO TAKEN 1 BAG HEROIN, METHADONE, AND VODKA ON MONDAY, DOES NOT REMEMBER ANYTHING PAST THAT. CK'S 40,000, TROP 5, K+ 7. PT TO EW. CK'S 80,000, K+ TREATED W/ KAYEXALATE, D50, INSUIN, CA+. FLUIDS GIVEN FOR RHABDO. LITTLE U/O. AT 2200 DECREASE IN MS, MUSCLE TWITCHING, ABG 7.17/74/85. PT W/ GREAT DIFFICULTY. ATTEMPTES X6, DONE UNDER FIBER OPTICS. PT DIFFICULT TO OXYGENATE. TOTAL 6AMP BICARB GIVEN. K+ DOWN TO 5. TO MICU.\n\nNKDA. PMH ASTHMA, ETOH, DRUG ABUSE.\n\nNEURO: PT SEDATED ON PROPOFOL GTT AT 20MCG/KG/MR. PT DID WAKE W/ HD LINE PLACEMENT. WAS ABLE TO FOLLOW COMMANDS. RESEDATED.\n\nRESP: ON ADMIT TO UNIT ABG 7.22/50/91 ON 100% FIO2. CHANGES MADE TO RATE. BY THIS AM ABLE TO WEAN DONW FIO2. PT CURRENTLY ON AC 600X22 PEEP 10 50%. ABG 7.36/39/139. LS COARSE. OCCASIONAL EXP WHEEZE. NO ABLE TO OBTAIN O2 PLETHS. TEAM AWARE.\n\nCV: HR 90-120'S NSR. SBP 90-120'S. TMAX 102.2. PT GIVEN RECTAL TYLENOL, ICE PACKS. DIALYSIS NURSE BATH. BC SENT IN EW. REPEAT BC SENT THIS AM. PT STARTED ON VANCO, FLAGYL, LEVAQUIN. IN MICU K+ 6.9 TREATED W/ 10UNITS IV INSULIN, 1AMP D50. REPEAT K+ 5.3. IONIZED CA+ .78, 3GMS CA+ GIVEN. AM CA+ .85. PER RENAL NOT TO REPLEAT AT THIS TIME. AM CK'S CONT TO CLIMB 100,000. PT R/I FOR AWMI.\n\nGI/GU: ABD SOFT, DISTENDED. +BS, NO BM. PT HAS RECEIVED 2 DOSES OF KAYEXALATE BETWEEN BOTH HOSPITALS W/ NO RESULTS. NOT ABLE TO PLACE OGT, NO ABLE TO PASS DOWN, ? FROM EDEMA FROM DIFFICULT INTUBATION. FOLEY INTACT DRAINING BROWN CLOUDY URINE, MIN OUT PUT. PT GIVEN 80MG IV LASIX IN EW W/ NO RESULT. ADDITIONAL 160MG IV LASIX GIVEN IN MICU W/ NO RESULT.\n\nRENAL: DUE TO HIGH K+, PUL EDEMA, EMERGENT DIALYSIS STARTED THIS AM, 0530. SO FAR PT TOLERATING WELL.\n\nACCESS: PT HAS 3 PIV'S. RIGHT SUBCLAVIAN TLC, RIGHT ALINE. RIGHT FEM HD LINE.\n\nSKIN: PT HAS AREAS OF BURNS FROM RHABO, ALL OUTLINED IN MARKER. SKIN TEAR TO LEFT UPPER ARM. LEFT HAND W/ LARGE BLISTER, WRAPPED IN ABSORBENT DRESSING.\n\nDISPO: PLAN FOR CT, ECHO, HD. MONITOR LABS. TEAM ABLE TO GET IN CONTACT W/ MOTHER. SHE WILL BE IN THIS AM. PT'S WALLET TO HOSPTIAL SAFE. PT IS A FULL CODE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-20 00:00:00.000",
"description": "Report",
"row_id": 1412302,
"text": "Respiratory Care\nPt was on with an LMA ETT, with continuous cuff leak. Anesthesia notified and tube changed to 7.5 OET tube over cook catheter. CPAP trial was done in the morning , pt was unable to tolerate with increased respiratory acidosis. Pt currently sedated and vented on A/C see current settings in flow sheet. combivent Q6 PRN\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-20 00:00:00.000",
"description": "Report",
"row_id": 1412303,
"text": "npn 7-7pm\n\nPt received dialysis early this am.\n\nAt 1200 pm he had a very large cuff leak. Inserted additional air into cuff and repositioned his head. Stat page anaesthia to change tube. Emergency airway cart in room. Pt was a difficult intubation last night (6 attempts and was finally fiberoptically). decision was made to change tube with later this afternoon. At 1500 was changed to a 7.5 ETT over a cooks catheter.\n\nneuro: When sedation is lightened pt is alert, mouthes words and is able to communicate his needs. Currently sedated on 20mcg/kg/min of propofol. Bolused occasionally with 2-4cc. Folllows commands, MAE on the bed and PERL.\n\nresp: AC 600/22/50% PEEP 10. LS coarse. ? is patient aspirated as he was found down after 2 days.\n\ncv: ST 120-130, BP 110-120/60-80. No ectopy. L bundle branch block is not a new finding.\n\naccess: 3 piv and R sc tlc. R femoral dialysis catheter was placed last evening. R radial aline.\n\ngi/gu: No po access. BS + and belly is soft and distended. Patent foley with minimal to no urine. Pt is 10 liters + in the last 24 hours.\n\nskin: Several red areas of pressure points from when patient was found down.\n\nID: T max 102.2. Ice packs in place, blankst, and tylenol administered.\n\nendo: no issues. BS q6 hours.\n\nsocial: Mother and brother visited this afternoon.\n\nPlan: CT of head, neck, thoracic, abdomen this afternoon. Monitor respiratory status.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-22 00:00:00.000",
"description": "Report",
"row_id": 1412310,
"text": "MICU NPN 7P-7A\nNEURO: RECEIVED ON 20MCG PROPOFOL, RESTLESS/AGITATED AT START OF SHIFT. BOLUSED AND INCREASED GTT TO 40MCG WITH GOOD EFFECT. LATER DECREASED PPF BACK TO 20MCG. BOLUSED SEVERAL TIMES DURING THE NIGHT AS PATIENT WOULD SPONTANEOUSLY WAKE UP AND BE RESTLESS. PERL @3MM AND BRISK. FOLLOWING COMMANDS AND MOVING EXTREMITIES WEAKLY. RESTRAINED FOR SAFETY OF LINES/TUBES. THIS AM C/O CP, ASKED IF HE HAD OTHER PAIN HE NODDED YES, PAIN PRESENT IN BOTH LEGS AS WELL. MEDICATED WITH 25MCG FENTANYL WITH LITTLE EFFECT. EKG DONE AND MD MADE AWARE.\u0014 J COLLAR INTACT, LOGROLL PRECAUTIONS MAINTAINED.\n\nCARDIAC: HR 118-127 ST WITH NO ECTOPY. BP 131-152/83-99. PULSES BY DOPPLER, RIGHT LEG STILL COOLER THAN THE LEFT. LENI'S NEGATIVE FOR DVT'S. HCT 35.9 DOWN FROM 39.5. NO SIGNS OF BLEEDING. CK'S DOWN TO .\n\nRESP: RECEIVED ON MMV 600X8 40% 5/+5. PATIENT WILL BE ANYWHERE FROM BREATHING 8 WITH TV'S OF 600 TO 21 WITH TV'S ON 1.5-2L. SATS REMAIN 98-100. ABG 7.43/35/85/24. LS COARSE AND SXTED FOR THICK WHITE SPUTUM.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. NO GI ACCESS. 20CC OF BROWN URINE FOR THE SHIFT. CREAT 7.4 IS TRENDING UP DESPITE HD YESTERDAY.\n\nFEN: ANASARCA. +6.2L. LYTES PER CAREVUE. REMAINS NPO.\n\nID: TMAX 100.4 WITH WBC 15.9. LACTATE 2.5. REMAINS ON VANCO, LEVO, FLAGYL. BLOOD AND SPUTUM CX'S PENDING.\n\nSKIN: RIGHT AXILLA WITH BLISTER AND RED, LEFT UPPER ARM WITH BROKEN BLISTERS, BOTH LOTA. RAC WITH FLUID FILLED INTACT BLISTER. LEFT HAND WITH DSD. MEDIAL ASPECTS OF KNEES AND AND LEFT BUTTOCK WITH REDDENED, WARM, AND BLANCHABLE AREAS. ALL AREAS MARKED.\n\nACCESS: RSC CVL, RIGHT ART LINE, RIGHT FEM DIALYSIS LINE. PIV X3.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. PLAN IS TO WEAN TO EXTUBATE TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-22 00:00:00.000",
"description": "Report",
"row_id": 1412311,
"text": "npn 7-7pm\n\nGoal today is to extubate. Pt was trialed on PS 5/0 and tolerated this well. Extubated at 1715 without incident. anaesthia at bedside, along with emergency airway cart and Bougie.\n\nneuro: Pt is axox3. He is fully aware of why he is in the hospital. MAE on the bed, PERL at 3mm. C spine cleared on CT and clinically prior to extubation. J removed.\n\npain: Patient c/o pain in L leg. It is noticeably swollen and warm to touch. Dr examined patient. vascular service consulted this evening. ? repeat LENI.\n\nresp: Currently on cool neb mask with sats 100%. LS coarse.\n\ncv: ST 115, no ectopy. BP 140-150.\n\naccess: R radial aline that is positional. R sc tlc. 3 piv.\n\ngi/gu: Belly is soft with + BS. Pt to be started on clear diet tonite as tolerated. Patent foley is draining only 8cc total this shift.\n\nskin: Multiple skin blisters and reddened areas of pressure--please see carevue.\n\nsocial: Mother visited this afternoon and was updated by Dr .\n\nplan: Monitor respiratory status. If patient needs re-intubation must have emergency airway cart in room. Begin diet tonite.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-21 00:00:00.000",
"description": "Report",
"row_id": 1412304,
"text": "MICU NPN 7P-7A\nNEURO: RECEIVED ON 20MCG PROPOFOL. EASILY AROUSABLE AND AT TIMES AWAKE AND ATTEMPTING TO SIT UP IN BED. RESTRAINTS IN PLACE FOR SAFETY OF LINES/TUBES. FREQUENTLY BOLUSED WITH 3-5CC OF PROPOFOL WITH EFFECT. PERL @3-4MM AND BRISK. FOLLOWING COMMANDS AND NODDING APPROPIATELY. MOVING ALL EXTREMITIES BUT WEAK. NECK COLLAR IN PLACE, LOGROLL PRECAUTIONS MAINTAINED. C/O PAIN INLOWER EXTREMITIES.\n\nCARDIAC: HR 115-124 ST WITH NO ECTOPY. BP 132-158/83-97. HCT 39.5 NO SIGNS OF BLEEDING. PULSES BY DOPPLER. RIGHT EXTREMITIES COOL, LEFT EXTREMITIES WARM. CK'S DOWN TO .\n\nRESP: RECEIVED ON A/C 600X22 50%. ON 10PEEP ABG 7.41/37/194/24. DECREASED PEEP TO 8 WITH ABG 7.46/31/214/23. DECREASED PEEP TO 5 THIS MORNING. RR 22-30 WITH SATS 99-100%. RSBI 27. DID NOT BREATH WHEN PLACED ON PSV. LS COARSE AND SXTED FOR THICK WHITE SPUTUM. CXR WITH POSSIBLE ASPIRATION OR PNEUMONITIS AND PULM EDEMA.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. NO GI ACCESS. 39CC OF URINE OVER SHIFT. CREAT UP TO 6.\n\nFEN: NOT RECEIVING FLUID. +8L SINCE ADMIT. ANASARCA. LYTES PER CAREVUE. PATIENT IS NPO.\n\nID: TMAX 101.5 GIVEN 650MG TYLENOL PR. WILL DRAW BLOOD CX'S. OTHER CX'S PENDING. CONTINUES ON VANCO, LEVO, AND FLAGYL. WBC DOWN SLIGHTLY TO 15.\n\nSKIN: AREAS RED, HOT AND BLANCHABLE ON INNER KNEES AND LEFT BUTTOCK. LEFT UPPER ARM AND RIGHT AXILLA WITH BLISTER BREAKDOWN AND RED. ALL AREAS MARKED. SKIN AND LIGHT RED AND RASHY IN AREAS, ?DRUG REACTION.\n\nACCESS: PIV X3, RIGHT ART LINE, RSC CVL, RIGHT FEM DIALYSIS LINE.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. PLAN FOR POSSIBLE HD AGAIN...CONTINUE TO WEAN VENT SUPPORT...IF NOT EXTUBTED A DOBHOFF TUBE NEEDS TO BE PLACED FOR NUTRITION...FOLLOW LABS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-21 00:00:00.000",
"description": "Report",
"row_id": 1412305,
"text": "Resp Care\nPt remains on vent and with # 7.5 @ 24. Bs course to clear. Suctioned mod amt of thick white secretions. Mdis given with good effect. Abgs WNL. Decreased peep due to high po2s. Rsbi 30, attempted ps trial yet had periods of apnea. Plan to repeat Ps trials.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-21 00:00:00.000",
"description": "Report",
"row_id": 1412306,
"text": "dialysis rn only able to take off 2.9 kg elevated hr to 130. Renal fellow aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-22 00:00:00.000",
"description": "Report",
"row_id": 1412312,
"text": "RESPIRATORY CARE: PT EXTUBATED TO A 50 % AEROSOL MASK\nAFTER A SUCCESSFUL SBT. NO STRIDOR NOTED AND DOING WELL\nW/ SPO2 100 %.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-23 00:00:00.000",
"description": "Report",
"row_id": 1412313,
"text": "Shift Assessment\nPt. is 44 yo Heroin OD/Poly substance abuser. Pt. was admitted in early AM. Extubated on in the afternoon. at time of first assessment at 1900, Pt. was tremulous, diaphoretic, anxious and restless. Pt. was AA0x2, but very anxiou. 10mg of valium was given. Pt. continued to become more anxious, restless, diaphoretic and tachypnic. Total of 25mg valium given between 1900 and 2200. Pt. more alert, with RR now in 's, no sweating,no tremors after Valium doses. Pt. on 2 L NC with sats 98-100%. Pt. has remained calm, oriented and cooperative since 2200. ABG at 2300 was satisfactory. HR has been tachy, but has decreased with decreasing anxiety. NBP WNL, at times Hypertensive, on IV metoprolol as scheduled. Rt. SC TLC, Rt. rad aline was functional, but would not draw back blood. DC'd at 0500 when it lost its waveform. Pt. now on clear liquids, taking them well, but requests drinks very frequently. Pt. takes po pills. No BM. Slightly febrile. Rt. leg is swollen and pt. reports pain. Negative for clot per studies, ortho saw pt. on , will cont. to observe. Pulse is dopplarable in Lt. leg. For more info see pt. adm. hx, flowsheet and previous notes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-21 00:00:00.000",
"description": "Report",
"row_id": 1412307,
"text": "neuro: remains on propofol @ 20 mcg/kg/min. opens eyes to voice and follows simple commands. cough/gag intact. +perrla noted. c/o bilat lower extremity leg pain and medicated with fentanyl 25 mcg with fair effect. collar intact.\ncv: monitor shows st with no ectopy noted. cardiac echo done at bedside with global dysfunction.\nresp: ls coarse throughout with broncial bs's lll. sxn for mod amt thick tan tenacious secretions via ett. sputum sent. pt placed on sbt and tolertated well with abg of 7.38/39/191. pt to be extubated after dialysis or in am depending on time per dr . anesthesia to be present for extubation difficult airway. current vent setting cpap +ps 5/5x.40 with rr 6-14 and tv's 800-1200.\ngi: abd soft and nontender. +bs no stools this shift. remains npo. no gi access at this time.\ngu: foley intact and patent for scant amts brown urine with no sedimentation noted. pt currently being dialysed with goal removal 4kg.\nskin: l hand dsg with lg blister on outer aspect of thumb...wash with ns, aquaphor and dsd applied. r axilla reddened with sm blisters noted. L upper arm with superficial reddened areas from ?blister. blanchable areas remain on inner thighs and L buttock. c/o lle pain and +swelling noted, leni's done...results pending.\ni-d: temp max 100.6. remains on flagyl,levofloxacin and vanco.\naccess: piv x3, r radial aline and r scv tlc.\npsy-soc: mother called x2 and updated on status and plan of care. mother to stay at other son's house tonight and contact #'s on chart. remains full code on micu service.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-21 00:00:00.000",
"description": "Report",
"row_id": 1412308,
"text": "Resp. Care Note\nPt remains and vented on settings as charted on resp flowsheet. Pt with RSBI 27 this morning. Placed on SBT with good ABG, RR variable and TV>1.0L at times. In afternoon, due to irregular resp pattern, pt with periods of apnea. Vent placed in MMV with base minute volume of 4.8L (600x8).Decision made to hold on extubation until after dialysis, possibly in AM. Anesthesia to be present when extubated due to difficult airway. Sxn for tannish secretions, specimen sent. Combivent MDI Q vent check.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-09-22 00:00:00.000",
"description": "Report",
"row_id": 1412309,
"text": "Resp Care\nPt remains on vent. No changes made. suctioned mod amt of thick white secretions. Mdis given with good effect. Plan to wean to extubate in am with anesthesia present.\n"
}
] |
65,444 | 122,683 | 84 year-old woman presents with right-sided chest pain, shortness of breath, and tachycardia. She was treated for possible asthma exacerbation. Chest pain and shortness of breath resolved after the first night. On telemetry, the patient was found to have intermittent episodes of narrow-complex tachycardia to the 140's. Cardiology consult determined that she was atrial fibrillation. Metoprolol uptitrated for heart rate control and warfarin started. There was some concern that the patient had mild diastolic dysfunction on Echocardiogram and physical exam, so one dose of Lasix 10mg PO given. Patient was asymptomatic at the time of discharge. # Asthma exacerbation s/p 5 days azithromycin, prednisone, and nebs. | Mild [1+] TR. Modest ST-T wave changes.Findings are non-specific. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Modest low amplitude T waves are non-specific.Since the previous tracing of tachycardia is absent and sinus rhythmis now seen.TRACING #2 The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. Stable cardiomegaly. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There is mild pulmonary artery systolic hypertension. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. Right ventricular function. Thereis no pericardial effusion.IMPRESSION: Normal global and regional biventricular systolic function. Mildaortic regurgitation is seen. Modest diffuse low amplitudeT wave changes. ST-T waveabnormalities are non-specific. MildPA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Mild pulmonary hypertension.Compared with the prior study (images reviewed) of , the findings aresimilar. Since the previous tracing of ventricularresponse is now more irregular and ST-T wave changes have decreased.TRACING #1 Cardiomediastinal silhouette is unchanged including cardiomegaly. The diameters ofaorta at the sinus, ascending and arch levels are normal. Since the previous tracing of T wave amplitude appears lower but there may be no significant change.TRACING #1 Cardiomegaly is stable. Mildaortic and mitral regurgitation. Findings are non-specific. IMPRESSION: No pneumonia. Consider left atrial abnormality, although baseline artifactmakes assessment difficult. Sinus rhythm with A-V conduction delay. Rightventricular chamber size and free wall motion are normal. Regular narrow complex tachycardia of uncertain mechanism - baseline artifactmakes assessment difficult. Ventricular premature beat. FINDINGS: There is no pneumonia. Sinus rhythm. Since the previous tracing of the same datetachy-arrhythmia and ventricular ectopy are both now present.TRACING #2 HTN.Height: (in) 61Weight (lb): 135BSA (m2): 1.60 m2BP (mm Hg): 124/52HR (bpm): 82Status: InpatientDate/Time: at 14:18Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Delayed R wave progression. Valvular function. Irregular rhythm is probably atrial fibrillation but baseline artifact makesassessment difficult. TECHNIQUE: Chest radiograph, AP upright portable view. Mediastinal silhouette is stable although widened most likely due to portable technique of the study, but overload cannot be excluded. Left ventricular wall thickness, cavitysize and regional/global systolic function are normal (LVEF >55%). No AS. Bones are stable. IMPRESSION: AP chest compared to at 12:10 p.m.: Slight increase in pulmonary vascular and mediastinal venous caliber and moderate cardiomegaly could indicate early cardiac decompensation, although there is no pulmonary edema or appreciable pleural effusion as yet. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Portable AP chest radiograph was compared to . There is trace bibasilar atelectasis at the lung bases. No consolidation. There is no pleural effusion or pneumothorax. No appreciable pleural effusion or pneumothorax has been demonstrated. COMPARISON: . QTc interval may be borderline prolonged but it is difficultto measure. 2:42 PM CHEST (PORTABLE AP) Clip # Reason: Evaluate for interval change. Aorta is unfolded with calcification at the aortic knob. SESHa FINAL REPORT AP CHEST 2:54 P.M., HISTORY: Tachycardia and shortness of breath. REASON FOR THIS EXAMINATION: Evaluate for interval change. The tricuspid valve leaflets aremildly thickened. Admitting Diagnosis: ASTHMA;COPD EXACERBATION MEDICAL CONDITION: 84 year old woman with tachycardia, shortness of breath. 12:05 PM CHEST (PORTABLE AP) Clip # Reason: infiltrate MEDICAL CONDITION: 84 year old woman with SOB REASON FOR THIS EXAMINATION: infiltrate FINAL REPORT HISTORY: 84-year-old woman with shortness of breath. | 8 | [
{
"category": "Radiology",
"chartdate": "2191-12-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1165257,
"text": " 12:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with SOB\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old woman with shortness of breath.\n\n TECHNIQUE: Chest radiograph, AP upright portable view.\n\n COMPARISON: .\n\n FINDINGS: There is no pneumonia. There is trace bibasilar atelectasis at the\n lung bases. There is no pleural effusion or pneumothorax. Cardiomegaly is\n stable. Aorta is unfolded with calcification at the aortic knob. Bones are\n stable.\n\n IMPRESSION: No pneumonia. Stable cardiomegaly.\n\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-12-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1165494,
"text": " 2:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for edema, pneumonia\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with new SOB\n REASON FOR THIS EXAMINATION:\n evaluate for edema, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with shortness of breath.\n\n Portable AP chest radiograph was compared to .\n\n Cardiomediastinal silhouette is unchanged including cardiomegaly. Mediastinal\n silhouette is stable although widened most likely due to portable technique of\n the study, but overload cannot be excluded. No appreciable pleural effusion\n or pneumothorax has been demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1165430,
"text": " 2:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change.\n Admitting Diagnosis: ASTHMA;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with tachycardia, shortness of breath.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 2:54 P.M., \n\n HISTORY: Tachycardia and shortness of breath.\n\n IMPRESSION: AP chest compared to at 12:10 p.m.:\n\n Slight increase in pulmonary vascular and mediastinal venous caliber and\n moderate cardiomegaly could indicate early cardiac decompensation, although\n there is no pulmonary edema or appreciable pleural effusion as yet. No\n consolidation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2191-12-13 00:00:00.000",
"description": "Report",
"row_id": 83863,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Valvular function. HTN.\nHeight: (in) 61\nWeight (lb): 135\nBSA (m2): 1.60 m2\nBP (mm Hg): 124/52\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 14:18\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Mild\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is mild pulmonary artery systolic hypertension. There\nis no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mild\naortic and mitral regurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2191-12-11 00:00:00.000",
"description": "Report",
"row_id": 227370,
"text": "Sinus rhythm with A-V conduction delay. Modest diffuse low amplitude\nT wave changes. QTc interval may be borderline prolonged but it is difficult\nto measure. Findings are non-specific. Since the previous tracing of \nT wave amplitude appears lower but there may be no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2191-12-13 00:00:00.000",
"description": "Report",
"row_id": 227367,
"text": "Sinus rhythm. Consider left atrial abnormality, although baseline artifact\nmakes assessment difficult. Modest low amplitude T waves are non-specific.\nSince the previous tracing of tachycardia is absent and sinus rhythm\nis now seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2191-12-12 00:00:00.000",
"description": "Report",
"row_id": 227368,
"text": "Irregular rhythm is probably atrial fibrillation but baseline artifact makes\nassessment difficult. Delayed R wave progression. Modest ST-T wave changes.\nFindings are non-specific. Since the previous tracing of ventricular\nresponse is now more irregular and ST-T wave changes have decreased.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2191-12-11 00:00:00.000",
"description": "Report",
"row_id": 227369,
"text": "Regular narrow complex tachycardia of uncertain mechanism - baseline artifact\nmakes assessment difficult. Ventricular premature beat. ST-T wave\nabnormalities are non-specific. Since the previous tracing of the same date\ntachy-arrhythmia and ventricular ectopy are both now present.\nTRACING #2\n\n"
}
] |
85,056 | 128,472 | Pt admitted for back pain, found to have a Acute Type B intramural hematoma involving the descending thoracic, abdominal aorta and the common iliac arteries CTA below IMPRESSION: 1. Acute Type B intramural hematoma involving the descending thoracic, abdominal aorta and the common iliac arteries. 2. Origin is likely a penetrating ulcer with active extravasation into the aortic media at the distal portion of the aortic arch. Additional active foci of bleeding are seen at the mid aortic arch and in the mid descending aorta. 3. The major branches of the abdominal aorta are patent. 4. No evidence of pericardial or pleural effusions and no retroperitoneal hematoma. 5. Repeat CTA within 48 hours is recommended given the risk of progression to an aortic dissection. 6. Atrophic left kidney. Pt sent to the CVICU: Put on IV antihypertensives, this was gradually weaned to PO antihypertensives. Pt recieved ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Pt creatinine was elevated 2 days after CTA 3.4 from 1.2, Renal was consulted. thought to be secondary to contrast nephropathy. Pt did have multiple renal imaging: GRAYSCALE ULTRASOUND: The right kidney measures 13 cm, and appears normal. There are no focal masses, and there is preserved corticomedullary differentiation. There is no hydronephrosis. There are no renal stones identified. The left kidney which measures 8.4 cm is atrophic, with multiple foci of cortical thinning, as seen on recent CTA. There is a 2.3-cm simple cyst in the interpolar region. There is no solid mass or nephrolithiasis, and no hydronephrosis. COLOR AND SPECRTAL DOPPLER: The right main renal artery and main renal vein are seen to be patent. Resistive indices in the upper, mid, and lower poles in the interlobular arteries are measured as 0.72, 0.78, and 0.73 respectively. The left renal vasculature was technically difficult to evaluate, however, the main renal artery and main renal veins were seen to be patent, and resistive indices in the interlobular arteries in the upper, mid, and lower poles were similar to those on the right, measured as 0.71, 0.75, and 0.70, respectively. The IVC at the level of the renal veins was also seen to be patent. IMPRESSION: 1. Atrophic left kidney, with multiple foci of cortical thinning, likely reflecting scarring from prior vascular or infectious insult. Left renal cyst. 2. Patent main renal artery and main renal vein bilaterally, with resistive indices as reported above. On Dc creatinine improved to 1.3 Once blood pressure was stable in the CVICU. Pt transfered to the VICU for further management. Cardiology was then consulted for medical management. His PO regime of medications was optimized. On Dc his BP has been less then 120 x 48 hrs. Pt will follow up with PCP. DC summary faxed to PCP . Will follow with Dr as outpt. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). Disp:*360 Tablet(s)* Refills:*2* 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety for 10 days: prn for anxiety. Disp:*30 Tablet(s)* Refills:*0* 7. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a day: prn for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Area VNA Discharge Diagnosis: Aortic dissection ARF secondary to contrast nephropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call if you have any of the below sypmtoms or concerns: What are the symptoms of a thoracic aortic aneurysm? Thoracic aortic aneurysms often go unnoticed because patients rarely feel any symptoms. While only half of those with thoracic aortic aneurysms complain of symptoms, possible warning signs include: Pain in the jaw, neck, and upper back Chest or back pain Coughing, hoarseness, or difficulty breathing Followup Instructions: Provider: SCAN Phone: Date/Time: 1:15 Provider: , MD Phone: Date/Time: 2:15 You have an appointment scheduled with your PCP DR , at 1300. Name: , S. Location: MEDICAL Address: , , Phone: Fax: Completed by:[**2116-3-12** | There is nomitral valve prolapse. Repeat CT of the torso (without i.v. Normal interatrialseptum. Right ventricular function.Height: (in) 71Weight (lb): 180BSA (m2): 2.02 m2BP (mm Hg): 106/55HR (bpm): 76Status: InpatientDate/Time: at 13:53Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. There are only mild atherosclerotic calcifications at the origin of the ascending aorta and at the aortic arch. Patent main renal artery and main renal vein bilaterally, with resistive indices as reported above. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. No MS.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The mitral valveappears structurally normal with trivial mitral regurgitation. Lungs are essentially clear except for minimal bibasilar atelectasis and questionable left minimal pleural effusion. Left renal cyst. Thediameters of aorta at the sinus, ascending and arch levels are normal. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). Mild [1+]TR. Left anterior fascicular block. Left anterior fascicular block. Normal sinus rhythm Right and left arm lead reversal. Left ventricular function. TECHNIQUE: Single frontal radiograph of the chest was obtained. There is a moderate hiatal hernia. COLOR AND SPECRTAL DOPPLER: The right main renal artery and main renal vein are seen to be patent. ST-T waveabnormalities. ST-T waveabnormalities. 11:58 CHEST (PORTABLE AP) Clip # Reason: acute CT process? COMPARISON: Chest radiograph dated . The esophagus, stomach, small and appendix are normal. The right atrium is moderately dilated.No atrial septal defect is seen by 2D or color Doppler. Resistive indices in the upper, mid, and lower poles in the interlobular arteries are measured as 0.72, 0.78, and 0.73 respectively. The right kidney is normal. The right kidney is normal. The right kidney is normal. clot in IVC and renal veins. clot in IVC and renal veins. FINDINGS: Mild mediastinal widening is unchanged since . Axial, coronal and sagittal reformats were obtained. No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). The cardiac size is at the upper limits of normal. Renogram images show a smaller left kidney compared to the right kidney along with excretion from bilateral kidneys with no evidence of obstruction. There are moderate calcifications of the abdominal aorta including at the celiac axis (series 2, image 124). Cardiomegaly is unchanged. The major branches of the abdominal aorta are patent. Mild mediastinal widening unchanged since the initial radiograph. No contraindications for IV contrast WET READ: JBRe FRI 1:17 AM 1. There is a 2.3-cm simple cyst in the interpolar region. There are no focal masses, and there is preserved corticomedullary differentiation. Major branches of the abdominal aorta are patent. Atrophic left kidney. FINDINGS: The hila are normal. Sinus rhythm. Sinus rhythm. Sinus rhythm. , M.D. , M.D. Since the previous tracingof sinus bradycardia is absent, axis is less leftward and T wave changeshave decreased. COMPARISON: CTA torso . Right ventricular chamber size and free wall motion are normal. There are mild bibasilar atelectasis. FINDINGS: CTA OF THE CHEST: The thyroid gland is normal. Compared to the previous tracing of no diagnostic intervalchange. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. There is mild right basilar atelectasis. There is mildsymmetric left ventricular hypertrophy with normal cavity size andregional/global systolic function (LVEF>55%). Superior axis. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. The pancreas, spleen and adrenal glands are normal. 3:00 PM MMS SUGICAL PLANNING SERVICE Clip # Reason: AAA MEDICAL CONDITION: AAA REASON FOR THIS EXAMINATION: AAA No contraindications for IV contrast FINAL REPORT This report is for reference only, generated by M2S. IMPRESSION: Prominent aorta. Probably within normallimits. There is a hypoattenuating lesion at the segment II of the left lower lobe (series 2, image 106), likely representing a simple cyst based on a Hounsfield unit measurement of 8. (Over) 12:18 AM CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS; CTA CHEST W&W/O C&RECONS, NON-CORONARYClip # Reason: CHEST PAIN RADIATING TO BACK. The left kidney which measures 8.4 cm is atrophic, with multiple foci of cortical thinning, as seen on recent CTA. The left renal vasculature was technically difficult to evaluate, however, the main renal artery and main renal veins were seen to be patent, and resistive indices in the interlobular arteries in the upper, mid, and lower poles were similar to those on the right, measured as 0.71, 0.75, and 0.70, respectively. The main renal artery and main renal vein are patent on both the right and the left. The main renal artery and main renal vein are patent on both the right and the left. Prominent aorta. The tricuspid valve leaflets are mildly thickened.There is mild pulmonary artery systolic hypertension. Theaortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic stenosis or aortic regurgitation. (Over) 8:12 AM RENAL U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # DUPLEX DOP ABD/PEL LIMITED Reason: INTRAMURAL HEMATOMA ,EVAL FLOW IN KIDNEYS, CLOT IN IVC ,RENAL VEINS Admitting Diagnosis: AORTIC DISSECTION FINAL REPORT (Cont) | 13 | [
{
"category": "Radiology",
"chartdate": "2116-03-09 00:00:00.000",
"description": "MMS SUGICAL PLANNING SERVICE",
"row_id": 1191943,
"text": " 3:00 PM\n MMS SUGICAL PLANNING SERVICE Clip # \n Reason: AAA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n AAA\n REASON FOR THIS EXAMINATION:\n AAA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n This report is for reference only, generated by M2S.\n\n (), DOB: (Age 62) AAA/TAA\n Date of Service: \n Physician : , MD\n\n Current Status\n\n\n was last scanned on and is a pre-operative\n AAA/TAA patient. Mr. was previously scanned at Pre-op on -. His AAA volume is 63.3cc. His TAA volume is 323.2cc. His AAA\n diameter is 2.9cm. His TAA diameter is 4.2cm.\n\n\n Nb: This note was automatically generated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-06 00:00:00.000",
"description": "CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS",
"row_id": 1184612,
"text": " 12:18 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS; CTA CHEST W&W/O C&RECONS, NON-CORONARYClip # \n Reason: CHEST PAIN RADIATING TO BACK. EVAL\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with sudden onset midscapular back pain and chest pain, eval\n for dissection\n REASON FOR THIS EXAMINATION:\n dissection?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe FRI 1:17 AM\n 1. Intramural hematoma of the descending aorta (type B) extending into the\n abdominal aorta and the common iliac arteries.\n 2. Active extravasation into the aortic media at the mid (3; 34) and distal\n aortic arch (2; 40) and mid descending aorta (2; 49).\n 3. No pericardial and no pleural effusion.\n 4. Major branches of the abdominal aorta are patent.\n 5. Repeat CT of the torso (without i.v. contrast) is recommended.\n 6. In case of conservative treatment, repeat CTA is recommended within 48\n hours for risk of aortic dissection.\n\n Findings d/w Dr. at 0:30 am by Dr. .\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with sudden onset of midscapular back pain, chest\n pain. Please evaluate for dissection.\n\n TECHNIQUE:\n Initially, CT angiography of the chest and abdomen were performed after\n administration of intravenous contrast.\n About two hours after the initial scan, additional non-enhanced CT images were\n acquired. Axial, coronal and sagittal reformats were obtained.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n CTA OF THE CHEST:\n The thyroid gland is normal. There is no pneumomediastinum, pericardial or\n pleural effusion. There is no pneumothorax. There is no focal consolidation.\n There are mild bibasilar atelectasis. There are only mild atherosclerotic\n calcifications at the origin of the ascending aorta and at the aortic arch.\n There is an acute intramural hematoma, originating at the origin of the left\n subclavian artery and involving the abdominal aorta and the common iliac\n arteries. No dissection flap is visualized.\n There is active extravasation of blood into the aortic at the distal aortic\n arch (series 2, image 40) likely related to a penetrating ulcer. Additionally\n foci of active extravasation are seen at the mid aortic arch (series 2, image\n 35) and in the mid descending aorta (series 2, image 49).\n\n (Over)\n\n 12:18 AM\n CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS; CTA CHEST W&W/O C&RECONS, NON-CORONARYClip # \n Reason: CHEST PAIN RADIATING TO BACK. EVAL\n Field of view: 40 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CTA OF THE ABDOMEN:\n The intramural hematoma extends into the common iliac arteries. The major\n branches of the abdominal aorta are patent including both renal arteries,\n celiac axis, SMA and . There are moderate calcifications of the abdominal\n aorta including at the celiac axis (series 2, image 124).\n There is a hypoattenuating lesion at the segment II of the left lower lobe\n (series 2, image 106), likely representing a simple cyst based on a Hounsfield\n unit measurement of 8.\n Small calcification or stone in or adherent to the wall of the gallbladder is\n incidentally noted. The pancreas, spleen and adrenal glands are normal. The\n right kidney is normal. The left kidney is atrophic with multiple\n hypoattenuating lesions, the largest at the mid pole measuring about 14 x 18\n mm with Hounsfield unit measuring 50, likely consistent with a simple cyst.\n There is no free air and no free fluid.\n There is a moderate hiatal hernia. The esophagus, stomach, small and appendix\n are normal. There is mild diverticulosis at the splenic flexure without\n evidence of diverticulitis.\n\n\n BONES: There are no suspicious lytic or sclerotic bony lesions. Mild\n degenerative changes of lumbosacral junction with intervertebral disc disease\n at L5/S1.\n\n IMPRESSION:\n 1. Acute Type B intramural hematoma involving the descending thoracic,\n abdominal aorta and the common iliac arteries.\n 2. Origin is likely a penetrating ulcer with active extravasation into the\n aortic media at the distal portion of the aortic arch. Additional active foci\n of bleeding are seen at the mid aortic arch and in the mid descending aorta.\n 3. The major branches of the abdominal aorta are patent.\n 4. No evidence of pericardial or pleural effusions and no retroperitoneal\n hematoma.\n 5. Repeat CTA within 48 hours is recommended given the risk of progression to\n an aortic dissection.\n 6. Atrophic left kidney.\n\n Findings were discussed with Dr. at 12:30 a.m. by Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1184658,
"text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusion\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with intramural hematoma of the aorta\n REASON FOR THIS EXAMINATION:\n eval for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intramural hematoma of the aorta, evaluate for pleural effusion.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: Mild mediastinal widening is unchanged since . There is no\n evidence of pleural effusion, atelectasis or consolidation. The cardiac size\n is at the upper limits of normal.\n\n IMPRESSION:\n 1. No evidence of pleural effusion.\n 2. Mild mediastinal widening unchanged since the initial radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1184610,
"text": " 11:58\n CHEST (PORTABLE AP) Clip # \n Reason: acute CT process?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with c/o of chest and back pain, hypertensive for EMS eval for\n acute changes\n REASON FOR THIS EXAMINATION:\n acute CT process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old man with chest and back pain, hypertensive, please\n assess for acute process.\n\n TECHNIQUE: Single frontal radiograph of the chest was obtained.\n\n COMPARISON: There are no comparison studies available.\n\n FINDINGS:\n The hila are normal. Prominent aorta. There is no pleural effusion and no\n pneumothorax. There is mild right basilar atelectasis.\n\n IMPRESSION: Prominent aorta.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-09 00:00:00.000",
"description": "RENAL SCAN",
"row_id": 1185028,
"text": "RENAL SCAN Clip # \n Reason: 62 YEAR OLD MAN WITH INTRAMURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 5.0 mCi Tc-m MAG3 ();\n HISTORY: 62 year old man with aortic intramural hematoma and renal failure.\n\n Flow and dynamic images were obtained after intravenous administration of\n tracer.\n\n Blood flow images show appropriate perfusion of both kidneys.\n\n Renogram images show a smaller left kidney compared to the right kidney along\n with excretion from bilateral kidneys with no evidence of obstruction.\n\n The differential function obtained by analysis of tracer concentration in the\n parenchyma from 2 to 3 minutes post tracer injection shows the left kidney to be\n performing 28% of the total renal function and the right kidney performing\n 72%.\n\n IMPRESSION:\n\n Renal Scan demonstrates perfusion of bilateral kidneys along with excretion with\n no evidence of obstruction. The left kidney is noted be much smaller and\n performing 28% of the total renal function compared with 72% of the work for the\n right kidney.\n\n\n\n , M.D.\n , M.D. Approved: TUE 4:05 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1184785,
"text": " 1:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Fluid collection\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n Fluid collection\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypertension.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n Cardiomegaly is unchanged. Mediastinal silhouette is stable. Lungs are\n essentially clear except for minimal bibasilar atelectasis and questionable\n left minimal pleural effusion. There is no pneumothorax.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2116-03-07 00:00:00.000",
"description": "Report",
"row_id": 92347,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Left ventricular function. Right ventricular function.\nHeight: (in) 71\nWeight (lb): 180\nBSA (m2): 2.02 m2\nBP (mm Hg): 106/55\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 13:53\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and\nregional/global systolic function (LVEF>55%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\ndiameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The tricuspid valve leaflets are mildly thickened.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-07 00:00:00.000",
"description": "RENAL U.S. (PORTABLE)",
"row_id": 1184810,
"text": " 8:12 AM\n RENAL U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: INTRAMURAL HEMATOMA ,EVAL FLOW IN KIDNEYS, CLOT IN IVC ,RENAL VEINS\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with intramural hematoma\n REASON FOR THIS EXAMINATION:\n ? flow to both kidneys and ?? clot in IVC and renal veins. CRT now 3.4\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy SAT 9:57 AM\n Atrophic left kidney, with multiple foci of cortical thinning, likely\n reflecting prior infectious or ischemic insult. The right kidney is normal.\n There is no nephrolithiasis or hydronephrosis bilaterally. The main renal\n artery and main renal vein are patent on both the right and the left. Normal\n waveforms are seen in the interlobular arteries bilaterally as well. The IVC\n appears patent.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old male with acute intramural hematoma of the aorta.\n Evaluate renal blood flow.\n\n COMPARISON: CTA torso .\n\n GRAYSCALE ULTRASOUND: The right kidney measures 13 cm, and appears normal.\n There are no focal masses, and there is preserved corticomedullary\n differentiation. There is no hydronephrosis. There are no renal stones\n identified. The left kidney which measures 8.4 cm is atrophic, with multiple\n foci of cortical thinning, as seen on recent CTA. There is a 2.3-cm simple\n cyst in the interpolar region. There is no solid mass or nephrolithiasis, and\n no hydronephrosis.\n\n COLOR AND SPECRTAL DOPPLER: The right main renal artery and main renal vein\n are seen to be patent. Resistive indices in the upper, mid, and lower poles\n in the interlobular arteries are measured as 0.72, 0.78, and 0.73\n respectively. The left renal vasculature was technically difficult to\n evaluate, however, the main renal artery and main renal veins were seen to be\n patent, and resistive indices in the interlobular arteries in the upper, mid,\n and lower poles were similar to those on the right, measured as 0.71, 0.75,\n and 0.70, respectively. The IVC at the level of the renal veins was also seen\n to be patent.\n\n IMPRESSION:\n\n 1. Atrophic left kidney, with multiple foci of cortical thinning, likely\n reflecting scarring from prior vascular or infectious insult. Left renal cyst.\n\n 2. Patent main renal artery and main renal vein bilaterally, with resistive\n indices as reported above.\n (Over)\n\n 8:12 AM\n RENAL U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: INTRAMURAL HEMATOMA ,EVAL FLOW IN KIDNEYS, CLOT IN IVC ,RENAL VEINS\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-03-07 00:00:00.000",
"description": "RENAL U.S. (PORTABLE)",
"row_id": 1184811,
"text": ", VSURG CSRU 8:12 AM\n RENAL U.S. (PORTABLE); -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: INTRAMURAL HEMATOMA ,EVAL FLOW IN KIDNEYS, CLOT IN IVC ,RENAL VEINS\n Admitting Diagnosis: AORTIC DISSECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with intramural hematoma\n REASON FOR THIS EXAMINATION:\n ? flow to both kidneys and ?? clot in IVC and renal veins. CRT now 3.4\n ______________________________________________________________________________\n PFI REPORT\n Atrophic left kidney, with multiple foci of cortical thinning, likely\n reflecting prior infectious or ischemic insult. The right kidney is normal.\n There is no nephrolithiasis or hydronephrosis bilaterally. The main renal\n artery and main renal vein are patent on both the right and the left. Normal\n waveforms are seen in the interlobular arteries bilaterally as well. The IVC\n appears patent.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-03-12 00:00:00.000",
"description": "Report",
"row_id": 258656,
"text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. ST-T wave\nabnormalities. Late R wave progression. Since the previous tracing\nof there is arm lead reversal on the prior tracing. Otherwise,\nprobably unchanged.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-03-10 00:00:00.000",
"description": "Report",
"row_id": 258657,
"text": "Normal sinus rhythm Right and left arm lead reversal. Probably within normal\nlimits. Compared to the previous tracing of no diagnostic interval\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-03-10 00:00:00.000",
"description": "Report",
"row_id": 258658,
"text": "Sinus rhythm. Left anterior fascicular block. Since the previous tracing\nof sinus bradycardia is absent, axis is less leftward and T wave changes\nhave decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-03-05 00:00:00.000",
"description": "Report",
"row_id": 258659,
"text": "Sinus rhythm. Superior axis. Late R wave progression. ST-T wave\nabnormalities. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\n\n"
}
] |
1,944 | 157,104 | Hospital course: Mr. was a 54 yo male with pmh of CHF (EF 25%), DM1 s/p pancreatic/ kidney transplant, CAD s/p CABG, admitted for SOB/hypoxia, found to have asp. PNA. He was transferred to the CCU to VT/VF. In the CCU he had several episodes of VT/VF s/p multiple shocks. He was started on CVVH to ARF. He remained ventilator dependent. He had intermittent pressor requirements and was maintained on a lidocaine GTT. He was made DNR/DNI and expired from cardiac arrest. . 1. VT/VF: Pt. has a h/o of VT in the past for which an ICD was placed. On day of transfer to the CCU, the patient had several episodes of VT/VF and was shocked numerous time by his ICD unsuccessfully, requiring external shocks as well. Etiology of the current episode is likely due to his pre-disposition to this arrythmia in combination with metabolic derrangements (hyperkalemia, acidosis). Pt. was given lidocaine boluses, his metabolic derrangements were corrected and burst pacing was used to terminate his VT. He was kept on a lidocaine drip transiently. While weaning off the lidocaine drip, mexiletine has been started. Despite antiarrythmics, he continued to have episodes of VT which again req. several external shocks. Because of his rapidly deteriorating condition, he was made DNR/DNI. He expired surrounded by his family. . 2) Hypovolemia: Pt. appeared dry on admission, with high BUN/CRT ratio. He was also several pounds below his dry weight. He received aggressive re-hydration. His volume status was monitored by clinical exam and by CVP. . 3) SOB/Hypoxia: Multifactoral etiology. He had amiodarone-induced pulm fibrosis and aspiration PNA. It was felt that his SOB was not due to CHF. He remained intubated since the VT/VF event and developed MRSA pneumonia (VAP)/bacteremia contributing further to hypoxia. He was continued on Vanc and Zosyn. Flagyl was discontinued. As an outpatient he was receiving HD steroids for amiodarone toxicity. He was started on stress dose steroids in the CCU, these were being slowly weaned. . 4) Hypotension- during episodes of VT/VF the pt. became hypotensive to arrythmia, pressors were started (neo, dopamine). Once the arrythmia was terminated, pressors were weaned. He was also started on stress dose steroids. He had several more episodes of hypotension which were treated with IVF and pressors. On the night prior to his death, he became hypotensive and received IVF, vassopressin, levophed, neosynephrine. Despite this, he became progressively hypotensive. He had several more episodes of VT and became hemodynamically unstable despite external shocks and pressors. He was made DNR/DNI and expired. . 5) Presumed adrenal insufficiency: Pt. was on high-dose steroids for amiodarone toxicity. Therefore, he was likely adrenally insuff. due to long term steroid use. As he was critically ill and hypotensive, stress dose steroids were started. He was started on a steroid taper. . 6) Metabolic Acidosis:This was likely due to ARF on CKD . Initially he had a non-AG and mild AG metabolic acidosis with complete respiratory compensation. His acidosis slowly resolved with bicarb infusions and correction of fluid status. He was started on CVVH. . 7) DM s/p panc/kidney transplant: Tx in . Baseline Cr 2.5-2.8. Patient was continued on Sirolimus 1 mg QD. Prednisone 5mg daily was held while stress dose steroids were given. . 8) ARF- Chronic kidney disease: His baseline Cr (2.5-2.8) with Cr 3.0 on transfer to CCU. His creatinine slightly improved and he remained largely around baseline thereafter. However, BUN baseline was around 60 and was significantly elevated indicating acute on chronic failure. Initial metabolic AG and non-AG acidosis was corrected. Calcitriol 0.25 mcg qd was continued. Tunneled HD catheter was placed in right IJ on . CVVH was initiated. . 9) CHF- EF 25-30% on ECHO . Patient was initially dry but accumulated up to 10 L throughout his CCU stay. He received IVF or Lasix as needed to keep him euvolemic clinically. Lopressor was restarted once his blood pressure was stable. Isosorbide dinitrate and hydral were held. . 10) CAD: status post multiple MIs. He had a h/o ventricular tachycardia status post pacer/AICD placement. Patient was continued on aspirin and statin. BB was held while hypotensive, then added back. ISDN was held. . 11) Anemia - due to CKD. Ferritin wnl. Patient was continued on Epo (increased dose per ). His stools were guaiac positive but without gross blood. He also developed bloody sputum (streaks) during intubation. His Hct dropped during his CCU stay and he received 3U of PRBC with appropriate response on . . 12) Thrombocytopenia - Platelets dropped since this admission from the 300s to 70s. DIC labs were initially checked and came back negative. Heparin products were d/c'd and HIT Ab test sent which was also negative. . 13) FEN: TFs while intubated. . # PPX: Protonix, SC Heparin initially, was d/c'd when platelets fell. Then on pneumoboots. . # Access: Right SC CVL, Right IJ tunneled catheter. . # CODE: full code (confirmed with family during CCU stay) . # Contact: HCP T Daughter C -, H Wife C . Dispo- expired. | Right subclavian triple lumen catheter tip remains at or just below the level of the cavoatrial junction. The ICD leads terminate in right atrium and right ventricle in unchanged position. There is moderate global right ventricular free wall hypokinesis.Moderate (2+) aortic regurgitation is seen. Sinus rhythmFirst degree A-V blockLeft atrial abnormalityRight bundle branch blockInferior myocardial infarctionSince previous tracing of , atrial fibrillation has reverted to normalsinus rhythm and ventricular tachycardia is not seen Severe global LV hypokinesis.RIGHT VENTRICLE: Normal RV chamber size. Moderate aortic regurgitation.Compared with the prior study (images reviewed) of , no change. Assess for effusionHeight: (in) 68Weight (lb): 150BSA (m2): 1.81 m2BP (mm Hg): 90/50HR (bpm): 97Status: InpatientDate/Time: at 00:21Test: Portable TTE (Focused views)Doppler: Color Doppler onlyContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Retrocardiac opacity and probable left effusion at the CP angle are grossly unchanged. CHEST AP: There has been interval placement of a right subclavian CVL with the tip in the right atrium. IMPRESSION: AP chest compared to through 24: Somewhat asymmetric pulmonary edema is stable. TECHNIQUE: The gallbladder appears normal without evidence of stones. IMPRESSION: Overall stable radiographic appearance of the chest with left lower lobe consolidation consistent with pneumonia or atelectasis and moderate left pleural effusion. FINAL REPORT INDICATION: Right upper quadrant tenderness and elevated LFTs. Consolidation at the base of the left lung accompanied by small-to-moderate left pleural effusion could be either pneumonia or atelectasis, also unchanged. The patient is after median sternotomy and CABG with broken lower sternal wires broken, unchanged. Moderate global RV free wallhypokinesis.AORTIC VALVE: Moderate (2+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The left-sided pacemaker with its two leads terminating in the right atrium and right ventricle is unchanged. Pt returned to previous mode of ventilation overnoc and tol well; ABGs pending. Pt was noted to have bandemia on his WBC diff...sent to ED. ccu nsg progress note.o:neuro=sedated w fent/versed gtts w effect. ?wean sedation-attempt cpap. heme= hct 24.8--tx w 1urbc--repeat hct 27.1. id=afebrile. K+ 5.4(4.9) & Hyponatremic 122 (121) RF...? Pt tolerating clear lix.Resp: Pt rec'd on NRB @ 15.0 lpm from ED. Cortisol test done..pnd'ing results. SBO) and CXR done...pending results.ROS:Neuro: Pt lethargic, opening eyes spontaneously, oriented to self and place only. Mixed venous O2 sats 28-38.CV: NBP 1teens-130s/40s-80s, HR 60s-70s. WBC 20.9 (29.4), started on vanco, flagyl, and zosyn.Skin: Skin to BUEs fragile, ecchymotic, thin w/ several skin tears. Wound consult ordered.Access: RIJ pre- cath in place....patent, wnl.All Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Pt HOH.Pain: pt C/o abdominal pain..given tramadol po w/ fair effect. am k-4.2 & bun/creat 161/2.7. Sinus rhythm with first degree A-V delay. BUN/Creat 164/2.7. Pt was given vanco, levaquin, and flagyl and sent to MICU6 on sepsis protocol. access=rsc mlc & r fem aline. cv=hemody stable. hypovolemia. ABLE TO WEAN PRESSERS ,CONTINUED TO HAVE WCT TO VFIB CONVERTED C AICD FIRING OR PACED OUT BY EP FELLOW .ACIDOSIS/K CORRECTED C FLUID,BICARB, PTS RHYTHM. renal=adeq uo. Lactic acid 1.1-2.0. UA/UC sent in ED...neg.ID: Temp max 99.0 rectally. (cortisol level in ED 225.8). HR 79-86 with wide complex freq falsely identified by monitor as V-tach. KUB done for c/o abdominal pain (? Prior tracing appears consistentwith ventricular tachycardia, although was interpreted as sinus tachycardia.TRACING #1 CVP 0-4, NS IV @ 100ml/hr.GI: Abd soft with + BS. Compared to tracing #1, frequent ventricular ectopy is present. Nursing note addendum (0650):Pt w/ 3 to 4 8-10 beat runs of V-tach. Lung sounds RL slightly coarse, LL clear/diminished at bases. Given biscodyl and senna po. Intraventricular conduction delay.Biatrial enlargement. Breathing over set RR. gi=ngt placed. Axis is rightward and there are diffuse ST-T wavechanges(repolarization from intraventricular conduction delay). Changed back to AC d/t tachypnea, desaturation, and desynchrony, ^^WOB. Allevyn reapplied to both and edges sealed with hytape. Conts on Mexiletine. cv=hemody stable. 0330am given 1mg versed w/ some effect in decreasing RR. cxr done during episode-unchged from previous. gi=tf resumed @ goal w minimal residuals. on zosyn + vanco. echo=wo chg. ekg=wo ischemic chges. rsc mlc-center port clotted. renal=contins on cvvhdf w pfr=0. med x2 w versed/fent for comfort w effect. CCU NSG NOTE: ALT IN RENAL/CV/SKINO: For complete VS see CCU flow sheet.ID: Pt afebrile. am bun/creat-106/1.7. allevyn dsg to Rt upper back + coccyx ulcer. Propofol gtt started w/ better effect. BUN/CR 151/2.7. Hold all heparin until HIT screen is back. sedation for resp rate control. Lytes pending.ID: Conts on Zosyn. Cont with VAP protocol. Restart TF when possible. breath sounds=deminished throughout. breath sounds=deminished throughout. Level to be drawn in am. Ventilator changes where made from A/C to CPAP w/ PS (). He conts on PPI.RENAL: BUN/Creat stable at 145/2.6. Started on propofol drip at 0515am.ID: Temp spike 101.3. pan cultured. monitor resp status/abgs. Versed and Fentanyl prn doses overnite. wo further episodes of vt off amiodarone. Plan to wean to PS if tolerates. rhythm-ns to st w pvc's. RESPIRATORY CARE NOTESPt. r radial aline postional. To start CRRT after tap. CRRT as per renal orders. Dsg to L arm changed-the weeping areas had aquacel applied and dry areas wound gel and adaptic. CCU NSG NOTE: ALT IN RENAL/CV/SKIN(Continued) tube. He was K+ and Calcium replaced. + corneals. presently on levo @ 0.5mcg/kg/min, vassopressin @ 2.4u/hr, & neosynephrine @ 5.0mcg/kg/min w maps >60. episodes of ventricular bigeminy-self limiting. CVP ~. abx as ordered. am abg: 7.44/39/95 Sx tan thick secretions. CCU progress note 7p-7aEVENTS: after midnite pt overbreathing vent on PS 30s-40s. id=afebrile. id=afebrile. Thoracentesis of L lung done by IP, 250cc's of sero sanguinous fluid removed. ica 1.0 on cal gluc gtt. versed & fent gtt's @ low dose w effect. contin episodes oh hypotension w maps to low 50's-rxed w addition vassopressin & neosynephrine w weaning & dc of dopa. | 56 | [
{
"category": "Radiology",
"chartdate": "2110-04-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961922,
"text": " 10:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL ADDENDUM\n This is the correct report for this patient. Please disregard the previous\n report.\n\n INDICATION: Endotracheal tube placement.\n\n Endotracheal tube terminates 3 cm above the carina, and a nasogastric tube has\n been placed, terminating in the region of the distal stomach. There has been\n slight improvement in the degree of pulmonary edema, with otherwise no short\n interval change in the appearance of the chest since the recent study\n performed several hours earlier.\n\n\n 10:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated, new ET\n placements\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 2204\n\n COMPARISON: , 1221.\n\n INDICATION: Endotracheal tube placement.\n\n Endotracheal tube tip terminates about 3 cm above the carina. Other\n indwelling devices are unchanged in position. Pulmonary edema has slightly\n improved, with otherwise no substantial change in appearance of the chest\n compared to the recent radiograph of several hours earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-25 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 961727,
"text": " 11:32 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: please eval for obstruction/free air\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with T1DM s/p renal/pancreas transplant, presents with\n leukocytosis diffuse abd pain,\n REASON FOR THIS EXAMINATION:\n please eval for obstruction/free air\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post renal and pancreas transplant, presenting with acute abdominal\n pain, evaluate for obstruction or free air.\n\n SUPINE AND UPRIGHT RADIOGRAPH OF THE ABDOMEN: No free air is seen under the\n diaphragms. No dilated loops of bowel are seen. No air-fluid levels are\n present. Splenic artery vascular calcifications are noted. Incidental note is\n made of atelectasis at the left lung base. Pacemaker wires are seen and the\n patient has had a prior CABG. A central line upper portion obscured is seen\n with its tip projecting over the lower SVC. There are phleboliths seen in the\n pelvis.\n\n IMPRESSION:\n 1. No free air under the diaphragm.\n 2. No air-fluid levels or dilated loops of bowel seen to suggest obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961700,
"text": " 4:09 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?central line placement, ptx?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, amio toxicity to lungs, COPD, bronchitis now with\n SOB, hypoxia s/p central line in RIJ\n REASON FOR THIS EXAMINATION:\n ?central line placement, ptx?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of central line placement.\n\n Portable AP chest radiograph compared to previous film obtained an hour and 13\n minutes earlier. The central venous line was inserted through right internal\n jugular line with its tip terminating at the level of superior SVC. There is\n no pneumothorax or apical hematoma. The rest of the findings are unchanged\n comparing to the previous study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961684,
"text": " 2:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, amio toxicity to lungs, COPD, bronchitis now with\n SOB, hypoxia\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n WET READ: DLnc FRI 4:07 PM\n New RLL and worsening LLL consolidations: could be pneumonia or aspiration\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The patient is after median sternotomy and CABG with broken lower sternal\n wires broken, unchanged. The left-sided pacemaker with its two leads\n terminating in the right atrium and right ventricle is unchanged. The heart\n size is enlarged but stable.\n There is slight worsening of left lower lobe opacity which is kmown\n to be partially due to round atelectasis but a new overlying infection or\n aspiration cannot be excluded. In addition, there is worsening of the right\n lower lobe consolidation, thus a combination of this finding is strongly\n suggestive for aspiration, although bilateral infection process is a\n possibility.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962087,
"text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated, new ET\n placements\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient with congestive heart failure,\n pneumonia.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 4 cm above the carina. The NG tube passes below the\n diaphragm. The right subclavian line tip terminates at the upper right\n atrium. The ICD leads terminate in right atrium and right ventricle in\n unchanged position.\n\n There is slight improvement of the right lower lobe consolidation with\n unchanged appearance of the left retrocardiac consolidation as well as a\n small-to-moderate loculated left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-25 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 961714,
"text": " 7:37 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: cholecystitis?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with RUQ tenderness and elevated lft's\n REASON FOR THIS EXAMINATION:\n cholecystitis?\n ______________________________________________________________________________\n WET READ: ARHb FRI 7:59 PM\n No evidence of cholecystitis. Small right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper quadrant tenderness and elevated LFTs.\n\n COMPARISON: CT abdomen .\n\n TECHNIQUE: The gallbladder appears normal without evidence of stones. No\n wall thickening or pericholecystic fluid is seen. The common bile duct\n measures approximately 4 mm and no intra- or extra-hepatic ductal dilatation\n is seen. No focal or textural abnormality of the liver is identified. A\n small right pleural effusion is noted.\n\n IMPRESSION:\n 1. No son evidence of cholecystitis.\n 2. Small right-sided pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961884,
"text": " 12:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT and OGT placment\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated\n\n REASON FOR THIS EXAMINATION:\n assess ETT and OGT placment\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 12:21 P.M.\n\n HISTORY: Assess endotracheal and orogastric tube placements.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Consistent with the given history, an endotracheal tube has been\n placed with the distal tip approximately 3 cm from the carina in appropriate\n position. However, no orogastric or nasogastric tube is identified. There is\n a right internal jugular approach central line stable in course and position.\n Also stable is a dual chamber pacemaker/AICD. There is dense consolidation\n with air bronchograms in the left lower lobe. There is a left pleural\n effusion. Diffuse worsening opacity in both interstitial and alveolar pattern\n is noted throughout the lungs, particularly in the right perihilar and right\n lower lung zones. Extensive postsurgical findings consistent with prior CABG\n and median sternotomy are evident.\n\n IMPRESSION: Endotracheal tube in satisfactory position. No orogastric tube\n identified. Dense retrocardiac left lower lobe opacity likely atelectasis,\n although pneumonia cannot be excluded. There is a left pleural effusion and\n diffuse worsening cardiogenic hydrostatic edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 962046,
"text": " 4:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate line placement, rule out PTX\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated, s/o new RSC\n line placement\n REASON FOR THIS EXAMINATION:\n evaluate line placement, rule out PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old man status post right subclavian CVL placement.\n\n COMPARISON: .\n\n CHEST AP: There has been interval placement of a right subclavian CVL with\n the tip in the right atrium. There is no evidence of pneumothorax. The\n appearance of the chest is otherwise stable with multiple lines and tubes.\n The degree of pulmonary edema has not significantly changed from prior\n examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961705,
"text": " 5:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ?RIJ in right place\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, amio toxicity to lungs, COPD, bronchitis now with\n SOB, hypoxia s/p central line in RIJ -- now pulled back\n REASON FOR THIS EXAMINATION:\n ?RIJ in right place\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF with amiodarone toxicity, COPD and bronchitis with acute\n shortness of breath status post right IJ line readjustment.\n\n Portable chest radiograph was compared to one hour prior and demonstrates\n withdrawal of the IJ line approximately 3 cm, now located at the cavoatrial\n junction. The study is otherwise unchanged in the very short interval. There\n is no pneumothorax.\n\n IMPRESSION: IJ line at cavoatrial junction without pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-04-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962239,
"text": " 6:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated, s/o new RSC\n line placement\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST, 7:34 A.M., \n\n INDICATION: CHF. Pneumonia.\n\n FINDINGS: Compared with 5/22 and , the infiltrate at the right base\n has shown further partial interval clearing. Retrocardiac opacity and\n probable left effusion at the CP angle are grossly unchanged. No overt\n pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-05-02 00:00:00.000",
"description": "P VEN DUP EXTEXT BIL (MAP/DVT) PORT",
"row_id": 962596,
"text": " 9:31 AM\n DUP EXTEXT BIL (MAP/DVT) PORT Clip # \n Reason: please evaluate anatomy of femoral veins for tunnel cath pla\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with bilateral fem- bypasses, renal failure, needs femoral\n tunneled dialysis catheter, IR unable to visualize femoral veins\n REASON FOR THIS EXAMINATION:\n please evaluate anatomy of femoral veins for tunnel cath placement (IR unable\n to find them)\n ______________________________________________________________________________\n FINAL REPORT\n LIMITED BILATERAL LOWER EXTREMITY DUPLEX VENOUS ULTRASOUND\n\n INDICATION: History of bilateral fem- bypass grafts. Interventional\n radiology was not able to visualize/localize the common femoral veins with a\n portable machine prior to anticipated tunnelled femoral hemodialysis catheter\n placement.\n\n FINDINGS: Both the left and right common femoral veins were able to be\n localized with color and duplex Doppler. However, the common femoral veins\n were located deep to the common femoral arteries and posterior to the proximal\n bypass grafts, suggesting that percutaneous access to them would be difficult\n and might jeopardize his bypass grafts.\n\n IMPRESSION: Patent common femoral veins bilaterally, but not ideally located\n for tunneled catheter placement, as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-05-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962463,
"text": " 9:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated, s/o new\n RSC line placement\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old man with CHF, pneumonia, status post VT code, now\n intubated.\n\n COMPARISON: .\n\n CHEST AP: There is stable cardiomegaly. The aorta is calcified and tortuous.\n There continues to be pulmonary vascular congestion and mild interstitial\n edema. The left lower lobe opacity and pleural effusion is stable. Lines and\n tubes are in unchanged position. The right subclavian catheter tip is in the\n proximal right atrium.\n\n IMPRESSION: Overall stable radiographic appearance of the chest with left\n lower lobe consolidation consistent with pneumonia or atelectasis and moderate\n left pleural effusion. Right subclavian CVL tip in proximal right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962677,
"text": " 5:38 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o pneumothorax s/p thoracentesis\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code and intubated, now s/p\n left thoracentesis\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax s/p thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n INDICATIONS: Pneumonia, CHF with V-tach arrest and left thoracentesis. Assess\n for pneumothorax.\n\n PORTABLE SEMI-UPRIGHT AP CHEST: Comparison is made to the study from 10 hours\n earlier. Slight interval reduction in size of left pleural effusion with a\n slightly improved aeration in the left lower lobe. No definite pneumothorax\n is identified, although this study appears to be predominantly supine. There\n is a new dual-lumen right internal jugular hemodialysis catheter with the tip\n in the right atrium. Right subclavian triple lumen catheter tip remains at or\n just below the level of the cavoatrial junction. Dual-chamber pacemaker/AICD\n leads are unchanged in configuration. ET tube in good position several\n centimeters above the carina. Multiple fractured sternal wires unchanged.\n Equivocal worsening of bilateral airspace opacities, likely indicating\n congestive heart failure/fluid overload. NG tube tip in stomach. No\n pneumothorax.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2110-05-02 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 962651,
"text": " 1:50 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place tunneled right IJ catheter for hemodialysis\n Admitting Diagnosis: PNEUMONIA\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with left sided AICD, sepsis, renal failure requiring CVVH.\n REASON FOR THIS EXAMINATION:\n Please place tunneled right IJ catheter for hemodialysis\n ______________________________________________________________________________\n FINAL REPORT\n TUNNELED RIGHT IJ CATHETER PLACEMENT.\n\n INDICATION: Sepsis and renal failure requiring dialysis.\n\n RADIOLOGISTS: and , with Dr. , the\n Attending Radiologist, being present and supervisig the entire procedure.\n\n FINDINGS: The risks and benefits of the procedure were explained to the\n patient, signed informed consent was obtained. The patient was placed supine\n on the angiographic table and the right neck and chest were prepped and draped\n in usual sterile fashion. Using ultrasound, the right internal jugular vein\n was identified and 1% lidocaine was injected for local anesthesia.\n Venopuncture of the right internal jugular vein was performed under direct\n ultrasound guidance and 0.018 inch guidewire was inserted into the SVC under\n fluoroscopic guidance. Hard copy ultrasound images were obtained before\n and after venous access documetning vessel patency. The needle was then\n exchanged for 4 French micropuncture sheath. Wire was exchanged for \n wire that was advanced into the inferior vena cava. Attention was then\n directed towards the creation of a tunnel in the right chest utilizing 1%\n Xylocaine for local anesthesia and a small incision to either tunneled entry\n site. A 23 cm double lumen 14.5 French dialysis catheter was then tunneled\n into the subcutaneous tract in the right chest. The right IJ entry site was\n then progressively dilated with 8, 12, and 14 French dilators until a 14\n French peel-away sheath was placed into the right atrium. The tunneled\n dialysis catheter was inserted into the right atrium as the peel-away sheath\n was removed. The line was flushed, hep locked, and secured with Prolene\n sutures. The neck incision was closed with Dermabond. Final fluoroscopic\n image demonstrates the tip of the catheter in the right atrium. The patient\n tolerated the procedure without immediate complications.\n\n IMPRESSION: Successful double lumen right internal jugular tunneled dialysis\n catheter placement. The line is ready to use. Dr. and Dr.\n performed the procedure. Dr. , the attending, scrubbed and\n supervised.\n\n\n\n (Over)\n\n 1:50 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: Please place tunneled right IJ catheter for hemodialysis\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962579,
"text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code now intubated,\n\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:41 A.M. \n\n HISTORY: CHF, pneumonia. Intubated after code.\n\n IMPRESSION: AP chest compared to through 24:\n\n Somewhat asymmetric pulmonary edema is stable. Consolidation at the base of\n the left lung accompanied by small-to-moderate left pleural effusion could be\n either pneumonia or atelectasis, also unchanged. Mild cardiomegaly stable.\n No pneumothorax. ET tube is in standard placement. Right subclavian line tip\n projects over the superior cavoatrial junction while a transvenous right\n atrial pacer and right ventricular pacer defibrillator lead are continuous\n from the left axillary pacemaker. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-05-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962706,
"text": " 10:45 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please assess for pneumothorax or hemothorax s/p tap.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with CHF, PNA, s/p VT code and intubated, s/p\n left thoracentesis, now coded for VTach\n REASON FOR THIS EXAMINATION:\n Please assess for any acute process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Ventricular tachycardia arrest.\n\n PORTABLE AP CHEST AT 2255: Comparison is made to the study from five hours\n earlier. Lines and tubes are unchanged. There are worsening airspace\n opacities bilaterally consistent with fluid overload/CHF. Continued\n collapse/consolidation in the left lower lobe unchanged. No new pneumothorax.\n Continued left pleural effusion. No rib fracture identified.\n\n DR. \n"
},
{
"category": "Echo",
"chartdate": "2110-05-03 00:00:00.000",
"description": "Report",
"row_id": 66853,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension. Recent HD line placement. Assess for effusion\nHeight: (in) 68\nWeight (lb): 150\nBSA (m2): 1.81 m2\nBP (mm Hg): 90/50\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 00:21\nTest: Portable TTE (Focused views)\nDoppler: Color Doppler only\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Severe global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nThere is severe global left ventricular hypokinesis (EF 20%), with more\nprominent septal hypokinesis. Due to limited views, more precise regional wall\nmotion abnormalities cannot be assessed. Right ventricular chamber size is\nnormal. There is moderate global right ventricular free wall hypokinesis.\nModerate (2+) aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no pericardial effusion.\n\nIMPRESSION: No pericardial effusion. Severe left ventricular systolic\ndysfunction. Moderate aortic regurgitation.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 145830,
"text": "Sinus rhythm\nFirst degree A-V block\nLeft atrial abnormality\nRight bundle branch block\nInferior myocardial infarction\nSince previous tracing of , atrial fibrillation has reverted to normal\nsinus rhythm and ventricular tachycardia is not seen\n\n"
},
{
"category": "ECG",
"chartdate": "2110-05-02 00:00:00.000",
"description": "Report",
"row_id": 145829,
"text": "Atrial fibrillation. Right bundle-branch block. Non-specific T wave changes.\nCompared to the previous tracing of atrial fibrillation is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-27 00:00:00.000",
"description": "Report",
"row_id": 145831,
"text": "Atrial fibrillation with moderate ventricular response\nParoxysmal idioventricular rhythm or ventricular tachycardia\nExtensive intraventricular conduction defect\nInferior infarct - age undetermined\nLateral infarct - age undetermined\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-27 00:00:00.000",
"description": "Report",
"row_id": 145832,
"text": "Atrial fibrillation with moderate ventricular response and intraventricular\nconduction delay\nVentricular tachycardia with rapid ventricular response\nSince previous tracing of the same date, ventricular tach is new\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-27 00:00:00.000",
"description": "Report",
"row_id": 145833,
"text": "Compared to tracing #1, frequent ventricular ectopy is present. Otherwise, the\nfindings are similar with further prolongation of the QTc interval.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2110-04-25 00:00:00.000",
"description": "Report",
"row_id": 145834,
"text": "Sinus rhythm with first degree A-V delay. Intraventricular conduction delay.\nBiatrial enlargement. Axis is rightward and there are diffuse ST-T wave\nchanges(repolarization from intraventricular conduction delay). Compared to the\nprevious tracing of at 11:11pm sinus tachycardia is no longer present,\nthe axis has shifted rightward and QRS morphology is markedly different,\n(similar to prior ECG of at 9:02am). Prior tracing appears consistent\nwith ventricular tachycardia, although was interpreted as sinus tachycardia.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-26 00:00:00.000",
"description": "Report",
"row_id": 1286633,
"text": "Nursing progress note (2230-0700):\n\n54 yo male with recent hospitalization for DOE to a RLL PNA, CHF, & possible amiodarone toxicity. Pt was discharged on to rehab for Physical therapy w/ a 3L O2 requirement. Pt refused rehab, so went home instead w/ home health & ended up back in ED and eventually sent to . Per pt's wife, he has been going \"down-\" ever since he entered rehab where they continued a 1000cc fluid restriction diet and diuresed him to the point of pt feeling very dehydrated. Pt c/o shortness of breath @ rehab today & was found to be increasingly lethargic and hypoxic into the 80s on RA, & sating 90% on 6L O2. Pt was noted to have bandemia on his WBC diff...sent to ED. In the , pt noted to be febrile to 101.2, BP 106/70, & 88% on RA. Pt placed on 6L O2 w/ sats 93-100%. RIJ pre- cath placed w/ a CVP of 4. Pt was given vanco, levaquin, and flagyl and sent to MICU6 on sepsis protocol. WBC 29.4 and ? of worsening RLL PNA.\n\n\nEvents: Abdominal ultrasound done prior to admission to MICU 6 for elevated LFTs...negative for cholecystitis. KUB done for c/o abdominal pain (? SBO) and CXR done...pending results.\n\nROS:\n\nNeuro: Pt lethargic, opening eyes spontaneously, oriented to self and place only. Following commands, MAE. Pt HOH.\n\nPain: pt C/o abdominal pain..given tramadol po w/ fair effect. Pt stated feeling constipated, but states that his last BM was yesterday. Given biscodyl and senna po. BS hypoactive, Abdom soft, ND, slightly tender to touch..Abd w/ ecchymotic to ? heparin injections...Pt had recent fall in his last admission- rt side of abdominal area w/ ecchymotic area. KUB done. No c/o N/V. Pt tolerating clear lix.\n\nResp: Pt rec'd on NRB @ 15.0 lpm from ED. ABG 7.36/37/233/22/97%...pt placed on 5L NC subsequently. O2 sats on 5L NC between 94-97%. RR regular 16-20. Non-productive cough. LS clear to apices and crackles to bilateral bases. SVO2 ranging between 50-63... to cardiomyopathy. Mixed venous O2 sats 28-38.\n\nCV: NBP 1teens-130s/40s-80s, HR 60s-70s. AV paced. occas-freq PVCs. Pacer/AICD to Left side of chest wall. CVP 2-4. Being given 500cc NS @ 100cc/h. Lactic acid 1.1-2.0. K+ 5.4(4.9) & Hyponatremic 122 (121) RF...? hypovolemia. Cortisol test done..pnd'ing results. (cortisol level in ED 225.8). HCT stable @ 32.4(32.0). BNP ^^ 39,984. Tox screen + for amphetamines & barbituates.\n\nGU: Pt w/ CRI...baseline creat 2.5-2.8. ARF likely pre-renal. BUN/Creat 164/2.7. Urine clear/yellow, UOP 50-90cc/h. Urine lytes sent. UA/UC sent in ED...neg.\n\nID: Temp max 99.0 rectally. WBC 20.9 (29.4), started on vanco, flagyl, and zosyn.\n\nSkin: Skin to BUEs fragile, ecchymotic, thin w/ several skin tears. Lt hand skin tear oozing serosang. Coccyx and rt lower back w/ abrasions...no drainage, allevyn dsgs applied. Both heels w/ ulcers...no drainage, mulipodus boots ordered. Lt knee w/ 5cmx5cm wound..wet to dry dsg applied. Wound consult ordered.\n\nAccess: RIJ pre- cath in place....patent, wnl.\n\nAll\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-26 00:00:00.000",
"description": "Report",
"row_id": 1286634,
"text": "(Continued)\nergies: Cipro, aldactone.\n\nSocial: Wife called and updated on pt's status and POC. Pt's daughter, , is pt's HCP.\n\nCode status: full code.\n\nPlan: Wean O2 as tol, Pulmonary toileting, labs due @ 0800, sputum & stool cx to be collected, ? need for dialysis per team, wound care consult, monitor labs, f/u cx's, gentle IVFs, PT, maintain safety.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-26 00:00:00.000",
"description": "Report",
"row_id": 1286635,
"text": "Nursing note addendum (0650):\n\nPt w/ 3 to 4 8-10 beat runs of V-tach. Pt has pacer/AICD. Dr. notified...pt to have EP consult today. Pt denies CP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-26 00:00:00.000",
"description": "Report",
"row_id": 1286636,
"text": "Nursing Progress/Transfer note 0700-1500\nSee Nursing Transfer note for PMH.\nReview of Systems:\nNeuro: Pt lethargic, O x . MAEE with general weakness. Nods to answer questions, will rarely speak to request items. He C/O abd discomfort R/T constipation.\nResp: O2 sat 95-97% on 5l NC with RR 16-23 and regular. Lung snds with diffuse crackles team assoc with pulm amio toxicity znd asp PNA rather than excess fluid. Non-productive cough.\nCV: A-V pacer with AICD. HR 79-86 with wide complex freq falsely identified by monitor as V-tach. BP 111/59-123/93. CVP 0-4, NS IV @ 100ml/hr.\nGI: Abd soft with + BS. Pt on aspiration precautions, taking small amt liqs with pills. Pt had small brown, trace heme + stool in am, and was disimpacted for mod amt.\nGU: Urine yellow with sed, draining via foley in adequate amts. 24hr fluid blance +500ml, LOS balance + 1 liter.\nSkin: Pt with multiple hematomas, skin tears. Following wound care advice from previous admit .\nSocial: Dgtr called for update. Dr. (page )would like to speak with her when she visits today.\nPlan: Transfer to floor. Cont to hydrate. Aspiration precautions, ? speech/swallow test. Repeat labs @ 1700.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-27 00:00:00.000",
"description": "Report",
"row_id": 1286637,
"text": "Respiratory Care: Pt recieved orally intubated from the floors after V-fib arrest. Placed on AC. Several changes made to normalized Ph. Latest ABG showed compensated respiratory alkalosis with good oxygenation, Vt dropped from 600 to 550, FiO2 50%, SpO2 99-100%. Follow up ABG pending. Lung sounds RL slightly coarse, LL clear/diminished at bases. Suctioned for moderate bloody tinged thick secretions. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 1286641,
"text": "CCU Progress Note:\n\nS- intubated & sedated.\n\nO- see flowsheet for all objective data.\n\nId- (+) MRSA bacteremia per blood cultures- sputum & blood cultures X2 obtained & sent to lab- RIJ TLCL D/C'd- TLCL placed into R subclavian-\nL fem A-line to be D/C'd- WBC 22.3- con't on vanco and zosyn- afebrile.\n\ncv- Tele: SR with occ PVC's- HR 70-78- B/P 100-121/42-56 MAPs 65-73- con't on lidocaine gtt @ 2mg/min- Hct this am after 1u PRBC's 27.1 (from 24.8)- K 4.2- Mg 1.2 Mg sulfate 2gm given- INR 1.4- repeat labs pending.\n\nresp- con't on vent AC 550/20/50%/5- LAST ABG 7.35- 37-126-21 on NAHCO3 gtt @ 150cc/hr X1 liter- attempted CPAP this am, however unable to tolerate (PH 7.25), so placed back on AC- lung sounds coarse bilaterally- suctioned for thick brn/blood tinged colored mucous- SpO2 95-100%.\n\nneuro- sedated on fentanyl 25mcq/hr & versed 1mg/hr- opens eyes to verbal stimuli- unable to follow commands consistently- lethargic.\n\ngi- abd soft (+) hypoactive bowel sounds- NGT clamped @ present- to start TF this evening- FIB intake with small amt liq brown stool noted.\n\ngu- foley draining amber colored urine qs- U/O >40cc/hr- (+) 1800cc since 12am- BUN 161 Crea 2.7 & trending down.\n\nendo- glucose range 91-128 today- no insulin needed- on insulin sliding scale.\n\nskin- multiple breakdown areas noted- skin care given & dsg changes done.\n\nA- hemodynamically stable with no further VT.\n\nP- monitor vs, lung sounds, I&O and labs- follow labs- monitor CVP- ? decrease sedation in am- attempt to wean- support Pt & family- keep them updated on plan of care.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 1286642,
"text": "Resp Care\n\nPt remains intubated and currently vented on full support with no spontaneous efforts noted. Attempted to wean on psv today however pt unable to sustain consistent minute ventilation to compensate for metabolic acidosis and was placed back on A/C. No resp distress noted during weaning trial. VT ranged from 500-600cc and MV 7-8L on PS 10/5. BS course sxing for small amts of thick tan secretions. Bronchodilators started this evening with fair effect noted. Last ABG with fully compensated metabolic acidosis and good oxygenation on present settings. WIll cont with vent support and reassess for further weaning as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 1286643,
"text": "Addendum: R fem Aline D/C'd- R IJ TLCL D/C'd- both tips sent to lab for C&S- FIB changed- stool quiac (+)- skin tears & IV insertion sites oozing- dsgs reinforced- K 3.7- KCL 40meq ordered & given- seen by EP- AICD adjusted- awaiting feeding pump to begin TF- 1L NS @ 100cc/hr ordered & started @ 1900.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1286644,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings. Breathing over set RR. Appears agitated at times. Sxn for small amount yellow-tan secretions. RSBI completed on PS 5-33. Plan for PS trial.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1286645,
"text": "CCU Nursing Progress Note\nS-orally intubated without any signs of communication.\nO-Neuro-lightly sedated on fentanyl 25mcg/kg/min and versed 1mg/hr. Opens eyes to stimulation but has not followed any commands. Grimaces with turning. Will not look you in the eye Will raise arms up when allowed-AROM but mostly nonpurposeful. Appears to not like the wrist restaints, finding him pulling against the restraints making his aline dampen. Not moving his lower extremities much at all.\nCV-Brief episode of hypotension SBP 80 with SVP 6 received 250cc NS bolus with good effect MAP's > 65. Goal to keep CVP >10 NS at 100cc/hr adjusted to 50cc/hr with CVP 14 but sensitive to decrease in IVF. HR 80-100 atrial flutter with freq PVC's K+ 4.6 Lactic acid 2.0\nResp-orally intubated and sedated on vent 50% 550x20 AC PEEP 5, ABG this morning 7.28/33/136/-. Despite RSBI 33, SBT was not done and and was transiently changed over to PS but RR 20-30 with vT 200-800. LS coarse with small-moderate amount thick dark tan secretions with a few plugs. CPT was not tolerated with bleeding from blood sticks and poor skin integrity in general.\nID MRSA bacteremia afebrile on vanco q48hrs-level 23 and zosyn WBC remains elevated 24.9.\nGI-NGT in place and started tube feeds at 1900 Nutren renal at 10cc/hr and increased to 20cc/hr. Residuals 60cc at midnight and 20cc at 0500.\n+BS no BM, rectal bag intact.\nGU-BUN/Cr 151/2.8 foley draining well 50-70cc/hr with IVF NS at 100cc/hr for one liter.\nHeme-HCt decreased to 24.8 @ 2100 and 24.2 @ 0500. Moderate amount of blood loss from access sticks and from traumatic removal of defib pads. Crossmatched for 2 units. Intern aware.\nSkin-Continues to ooze from RIJ stick, left forearm laceration and upper chest from defib pads. Aloe Vesta cream top to toe. Wound RN to re-evaluate pt skin today. -air bed obtained.\nSocial-daughter called this am for update.\nAccess-right radial aline, right SC TLC/CVP.\nCode Status-Full\nA/P-Bacteremia with transient hypotension, metabolic acidosis and having difficulty weaning.\nClosely monitor CVP goal >10 and MAP's >65, IVF as ordered.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-27 00:00:00.000",
"description": "Report",
"row_id": 1286638,
"text": "54 YR OLD C CAD SP CABG ,MULTIPLE , 25%,CHF,DM, SP KIDNEY,PANCREAS TX,VT C AICD ,HTN,HOH.FIRST ADMITED C PNA,CHF AND AMNIODERONE TOXICITY.DC TO HOME ,REFUSED REHAB,READMITTED C SOB .DC TO REHAB.AGGRESSIVELY DIURESED THERE.DROPPED SAT TO 80S,T TO 101.2 READMIT TO TO MICU FOR SEPSIS PROTOCOL .FOUND TO HAVE METABOLIC ACIDOSIS,HYPERKALEMIA ,DEHYDRATED .TRANS TO F3 .THIS AM SEEN BY EPS FOR WCT.HAD 14 EPISODE VT/VFIB C SHOCK BY AICD,INTUBATED ON DOPAMINE,NEOSYNEPHERINE ,LIDOCAINE .BROUGHT TO CCU. ABLE TO WEAN PRESSERS ,CONTINUED TO HAVE WCT TO VFIB CONVERTED C AICD FIRING OR PACED OUT BY EP FELLOW .ACIDOSIS/K CORRECTED C FLUID,BICARB, PTS RHYTHM. FAMILY AT BEDSIDE ,DISCUSSED C DR ,FULL CODE,DIALYSIS IF NEEDED .\n\nSR NO ECT AT PRESENT .LIDOCAINE 2MG /MIN .4L OF FLUID .CVP 6 ,GOAL 10.BICARB GTT RUNNING AY PRESENT .\n\nAC 50/500/25/5 SATS 100%.BS DECREASED,SX ORALLY FOR BLOODY ,MIN ET .\n\nUNABLE TO PASS OG TUBE.POS BS.PASSING LG AMT STOOL SOFT BROWN .\n\nUO > 100CC/HR VIA FOLEY .SEEN BY RENAL WHO WILL PLACE GROIN CATH IF NEEDED FOR DIALYSIS .\n\nPT INITIALLY NONRESPONSIVE,NOW OPENS EYES TO NAME ,MOVES ARMS,PUPILS NO REACTING TO LIGHT .\n\nMULTIPLE OPEN SKIN AREAS ,HAS BEEN FOLLOWED BY SKIN CARE,NEEDS SPECIAL BED .DSD PER PROTOCOLS .\n\nBS WNL NOR REQUIRING SSRI.\n\nAFEBRILE ,ON ANTIBX.\n\nPT AS ACIDOSIS CORRECTED.\n\nFOLLOW LYTES,ABGS,BS\nREHYDRATION,MONITOR CVP\nSUPPORTIVE CARE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 1286639,
"text": "Respiratory Care Note:\n\nPt remain orally intubated & sedated on full ventilatory support. No vent change done. See Careview. Bs are bil clear. We are sxtn for scant amtof thick blood tinged secretions from ETT, none orally. Plan: Continue present ICU moniotoring. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-28 00:00:00.000",
"description": "Report",
"row_id": 1286640,
"text": "ccu nsg progress note.\no:neuro=sedated w fent/versed gtts w effect. arouses to noxious stim- grimaces & moves extrem on bed.\n pulm=intubated & vented w present settings-ac 550x20 50% +5. last abg-7.35 30 77 17 -7--fio2 increased from 40 to 50%. breath sounds= course throughout. sx-scant thick tannish secretions.\n cv=hemody stable. rhythm-ns wo ectopy. maps >60. access=rsc mlc & r fem aline.\n gi=ngt placed. rectal bag intact.\n renal=adeq uo. overall i&o-5l positive. am k-4.2 & bun/creat 161/2.7.\n heme= hct 24.8--tx w 1urbc--repeat hct 27.1.\n id=afebrile. abx as ordered.\n skin=multiple breakdown areas noted.\n\na:stable over night. wo further runs of vt.\n\np:contin present management. ?wean sedation-attempt cpap. support pt/ family as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-02 00:00:00.000",
"description": "Report",
"row_id": 1286659,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse improve sl with suct sm th tan sput. MDI given as per order. Pt returned to previous mode of ventilation overnoc and tol well; ABGs pending. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-02 00:00:00.000",
"description": "Report",
"row_id": 1286662,
"text": "Patient remains on mechanical ventilation tolerates PS better than A/C.Went to IR for dialysis catheter placement;done.Upon his return ,thoracentesis performed by team with removal of 250ccs of sanguinous blood.Patient treated with albuterol/atrovent. Has transient decrease of BP;treated with fluid bolus.suctioned PRN for minimal amount of yellow secretion.Bs coarse,no recent ABG drawn good saturation will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-02 00:00:00.000",
"description": "Report",
"row_id": 1286660,
"text": "ccu nsg progress note.\no:neuro=minimally responsive. appears ro attempt to turn to voice. grimaces w movement. sl moves upper extrem. med x2 w versed/fent for comfort w effect.\n pulm=intubed/vented on cpap/ps throughout night. acceptable abg w sats upper 90's. breath sounds=deminished throughout. sx-scant tannish secretions.\n cv=hemody stable. rhythm-ns to st w pvc's. episodes of ventricular bigeminy-self limiting. r radial aline postional. rsc mlc-center port clotted.\n gi=tf resumed @ goal w minimal residuals. stopped @ 0400. stooling- loose brown quiac neg.\n renal=lasix 80mg iv @ w gd effect. i&o remains positive overall.\n id=afebrile.\n labs=am sent.\n skin=all d&i.\n social=wife called- given.\n\na:stable throughout shift awaiting hd catheter placement.\n\np:contin present management. contin prn med for comfort. lower extremities vein ultrasound. ir-femoral tunneled hd catheter. support pt/family as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-02 00:00:00.000",
"description": "Report",
"row_id": 1286661,
"text": "Nursing Progress Note\n\nS: Pt remains intubated and minimally responsive.\n\nO: Please see flow sheet for objective data. Tele sinus with frequent PVC's including short self limiting runs. Conts on Mexiletine. K 3.3 pt given total of 40meq's IV. Transient periods of BP dropping into the 80's while pt is sleeping. Resolved without tx. Given 250NS for BP in 60's x 1.\n\nResp: Pt remains intubated on CPAP/PS 15/10 50%. TV 500's with rate 28-38. suctioned for sm amts of thick tan sputum. lungs are diminshed throughout. O2 sats >98%. Thoracentesis of L lung done by IP, 250cc's of sero sanguinous fluid removed. Fluid for studies sent by intern.\n\nNeuro: Pt opening his eyes to verbal stimulation. Pt does not follow commands. Pt nodding his head that he is not having pain. Pt telling the residents that he would like dialysis so he can get off the vent.\n\nGI/GU: Pt NPO for line placement in IR. Abd is soft nontender with bowel sounds present. Lg amt of liquid brown stool this am follow by 2 more mod loose BM's. Pt does not have any rectal tone so FIB applied by skin care nurse. CYU. No lasix today. To IR for Tunneled line placement via RIJ. HIT screen pending so line flushed with Citrate. To start CRRT after tap. Lytes pending.\n\nID: Conts on Zosyn. Vancomycin dose yesterday. Level to be drawn in am. WBC ^'d 30,000. hydrocortisone changed to prednisone.\n\nSocial: Daughter spoke with MD's regarding procedures taking place today and gave consent for them. Wife and daughter will be in this pm.\n\nA&P: Pt able to have tunneled line for CRRT placed in IR today. Check baseline lytes and abg prior to starting CRRT. CRRT as per renal orders. Hold all heparin until HIT screen is back. Restart TF when possible. cont with skin care protocol. Cont with POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-03 00:00:00.000",
"description": "Report",
"row_id": 1286663,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning per respiratory department protocol. Patient changed from cpap/ps to A/c after s/p cardiac arrest. Settings: A/C 500*20 100% 5 peep. Peep decreased because of low BP. ABG remains acidotic. Please see carevue for further data.\nPlan: Continue with current vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-03 00:00:00.000",
"description": "Report",
"row_id": 1286664,
"text": "ccu nsg progress note.\no:event= episode of hypotension w maps 50's-rxed w ivf bolus total 750ml & dopa gtt. on cvvhdf-pfr reduced to 0. continued borderline hypotension till 2215 w decrease maps 40's-rxed w ivf bolus total 500ml & addition dopa gtt. initially not responsive to pressors-rx w 1 amp epinephrine w subsequent increase in bp, but developed vt w aicd firing x2 & short period of cpr due to pulseless vt. loaded w amiodarone & placed on gtt-subsequently dced due to past hx amiodarone toxicity. contin episodes oh hypotension w maps to low 50's-rxed w addition vassopressin & neosynephrine w weaning & dc of dopa. presently on levo @ 0.5mcg/kg/min, vassopressin @ 2.4u/hr, & neosynephrine @ 5.0mcg/kg/min w maps >60. echo=wo chg. ekg=wo ischemic chges.\n neuro=initially very restless/appearing uncomfortable. versed & fent gtt's @ low dose w effect. presently intermittently responsive, but now following commands. sl moves upper extrem.\n pulm=w episode of hypotension chged from cpap/ps to ac w present settings-500x20 100% +5 w last abg-7.20 33 159 13 -13 w sats upper 90's. breath sounds=deminished throughout. sx-scant tannish secretions. cxr done during episode-unchged from previous.\n cv=remains on pressors x3 w maps >60. wo further episodes of vt off amiodarone.\n gi=presently npo. tf stopped due to deteriorating cardiac status.\n renal=contins on cvvhdf w pfr=0. am bun/creat-106/1.7. see dialysis flow sheet for hrly #'s. am k-4.7. ica 1.0 on cal gluc gtt.\n id=afebrile. abx as ordered.\n skin=unchged. dsgings chged.\nsocial=wife into visit pt. concerned about husbands state. stated \" he wouldn't want to be like this!\" talked about code status-explained difference between dnr & cmo. left stating \"i'll talk to my daughter.\" md called daughter to inform of hypotensive event. daughter called in am & updated-told remains on 3 pressors borderline bp & that overall condition very poor!\n\na:episode of hypotension requiring multiple pressors to maintain maps >60-?cause (cardio verses sepsis). improving bun/creat, but remains approx 11l positive.\n\np:contin present management. wean pressors as tolerated. contin discussion w family re:prognosis & code status. support pt/family as indicated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-03 00:00:00.000",
"description": "Report",
"row_id": 1286665,
"text": "CCU Progress Note:\n\nCardiac status deteriorated as stated in previous nursing note- family called in- Prior to arrival, Pt coded & epi gtt added to vasopressor, neosynephrine and levophed gtt's to maintain MAP 60- family arrived approx 0900- spoke with attending and Pt made DNR/DNI- CVVH D/C'd- AICD turned off- con't on pressors X4 and fentanyl & versed for comfort- had multiple runs of VT with hypotension, until agonal rhythm noted, then asystole- Pt pronounced dead @ 1126am- family with patient @ time of death- belongings given to family- post mortum care done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-30 00:00:00.000",
"description": "Report",
"row_id": 1286652,
"text": "Patient switched to PSV 5/5-.50 with good spt VT and ABG.Patient to rest over night on PS 10.BS with improves aeration.Suctioned for minimal amount of bloody thin secretion.Plan to decrease PS to in AM followed by RSBI measurement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-30 00:00:00.000",
"description": "Report",
"row_id": 1286653,
"text": "CCU NSG NOTE: ALT IN RENAL/CV/SKIN\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile. WBC 21.7 (24.7). Zosyn d/c and vanco changed to level dosing.\nCV: No runs of VT today. Pt conts on lidocaine at 1.5mg/hr. Hr has ranged 80-100 NSR/ST. Lopressor was increased to 37.5 but increased dose has not yet been given. BP stable 110-12-/50-60s. CVP ~. He was K+ and Calcium replaced. His pacer was interrogated and showed he was paced out of VT once early this am.\nHEME: Crit dropped to 19.8 this am. He received 2U PRBCs on days and tolerated them without problem. Repeat crit drawn 2hrs after 2nd unit was in was 27.\nRESP: Pt changed to cpap today and has been tolerating it well. Last gas was drawn on 50%/5 PEEP/ 5 PS with RR 24 and was 7.42/ 37/ 87/ 25/ 0. Breath sounds clearer, decreased at bases. He is suctioned for small amts thick blood streaked sputum. He will have PS increased overnight to rest him. He conts on VAP protocol.\nGI: Pt passing small formed stools. They were G+, but brown and did not appear melanotic. They was some rusty colored mucous with later stools however. He was restarted on nutren/renal tube feeds again at 1500 when it was decided to wait until tomorrow for dialysis line. GI aspirates were all G+ though not obviously so. He conts on PPI.\nRENAL: BUN/Creat stable at 145/2.6. He is protecting his pH. He is voiding ~80-100cc/hr however he is 1250cc pos for the day due to blood and >11liters pos LOS. Plan is for quentin placement tomorrow in IR followed by CVVHD. He conts on anti-rejection meds and steroids.\nENDO: He has not required ss reg insulin.\nSKIN: His skin continue to be a serious problem. changed today. Wound care nurse foam dsg for weeping L neck area. This dsg can be lifted up, the wound looked and then resealed. If needed either aquasel and/or surgigel can be added for greater absorbsion. No tape should be used on skin. Dsg to left knee was moist to dry, but gauze bits were stuck to wound. Area was cleansed and duoderm gel and DSD applied. This should be reassessed by wound ns who will come tomorrow. Both heel done. The L is dry and necrotic, the R however had purple area with softening. DSD applied to both. Dsg to L arm changed-the weeping areas had aquacel applied and dry areas wound gel and adaptic. All were covered with DSD. R arm lasceration fairly dry and wound gel and adaptice were covered with DSD. Both alleyvns were changed. The coccyx area has two pressure areas with yellow slough as well as a number of bleeding skin tears. The upper area is small ulcer with yellow slough and clean edges. Allevyn reapplied to both and edges sealed with hytape. All skin was lubricated with aloevesta moisture barrier cream several times.\nMS: Pts MS has greatly improved. He is having many less of the jerky arm motions. He is following command, squeezing hands and was able to wiggle toes on R, but not left. He denied pain and was able to participate in mouth care. He nodded to daughter. At one point he attempted to pull out ET\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-30 00:00:00.000",
"description": "Report",
"row_id": 1286654,
"text": "CCU NSG NOTE: ALT IN RENAL/CV/SKIN\n(Continued)\n tube. He nodded he wanted it out but seemed to understand the need at present. He was unrestrained much of the day, but is again restrained now. He has received no sedation today and has been awake all day. He denied needing anything, however daughter says he has insomnia and is used to sleeping pill every night.\nSOCIAL: His daughter was in to visit and spoke with Renal attending and Dr called her later. She agrees with plan for dialysis tomorrow.\nA: Tolerating CPAP/2u PRBCs/formed G+ stools\nP: NPO after MN. Plan for dialysis line placement and CVVHD tomorrow. Keep careful I & O. Let pt rest over night. Change position Q 4. Change dsg as needed. Lubricate skin frequently. Cont with VAP protocol. Sedation if necessary to help pt sleep.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1286646,
"text": "CCU Progress Note:\n\nS- intubated\n\nO- see flowsheet for all objective data.\n\nneuro- fentanyl & versed gtts weaned & D/C'd- con't to open eyes only- unable to track or follow simple command- has non-purposeful jerking movements of both upper extremities- unable to lift & hold- no lower extremity movement noted- withdraws to painful stimuli- PERL.\n\ngu- foley draining amber colored urine qs- (+) 1L since 12am- (+) 8.5L LOS- BUN 151 Crea 2.8- blood Ph 7.29 this am- started on NaHCO3 gtt @ 150cc/hr- repeat blood Ph 7.30- seen by renal- plan is to place renal access cath in IR tomorrow & begin CVVHD.\n\nresp- con't on vent AC 550/20/40%/5- last ABG 7.30-27-117-14- lung sounds coarse bilaterally- suctioned for thick tan/blood tinged colored mucous- occassional clot suctioned from mouth- SpO2 93-100%.\n\ncv- Tele: SR-ST with occ to rare PVC- on the monitor, rhythm appears to be A flutter, however EP in to check AICD- rhythm is sinus- HR 97-102- ABP 83-106/49-64 MAPs 57-65- A-line patterned dampened at times- cuff pressure on opposite arm 123-136/53-62 MAPs 73-79 reported to HO- Hct 24.2- K 4.0- Mg 2.5- ion Ca 1.02- lactic acid 1.2\n\ngi- abd soft distended- (+) bowel sounds- NGT clamped- TF D/C'd this am- small amt liq brown stool noted in FIB- glucose range 119- 190.\nno insulin given- Pt is on insulin sliding scale.\n\nId- WBC trending up 24.9 (22.3)- con't on zosyn and vanco- vanco level 23.7 this am- aferile.\n\ndispo- Pt is full code @ present- Dr. called family in for a meeting this evening to discuss code status.\n\nA- Worsening renal status with probable HD tomorrow.\n\nP- con't present management- support family- decrease lidocaine gtt by .5mg every 6hr, until off (Pt started on mexiletine 200mg Po TID).\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1286647,
"text": "REsp CAre\nPt remains intubated on A/C no vent changes made this shift. BLBS slightly course, suctioned for sm-mod amt of thick tan/ blood tinged secretions. Pt continues to have partially compensated met acidosis, bicarb drip given this morning. plan to continue to follow abgs and wean to psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-29 00:00:00.000",
"description": "Report",
"row_id": 1286648,
"text": "Addendum: family in- Pt noted to be responding to wife and daughter- nodding head appropriately to simple questions- opening eyes wide to command- Dr. in- Pt remains a full code- repeat labs done & pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-30 00:00:00.000",
"description": "Report",
"row_id": 1286649,
"text": "CCU progress note 7p-7a\n\nNEURO: difficult to assess mental status. nods head to questions - inconsistent movements of upper extremities - jerking up movements. PERLA 3mm. +cough. + corneals. will not squeeze hands to command.\n\nID: afebrile. on zosyn + vanco. contact precautions for MRSA bacteremia.\n\nRESP: AC 550x20 40% 5 peep. sats >98%. LS coarse. am abg: 7.44/39/95 Sx tan thick secretions. Bicarb gtt x 2L completed over past day/night.\n\nSKIN: poor skin integrity. ecchymotic over chest + extremities, tears easily - skin tears over both arms and hands. aquacel to sites that are still oozing blood. dsd intact to both heels. skin care nurse skin/dsgs today (saw pt yesterday). allevyn dsg to Rt upper back + coccyx ulcer. old sticks on L s/c continue to ooze - aquacell applied over sites w/ opsite - so far contained the ooze of blood overnite. RIJ TLC dsg changed (continues to ooze blood) as well as R radial aline. multipodus boots on. pneumo boots. on kinair bed.\n\nCARDIAC: SR/ST 80-90s o/pvcs - runs of VT 10-20beats after 230am - self limiting. HO notified - lido gtt increased back up to 1.5mg/min (pt was on a slow wean over 24hrs - that now stopped per verbal order by HO). Mexiletine 200mg TID continued. Lido @ 1.5mg/min. Lopressor 25mg po BID. SBP 100-130s overnite. Aline waveform dampens w/ pt moving arm - readjusted multiple times during nite, even w/ armboard + wrist restraints, pt able to damped waveform.\n\nGI/GU: foley patent. good u/o overnite. dk yellow. abd soft, distended. +BS. stooling small amts loose stool w/ formed lumps - guiac pos (visible hemhroids) - FIB leaking - removed. NPO for dialysis line placement.\nENDO: FS QID w/ RISS.\n\nPLAN: plan to go to IR today for dialysis catheter and to start CVVHD. monitor neuro status. pt remains FULL CODE per family meeting yesterday afternoon w/ Dr . restart tube feeds once procedures completed. monitor am labs. dsg changes. skin care nurse consult again today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-30 00:00:00.000",
"description": "Report",
"row_id": 1286650,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains iintubated and fully ventilated on AC settings. No vent changes made during the night. Sxn for thick tan secretions. ABG this AM shows adequate ventilation and oxygenation. RSBI completed on PS 5=33. Plan to wean to PS if tolerates.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-04-30 00:00:00.000",
"description": "Report",
"row_id": 1286651,
"text": "RESPIRATORY CARE NOTES\nPt. remains intubated. Ventilator changes where made from A/C to CPAP w/ PS (). Recent ABG's show adequate ventilation and oxygenation, no significant changes from previous ABG.\n , RTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-01 00:00:00.000",
"description": "Report",
"row_id": 1286655,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventilated on AC settings this AM. Changed back to AC d/t tachypnea, desaturation, and desynchrony, ^^WOB. Sedation issues. Increased FiO2 to 60%, Peep 10 d/t PaO2=69. BLBS at this time are crackles. Plan to keep on full support and increase sedation to lessen WOB and O2 consumption.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-01 00:00:00.000",
"description": "Report",
"row_id": 1286656,
"text": "CCU progress note 7p-7a\n\nEVENTS: after midnite pt overbreathing vent on PS 30s-40s. Temp spike of 101.3 by 2am. Given tylenol 650mg NGT x1 + Pan Cultured. Frequent ectopy PVCs and runs of PVCs since midnite. small amts of versed given per team w/ little effect. 0330am given 1mg versed w/ some effect in decreasing RR. 0415am given Versed 0.5mg + Fentanyl 50mcg IVP w/ good effect on decreasing RR - CCU team aware. Given lasix 80m ivp this morning for coarser/crackle lung sounds. Started on Propofol at 5am. HCT drop from 27 to 25- rec'd 1U PRBCs overnite. am CBC due 8am.\n\nCODE STATUS: FULL CODE.\n\nNEURO: at 8pm, pt would nod yes or no to questions and lifted arms up to command. After 10pm pt would inconsistently nod head, wouldn't move arms to command. 12am not obeying commands. 4am sedated. Versed and Fentanyl prn doses overnite. Started on propofol drip at 0515am.\n\nID: Temp spike 101.3. pan cultured. no standing abx currently. vanco dosed per daily levels. oral care q4h per VAP protocol.\n\nSKIN: multiple skin issues - ecchymotic and paper thin skin - multiple skin tears on arms, heels R>L. skin care nurse - orders for wound care/ in poe and in skin care nurses note. no tape/opsite if possible. allevyn to coccyx ulcer and to R shoulder blade/back ulcer. multipodus boots + pneumoboots on. on kinair bed.\n\nCARDIAC: SR/ST 90s-100s - increased ectopy since midnite - PVCs - runs VT. lytes WNL this morning. elevated temperature at time of increased ectopy and increased RR/effort. Lopressor 37.5mg . Mexiletine 200mg q8h. LIDO 1.5mg/min.\n\nACCESS: RIJ TLC. R radial Aline.\n\nRESP: PS 5/5 at beginning of shift, belly breathing, RT switched pt up to PS 10/5 to rest. Midnite RR went from 25 to 30s-40s. Different modes of ventilation tried - then sedation given w/ slight effect. RR unable to be fixed, ABGs becoming more acidotic. Propofol gtt started w/ better effect. sats dropped from 100s to 92% this morning PO2 68 at 3am - FIO2 increased to 60%(was 50) Peep increased to 10(was 5). 4am abg: 7.33/33/95 - another abg to be obtained at 6am.\n\nGI/GU/ENDO: abd large, distended +BS. stooling small amts w/ turns -loose brown streaked w/ blood - guiac pos. Nutren Renal TF @ GR 35cc/hr - minimal residuals. NGT patent. foley patent - good u/o. lasix 80mg IVP given this morning at 5am. BUN/CR 151/2.7. renal team following. FS QID w/ RISS.\n\n\nPLAN: ?to IR today for dialysis access line ?CVVHD after line placed. monitor resp status/abgs. obtain post transfusion CBC at 8am. monitor HCT later today. sedation for resp rate control. ?wean vent today if no line placed for dialysis. ?another family meeting to discuss code status and dialysis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-01 00:00:00.000",
"description": "Report",
"row_id": 1286657,
"text": "CCU NURSING 1500\nS. NODDING HEAD APPROPRIATELY TO QUESTIONS\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nNEURO/MS: PROPOFOL GTT D/C'D AT 0800 - PT OPENING EYES TO DAUGHTER'S VOICE, MOVING ALL EXTREMITIES ON BED, NODDING HEAD APPROPRIATELY TO QUESTIONS\n\nCV: HR 90'S SR, RARE ECTOPY, LIDO GTT D/C'D AT 1100, CONTINUES ON PO MEXILITENE; BP 80-90'S/SYST ON PROPOFOL, NOW UP TO 120-130/ OFF PROPOFOL\n\nRESP: REMAINS INTUBATED ON 20 PS 10 PEEP, LAST ABG 7.34/35/102 AT 0900; RR 20'S, SUX FOR SM AMTS THICK, BLOOD-TINGED SPUTUM; SATS 95-100%\n\nGI: TUBE FEEDS D/C'D AT 1400 FOR POSSIBLE LINE PLACEMENT IN IR LATER TODAY, OGT REMAINS IN PLACE, NO STOOL,\n\nENDO: RECEIVING SS INSULIN Q 4HOUR - LAST COVERED W/4U REGULAR FOR 201 @ 1300\n\nGU: URINE OUTPUT 80-90CC/HR VIA FOLEY; TO RECEIVE DIALYSIS CATHETER IN IR LATER TODAY OR IN AM FOR INITIATION OF CRRT\n\nSKIN: MULTIPLE SKIN TEARS/DECUBS - ALL DRESSINGS DONE BY SKIN CARE RN TODAY\n\nID: ON IV ZOSYN, TO RECEIVE DOSE VANCOMYCIN X1, AFEB ON DAYS, SPIKE LAST NIGHT\n\nA: STABLE RHYTHM ON MEXILITENE/OFF LIDO IV\n AWAITING LINE PLACEMENT IN IR\n\nP: TUBE FEEDS OFF - KEEP NPO FOR LINE PLAEMENT AND TO INITIATE CRRT\n FOLLOW CULTURES, ASSESSMENTAL STATUS OFF PROPOFOL, DRESSINGS PER SKIN CARE RN, MONITOR HR/RHYTHM, BP, INSULIN SS, CONT SUPPPORTIVE CARE, KEEP FAMILY INFORMED ABOUT CONDITION, PLAN OF CARE AS DISCUSSED IN ROUNDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-05-01 00:00:00.000",
"description": "Report",
"row_id": 1286658,
"text": "Patient slept on AC last night with rate of 20 switched to PSV this AM with ps 20 to deliver adequato st VT.ABG on PSV improved.Patient suctioned for moderate amount of small bloody secretion.Treated with Albuterol/Atrovent Q4.In IR for dialysis catheter placement,will keep on PSV over night.BS coarse will continue to follow.\n"
}
] |
50,739 | 132,843 | 69 y/o gentleman with RLL NSCLC and extensive mediastinal lymphadenopathy that is compressing the esophagus, left lower lobe segmental bronchi, and right pulmonary artery; he was admitted to the while he completed his radiation course. The patient did develop atrial fibrillation and rapid ventricular rate that was controlled with Metoprolol. PROBLEM LIST: #. /Hypoxia: New diagnosis of lung cancer with involvement of mediastinum and compression of right pulmonary artery, distal trachea, bilateral mainstem bronchi, and esophagus. Transferred to for expedited XRT and monitoring during therapy. Hypoxia likely multifactorial with right pulmonary artery compression, ? of post-obstructive pneumonia, and airway compression. Pt was given 5 days of XRT to fairly wide area in chest. After few days started having difficulty with substernal chest pain likely to mass effect and post-radiation changes/inflammation. He was also treated with a 7 day course of vanc/unasyn for emperic coverage of post-obstructive pna. All micro culture was negative. DNR/DNI status was established at initial presentation. A palliative care consult was obtained due to the nature of the disease process. Pain control recs were left and followed and a discussion was started about long term plans. Family expressed interest in having pt with son in area with home hospice. Pt expressing interest in going home to . Dr. office called to schedule f/u appointment in case pt stays in area on D/C. | Right lower lobe mass, with associated hilar, infrahilar and mediastinal adenopathy. Occlusive right cephalic venous thrombosis, which does not extend into the deep veins. Occlusive right cephalic venous thrombosis, which does not extend into the deep veins. Consider anterior wallmyocardial infarction of indeterminate age. Compared to tracing #1 atrial fibrillation has now changed to sinusrhythm.TRACING #2 Right apical nodules, 4:47 are most likely representing scarring. Right lower lobe mass compatible with known malignancy is unchanged measuring 3.4 x 3.6 cm. The upper portion of the right hilar lymph node is 3.0 x 2.1 cm, 2:35, unchanged. The left paraortic lymph node is 3.0 x 2.9 cm . Extensive mediastinal, hilar lymphadenopathy involving the entire mediastinum and hila bilaterally, with minimal change within the right hilum compared to prior study. Hilar lymph node on the right is 3.3 x 1.8, 2:37, and appears to be slightly decreased compared to prior study, 3.6 x 2.4. FINDINGS: As compared to the previous radiograph, the pre-existing left basal pleural effusion has mildly decreased in extent. The left pulmonary artery is compressed by the subcarinal lymph node up to minimal patency still present, 2:31. Lymph nodes in the anterior mediastinum and right paracardiac fat are multiple, unchanged. Bilateral pleural effusion, unchanged. The right internal jugular, subclavian, axillary, brachial and basilic veins are patent. The mid portion of SVC is significantly narrowed by the anterior mass, 2:22 with the pinpoint appearance, findings that might suggest the clinical presence of SVC syndrome, although no appreciable collaterals are demonstrated, thus potentially there is enough flow to sustain. A moderate left pleural effusion and basilar consolidation is present. FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. Assess for thrombosis. In addition to right main pulmonary artery there is also significant posterior compression with questionable invasion of the left atrium, 2:38, unchanged. Esophagus is narrowed and inseparable from the lymphadenopathy , in particular in the subcarinal aspect. The bulk of lymphadenopathy located in the anterior mediastinum is 10 x 7.7 cm, 2:24, not significantly changed as compared to prior radiograph. Sinus tachycardia, rate 105. Doppler waveforms from augmentation and respiratory variation are blunted, likely secondary to the known central compression from the known tumor masses. A small oval avascular fluid collection is seen in the left popliteal fossa, likely representing a small cyst. Lytic lesion with soft tissue component is seen in L1, with cortical breakthrough, 2:63, 2.0 cm in size. There is associated mediastinar, hilar and infrahilar adenopathy, much worse on the right. The adjacent large lymph node in the right upper anterior mediastinum, 2:28 is 3.6 x 3.5 cm. Sinus tachycardia. Sinus tachycardia. The more proximal portion of the cephalic vein is compressible and patent but demonstrates only minimal flow. AP UPRIGHT RADIOGRAPH OF THE CHEST: The right costophrenic angle is excluded from the field of view. Unchanged size of the cardiac silhouette. Small cyst seen in the left popliteal fossa. Please eval for thrombus. Multiple mesenteric lymph nodes, 2:73 are noted most likely representing involvement by disease. There is an occlusive thrombus in the distal right cephalic vein that extends up to the mid-upper arm level. TECHNIQUE: Color and -scale son was performed on the right upper extremity. Smaller lytic areas are scattered and it is unclear if represent metastatic involvement or osteopenia. Right lower lobe mass is 4.5 x 3.5 cm in diameter, 2:46, unchanged. Status post PEG insertion due to significant compromise of the esophagus by lymphadenopathy. Leftward precordial R wave transition point may be normalvariant. Interval increase in pericardial effusion is noted, small-to-moderate. COMPARISON: CT . Compared to the previous tracing of atrialfibrillation is new.TRACING #1 The imaged portion of the upper abdomen demonstrates inserted percutaneous gastrostomy most likely due to compromise of the esophagus by extensive mediastinal lymphadenopathy. Please eval for tumor extent/involvement. No deep vein thrombosis in the right upper extremity. No deep vein thrombosis in the right upper extremity. Hypodense lesion in the pancreas, 2:70 is seen, 11 mm in diameter. Hypodense pancreatic lesion, significance is unknown, might represent IPMN or involvement of the pancreas by metastatic process as well. Sinus rhythm with frequent atrial premature beats with atrial bigeminalpattern. The trachea is patent. Narrowing of the left lower lobe segmental bronchi is present with subsequent atelectasis by mediastinal lymphadenopathy. TECHNIQUE: MDCT of the chest was obtained after administration of IV contrast. The mass in the right lower lung as well as the extensive predominantly right mediastinal masses are unchanged in extent. Compared to the previoustracing of no diagnostic interval change. Poor R waveprogression in leads V1-V4 with late transition. Large mass of the right adrenal is 4.0 x 3.0 cm in size. Right lower lobe mass, unchanged. Compared to the previous tracing of no change. The lymphadenopathy encases aorta, right main pulmonary artery and SVC as described in details in the body of the report. Moderate left pleural effusion and basilar consolidation, which could reflect atelectasis and/or pneumonia in the right clinical setting. Extensive mediastinal bulky confluent lymphadenopathy is severe as well as involvement of the both hila, right more than left. Multiple mesenteric lymph nodes most likely representing a similar process. Metastasis involvement of L1 by lytic lesion with soft tissue component. DiffuseST-T wave changes. (Over) 4:47 PM CT CHEST W/CONTRAST Clip # Reason: ?tumor involvement of esophagus, trachea, and pulmonary arte Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) 8. | 10 | [
{
"category": "Radiology",
"chartdate": "2166-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151480,
"text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with lung cancer ?post obstuctive pneumonia, increased hypoxia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Lung cancer, status post post-obstructive pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing left basal\n pleural effusion has mildly decreased in extent. Otherwise, there is no\n relevant change. The mass in the right lower lung as well as the extensive\n predominantly right mediastinal masses are unchanged in extent. No evidence\n of newly occurred focal parenchymal opacities. Unchanged size of the cardiac\n silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151284,
"text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 69 year old man with RLL lung CA; large mass; please evaluat\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with RLL lung CA; large mass; please evaluate for pneumonia,\n effusion\n REASON FOR THIS EXAMINATION:\n 69 year old man with RLL lung CA; large mass; please evaluate for pneumonia,\n effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right lower lobe cancer; evaluate for effusion, pneumonia.\n\n COMPARISON: CT .\n\n AP UPRIGHT RADIOGRAPH OF THE CHEST: The right costophrenic angle is excluded\n from the field of view. A moderate left pleural effusion and basilar\n consolidation is present. Right lower lobe mass compatible with known\n malignancy is unchanged measuring 3.4 x 3.6 cm. There is associated\n mediastinar, hilar and infrahilar adenopathy, much worse on the right. There\n is no pneumothorax or pulmonary edema. Heart size is normal.\n\n IMPRESSION:\n 1. Moderate left pleural effusion and basilar consolidation, which could\n reflect atelectasis and/or pneumonia in the right clinical setting.\n\n 2. Right lower lobe mass, with associated hilar, infrahilar and mediastinal\n adenopathy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-07-26 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1152095,
"text": " 6:02 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ?THROMBIS/SWELLING\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with NSCLC known to have SVC involvement; has RUE swelling.\n Please eval for thrombus.\n REASON FOR THIS EXAMINATION:\n ?thrombus\n ______________________________________________________________________________\n WET READ: ENYa SUN 6:38 AM\n 1. Occlusive right cephalic venous thrombosis, which does not extend into the\n deep veins.\n 2. No deep vein thrombosis in the right upper extremity.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old man, with non-small-cell lung cancer, with known SVC\n encroachment, now with right upper extremity swelling. Assess for thrombosis.\n\n COMPARISON: None.\n\n TECHNIQUE: Color and -scale son was performed on the right upper\n extremity. There is an occlusive thrombus in the distal right cephalic vein\n that extends up to the mid-upper arm level. The more proximal portion of the\n cephalic vein is compressible and patent but demonstrates only minimal flow.\n\n The right internal jugular, subclavian, axillary, brachial and basilic veins\n are patent. Doppler waveforms from augmentation and respiratory variation are\n blunted, likely secondary to the known central compression from the known\n tumor masses.\n\n IMPRESSION:\n 1. Occlusive right cephalic venous thrombosis, which does not extend into the\n deep veins.\n 2. No deep vein thrombosis in the right upper extremity.\n\n Dr. has discussed the finding to the primary team, Dr. \n at 7:50 p.m. shortly after the completion of the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-07-22 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1151352,
"text": " 12:49 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: HYPOXEMIA, HX OF CANCER, RULE OUT DVT\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with new diagnosis NSCLC and increasing hypoxemia. Would like\n to assess presence of DVT\n REASON FOR THIS EXAMINATION:\n rule out DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 69-year-old man with hypoxemia, evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, superficial femoral, popliteal and tibial veins. There is\n normal flow, compression and augmentation seen in all of the vessels.\n\n A small oval avascular fluid collection is seen in the left popliteal fossa,\n likely representing a small cyst. This collection measures 1.3 x 2.8\n x 1.4 cm.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg. Small \n cyst seen in the left popliteal fossa.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-07-25 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1151951,
"text": " 4:47 PM\n CT CHEST W/CONTRAST Clip # \n Reason: ?tumor involvement of esophagus, trachea, and pulmonary arte\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with lung cancer with trachea/esophagus/pulm artery, now on\n radiation (3 days). Please eval for tumor extent/involvement.\n REASON FOR THIS EXAMINATION:\n ?tumor involvement of esophagus, trachea, and pulmonary arteries?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with lung cancer and\n tracheoesophageal pulmonary artery involvement, after radiation for three\n days.\n\n COMPARISON: Outside study from .\n\n TECHNIQUE: MDCT of the chest was obtained after administration of IV\n contrast. Axial images were reviewed in conjunction with coronal and sagittal\n reformats.\n\n Extensive mediastinal bulky confluent lymphadenopathy is severe as well as\n involvement of the both hila, right more than left. The bulk of\n lymphadenopathy located in the anterior mediastinum is 10 x 7.7 cm, 2:24, not\n significantly changed as compared to prior radiograph. The adjacent large\n lymph node in the right upper anterior mediastinum, 2:28 is 3.6 x 3.5 cm. The\n left paraortic lymph node is 3.0 x 2.9 cm . Large subcarinal mass is 5.1 x\n 5.8, unchanged since the prior study. Hilar lymph node on the right is 3.3 x\n 1.8, 2:37, and appears to be slightly decreased compared to prior study, 3.6 x\n 2.4. The upper portion of the right hilar lymph node is 3.0 x 2.1 cm, 2:35,\n unchanged. The mid portion of SVC is significantly narrowed by the anterior\n mass, 2:22 with the pinpoint appearance, findings that might suggest the\n clinical presence of SVC syndrome, although no appreciable collaterals are\n demonstrated, thus potentially there is enough flow to sustain. Invasion of\n SVC at that location, 2:22 cannot be excluded. The extensive mediastinal\n lymphadenopathy encases completely the anterior portion of aortic arch and\n significant amount of ascending aorta. The left pulmonary artery is\n compressed by the subcarinal lymph node up to minimal patency still present,\n 2:31. In addition to right main pulmonary artery there is also significant\n posterior compression with questionable invasion of the left atrium, 2:38,\n unchanged. Pericardial effusion is small, increased since the prior study.\n\n The trachea is patent. The main bronchi are patent as well as the lobar and\n segmental bronchi. Narrowing of the left lower lobe segmental bronchi is\n present with subsequent atelectasis by mediastinal lymphadenopathy. Bilateral\n pleural effusions have minimally increased in the interim but there is no\n change in bibasilar atelectasis. Right lower lobe mass is 4.5 x 3.5 cm in\n diameter, 2:46, unchanged. Esophagus is narrowed and inseparable from the\n lymphadenopathy , in particular in the subcarinal aspect.\n\n (Over)\n\n 4:47 PM\n CT CHEST W/CONTRAST Clip # \n Reason: ?tumor involvement of esophagus, trachea, and pulmonary arte\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Severe centrilobular emphysema mostly affecting the upper lobes. Right apical\n nodules, 4:47 are most likely representing scarring. There are several\n additional areas of bronchial wall thickening and small pulmonary nodules.\n Lymph nodes in the anterior mediastinum and right paracardiac fat are\n multiple, unchanged.\n\n The imaged portion of the upper abdomen demonstrates inserted percutaneous\n gastrostomy most likely due to compromise of the esophagus by extensive\n mediastinal lymphadenopathy. The patient is after cholecystectomy and surgery\n at the area of left adrenal. Hypodense lesion in the pancreas, 2:70 is seen,\n 11 mm in diameter. There is also surgery of the left kidney with an hypodense\n fat-density lesion seen that potentially might be related to prior surgery or\n represent angiomyolipoma. Multiple mesenteric lymph nodes, 2:73 are noted\n most likely representing involvement by disease. Large mass of the right\n adrenal is 4.0 x 3.0 cm in size.\n\n Lytic lesion with soft tissue component is seen in L1, with cortical\n breakthrough, 2:63, 2.0 cm in size. Smaller lytic areas are scattered and it\n is unclear if represent metastatic involvement or osteopenia. No posterior\n involvement of the spinal canal is seen on the current study.\n\n IMPRESSION:\n\n 1. Extensive mediastinal, hilar lymphadenopathy involving the entire\n mediastinum and hila bilaterally, with minimal change within the right hilum\n compared to prior study. The lymphadenopathy encases aorta, right main\n pulmonary artery and SVC as described in details in the body of the report.\n Interval increase in pericardial effusion is noted, small-to-moderate.\n\n 2. Right lower lobe mass, unchanged.\n\n 3. Bilateral pleural effusion, unchanged.\n\n 4. Large right adrenal mass, no comparison with prior studies is available\n and this area was not included on the prior outside study.\n\n 5. Multiple mesenteric lymph nodes most likely representing a similar\n process.\n\n 6. Hypodense pancreatic lesion, significance is unknown, might represent IPMN\n or involvement of the pancreas by metastatic process as well.\n\n 7. Status post PEG insertion due to significant compromise of the esophagus\n by lymphadenopathy.\n\n (Over)\n\n 4:47 PM\n CT CHEST W/CONTRAST Clip # \n Reason: ?tumor involvement of esophagus, trachea, and pulmonary arte\n Admitting Diagnosis: LUNG CANCER;AIRWAY OBSTRUCTION\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 8. Metastasis involvement of L1 by lytic lesion with soft tissue component.\n No involvement of posterior endplate and spinal canal is seen at this point.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-07-31 00:00:00.000",
"description": "Report",
"row_id": 236405,
"text": "Sinus tachycardia. Compared to the previous tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-07-26 00:00:00.000",
"description": "Report",
"row_id": 236406,
"text": "Sinus tachycardia, rate 105. Low voltage in the limb leads. Poor R wave\nprogression in leads V1-V4 with late transition. Compared to the previous\ntracing of no diagnostic interval change. Consider anterior wall\nmyocardial infarction of indeterminate age.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-07-25 00:00:00.000",
"description": "Report",
"row_id": 236407,
"text": "Sinus rhythm with frequent atrial premature beats with atrial bigeminal\npattern. Compared to tracing #1 atrial fibrillation has now changed to sinus\nrhythm.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2166-07-24 00:00:00.000",
"description": "Report",
"row_id": 236408,
"text": "Baseline artifact. Atrial fibrillation with rapid ventricular response. Diffuse\nST-T wave changes. Compared to the previous tracing of atrial\nfibrillation is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2166-07-22 00:00:00.000",
"description": "Report",
"row_id": 236409,
"text": "Sinus tachycardia. Leftward precordial R wave transition point may be normal\nvariant. No previous tracing available for comparison.\n\n"
}
] |
12,742 | 132,422 | She was seen and evaluated in the Emergency Department and given her peri-neurologic deficit, Solu-Medrol protocol was instituted. She was bolused and placed on a drip and a Emergency Neurosurgical consultation was held. The patient was found to be tender around the L1 area and the midline of the back and was weakest at the hip flexors on both sides with a 2 plus upper extremity reflexes and 1 to 2 plus lower extremity. Recommendations from me to continue with the Solu-Medrol drip with monitoring of her fingersticks and obtain an MRI of her thoracolumbar spine. This was obtained and it showed no evidence of fracture or spinal cord injury. However, there was a congenital anomaly of the L5 facet joint on the right with no associated herniated disc, no cauda equina syndrome either. The patient was seen by the neurosurgical attending who felt that she did not have any acute neurosurgical issues and the patient was cleared to be off log roll and out of bed. Her C-spine was clear clinically on hospital day number 1. She was switched to oral pain medication and on neurosurgery recommendations placed on Valium to relieve back spasm. She was afebrile and otherwise, hemodynamically stable and able to ambulate without assistance and was deemed stable for discharge to home. | IMPRESSION: No thoracic spine fracture. TECHNIQUE: Axial non-contrast helical scanning of the lumbar spine was performed without IV contrast. CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases are clear without evidence of effusions, nodules, or opacities. There is associated deformity of the spine and vacuum degenerative changes are seen in the right SI joint which is not widened. The alignment of the component vertebrae is normal without evidence of listhesis. TECHNIQUE: Axial noncontrast helical scanning of the cervical spine was performed without IV contrast. No intra-abdominal injury. IMPRESSION: No evidence of an acute intracranial pathologic process. No thoracic spine fractures are identified. No disc herniations are identified. No paraspinal abnormalities are identified. CT OF THE HEAD WITHOUT IV CONTRAST: There is no evidence of intra or extraaxial hemorrhage. FINDINGS: No disc, vertebral or paraspinal abnormalities are seen. No definite fractures are identified. PELVIS AP: There are no fractures or dislocations. There are no pleural effusions. No surrounding soft tissue abnormalities are noted. TECHNIQUE: Noncontrast CT exam of the head. FINDINGS: There is normal alignment of the thoracic vertebral bodies. There is no loss of height of vertebral bodies or intervertebral disc spaces. There is no mesenteric or retroperitoneal lymph adenopathy. TECHNIQUE: Multiplanar T1 and T2 weighted images along with STIR images were obtained without IV contrast. There is no other disc, vertebral or paraspinal abnormality seen. No other fractures or dislocations are present. No evidence of fracture or subluxation. There is no sign of fracture or abnormal alignment of the component vertebrae. IMPRESSION: Normal cervical spine. The spinal canal appears normal. There is no loss of vertebral body or disk height. The ventricles, cisterns and sulci are unremarkable, without effacement. The superior facet arises from the S2 segment, with no osseous attachment to S1. The surrounding soft tissue and osseous structures are unremarkable. There is no pelvic or inguinal lymph adenopathy. No other abnormalities identified. There is no evidence of increased signal on the STIR sequences to suggest edema. The visualized soft tissues, osseous structures and paranasal sinuses are unremarkable. The paraspinal soft tissues are within normal limits. No other fractures or abnormal alignment of the component vertebrae is seen. On the left at this level the facet joint is coronaly oriented, and demonstrates mild degenerative change, but otherwise appears normal. CHEST AP: The heart size, mediastinal and hilar contours are unremarkable. CT is not able to provide any intrathecal detail. There is no mass effect or shift of the midline structures. The visualized outline of the thecal sac appears unremarkable. IMPRESSION: Anomalous right lumbosacral facet joint as described above. REASON FOR THIS EXAMINATION: eval for spinal cord injury No contraindications for IV contrast FINAL REPORT INDICATION: Status post fall down 13'. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, distal ureters, uterus and adnexa are unremarkable. The spinal cord is normal in signal intensity. The pulmonary vasculature is normal. j collar on.solumedrol gtt at 5.4mg/kg/hrcv:sbp 110s.sb->sr,hr 45-65,slightly arrhythmic.no ectopy noted.pedal pulses 3+.resp:sao2>95% on room air.ls clear throughout.gi:soft abd but c/o pain to lower quadrants upon palpation.+bs. The pelvic loops of small and large bowel are normal. IMPRESSION: Anomalous right L5-S1 facet joint, likely congenital variant. The stomach and abdominal loops of small and large bowel are unremarkable. IMPRESSION: 1 Possible fracture of the right pars interarticularis of the L5 vertebra. Signal intensity of the discs are normal. FINDINGS: Redemonstrated is an anomaly of the facet joint of the L5-S1 level on the right, likely a congenital variant. There is no free air or free fluid present. There is no free air or free fluid present. FINDINGS: There an anomaly of the facet joint at L5-S1 on the right. Sub-cutaneous air is seen in the right buttock, probably from a recent injection. Lower extremity weakness and decreased sensation. Likely an old injury WET READ VERSION #1 FINAL REPORT (REVISED) *ABNORMAL! 12:38 AM MR THORACIC SPINE; MR L SPINE SCAN Clip # Reason: 24 Y/O FEMALE, S/P 13' FALL, NOW W/ LE WEAKNESS, DECREASED SENSATION. Possible fracture of the L5 post elements on the right side FINAL REPORT *ABNORMAL! Sub cutaneous right buttock air. There joint itself is deformed, perhaps due to old trauma, or abnormal stresses arising from the anatomic anomaly. Vacuum phenomenon is seen in the right SI joint. This is a re-dictation, the initial report was lost and the images have been resubmitted for interpretation. The liver, gallbladder, spleen, pancreas, adrenals, kidneys and proximal ureters are normal. Sagittal and coronal reconstructions were obtained. Sagittal and coronal reconstructions were obtained. Within the superior T6 vertebral body there is a well defined focus of T1 and T2 signal hyperintensity most likely representing hemangioma. 4:00 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: eval for intraabdominal injury Field of view: 36 Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 24 year old woman with s/p fall down 13 steps REASON FOR THIS EXAMINATION: eval for intraabdominal injury No contraindications for IV contrast WET READ: AZm TUE 7:53 PM No abdominal or pelvic pathology. | 8 | [
{
"category": "Radiology",
"chartdate": "2113-06-27 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 827771,
"text": " 4:00 PM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with s/p fall down 13 steps\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm TUE 8:06 PM\n Spondylolysis L5 right side. Likely an old injury\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: Fall. Pain.\n\n TECHNIQUE: Axial non-contrast helical scanning of the lumbar spine was\n performed without IV contrast. Sagittal and coronal reconstructions were\n obtained.\n\n FINDINGS: There an anomaly of the facet joint at L5-S1 on the right. The\n superior facet arises from the S2 segment, with no osseous attachment to S1.\n There joint itself is deformed, perhaps due to old trauma, or abnormal\n stresses arising from the anatomic anomaly. On the left at this level the\n facet joint is coronaly oriented, and demonstrates mild degenerative\n change, but otherwise appears normal. Vacuum phenomenon is seen in the right\n SI joint. There is no other disc, vertebral or paraspinal abnormality seen. No\n other fractures or abnormal alignment of the component vertebrae is seen. CT\n is not able to provide any intrathecal detail. The visualized outline of the\n thecal sac appears unremarkable.\n\n IMPRESSION: Anomalous right lumbosacral facet joint as described above. No\n evidence of fracture or subluxation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-27 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 827772,
"text": " 4:00 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for intraabdominal injury\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with s/p fall down 13 steps\n REASON FOR THIS EXAMINATION:\n eval for intraabdominal injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm TUE 7:53 PM\n No abdominal or pelvic pathology.\n Possible fracture of the L5 post elements on the right side\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Fall.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n lung bases through the symphysis pubis. 150 cc of IV Optiray was administered\n due to the trauma protocol.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases are clear without evidence\n of effusions, nodules, or opacities. The liver, gallbladder, spleen,\n pancreas, adrenals, kidneys and proximal ureters are normal. The stomach and\n abdominal loops of small and large bowel are unremarkable. There is no\n mesenteric or retroperitoneal lymph adenopathy. There is no free air or free\n fluid present.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder, distal ureters,\n uterus and adnexa are unremarkable. The pelvic loops of small and large bowel\n are normal. There is no pelvic or inguinal lymph adenopathy. There is no\n free air or free fluid present.\n\n Sub-cutaneous air is seen in the right buttock, probably from a recent\n injection.\n\n There is a possible fracture of the pars interarticularis of the L5 vertebra\n on the right side. There is associated deformity of the spine and vacuum\n degenerative changes are seen in the right SI joint which is not widened. No\n other fractures or dislocations are present.\n\n IMPRESSION:\n\n 1 Possible fracture of the right pars interarticularis of the L5 vertebra.\n Given other degenerative changes this may be an old injury. Evaluation with\n dedicated CT/MR views is recommended for more optimal\n assesment. No intra-abdominal injury.\n\n 2. Sub cutaneous right buttock air. Has this patient had a recent injection?\n\n\n (Over)\n\n 4:00 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval for intraabdominal injury\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-27 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 827761,
"text": " 3:19 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: eval for fx, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with\n REASON FOR THIS EXAMINATION:\n eval for fx, ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n CHEST AP: The heart size, mediastinal and hilar contours are unremarkable.\n The lungs are clear. There are no pleural effusions. The pulmonary\n vasculature is normal. The surrounding soft tissue and osseous structures are\n unremarkable.\n\n PELVIS AP: There are no fractures or dislocations. Joint spaces are\n preserved. No surrounding soft tissue abnormalities are noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-27 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 827769,
"text": " 3:58 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with s/p fall down 13 steps\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AZm TUE 6:33 PM\n Normal\n ______________________________________________________________________________\n PRELIMINARY REPORT\n INDICATION: Fall. Pain.\n\n TECHNIQUE: Axial noncontrast helical scanning of the cervical spine was\n performed without IV contrast. Sagittal and coronal reconstructions were\n obtained.\n\n FINDINGS: No disc, vertebral or paraspinal abnormalities are seen. There is no\n sign of fracture or abnormal alignment of the component vertebrae.\n\n IMPRESSION: Normal cervical spine.\n\n\n DR. \n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-27 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 827770,
"text": " 3:59 PM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with s/p fall down 13 steps\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 24-year-old female S/P fall down 13 steps evaluate for fracture.\n\n This is a re-dictation, the initial report was lost and the images have been\n resubmitted for interpretation.\n\n TECHNIQUE: Axial images were performed through the thoracic spine. Sagittal\n and coronal reformatted images were obtained.\n\n FINDINGS: There is normal alignment of the thoracic vertebral bodies. There\n is no loss of vertebral body or disk height. No thoracic spine fractures are\n identified. The spinal canal appears normal. The paraspinal soft tissues are\n within normal limits. In the visualized lungs there is calcified granuloma\n in the right lung base there is another calcified granuloma in the right lung\n apex.\n\n IMPRESSION: No thoracic spine fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-28 00:00:00.000",
"description": "MR THORACIC SPINE",
"row_id": 827804,
"text": " 12:38 AM\n MR THORACIC SPINE; MR L SPINE SCAN Clip # \n Reason: 24 Y/O FEMALE, S/P 13' FALL, NOW W/ LE WEAKNESS, DECREASED SENSATION.\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman s/p fall down 13 feet w/ lower extremity weakness, decreased\n sensation.\n REASON FOR THIS EXAMINATION:\n eval for spinal cord injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall down 13'. Lower extremity weakness and\n decreased sensation.\n\n COMPARISON: CT of the lumbar spine from .\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images along with STIR images were\n obtained without IV contrast.\n\n FINDINGS: Redemonstrated is an anomaly of the facet joint of the L5-S1 level\n on the right, likely a congenital variant. No definite fractures are\n identified. There is no evidence of increased signal on the STIR sequences to\n suggest edema. The spinal cord is normal in signal intensity. No disc\n herniations are identified. The alignment of the component vertebrae is\n normal without evidence of listhesis. There is no loss of height of vertebral\n bodies or intervertebral disc spaces. Signal intensity of the discs are\n normal. Within the superior T6 vertebral body there is a well defined focus\n of T1 and T2 signal hyperintensity most likely representing hemangioma. No\n paraspinal abnormalities are identified.\n\n IMPRESSION:\n\n Anomalous right L5-S1 facet joint, likely congenital variant. No other\n abnormalities identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-06-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 827768,
"text": " 3:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with s/p fall down 13 steps\n REASON FOR THIS EXAMINATION:\n eval for intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CTu TUE 4:41 PM\n negative\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall down 13 steps, assess for intracranial bleed.\n\n TECHNIQUE: Noncontrast CT exam of the head.\n\n CT OF THE HEAD WITHOUT IV CONTRAST: There is no evidence of intra or\n extraaxial hemorrhage. There is no mass effect or shift of the midline\n structures. The ventricles, cisterns and sulci are unremarkable, without\n effacement. The -white matter differentiation is well preserved. The\n visualized soft tissues, osseous structures and paranasal sinuses are\n unremarkable.\n\n IMPRESSION: No evidence of an acute intracranial pathologic process.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2113-06-28 00:00:00.000",
"description": "Report",
"row_id": 1429167,
"text": "npn 7p-7a\n\nadmission note:24 y/o female s/p fall down 13 steps.ambulated after fall but c/o le weakness.no LOC or incontinence but reported hematuria after fall.+cocaine and benzodiazipines per u/a.admitted to tsicu at .to mri w/o event.\n\nneuro:a&ox3,tearful and anxious.perrl,follows commands,mae's but bilat le weaker than ue.c/o tingling of legs but improving overnight.given 4mg morphine iv ~ q1h w/ little effect,c/o pain .given ativan prn.remains on logroll precautions although pt often attempting to sit up in bed or roll on side. j collar on.solumedrol gtt at 5.4mg/kg/hr\n\ncv:sbp 110s.sb->sr,hr 45-65,slightly arrhythmic.no ectopy noted.pedal pulses 3+.\n\nresp:sao2>95% on room air.ls clear throughout.\n\ngi:soft abd but c/o pain to lower quadrants upon palpation.+bs. npo but tolerating small amts of ice chips.on pepcid.\n\ngu:u/o adequate to foley.clear,yellow urine.LR at 80ml/hr.\n\nskin:intact.\n\nid:afebrile.\n\nendo:covered x 2 per ss.\n\nheme:hct stable.pneumo boots on.\n\nsocial:pt lives w/ father and sister.sister called for update and spoke w/ pt per phone.pt denies etoh and drug abuse.pt has 2 y/o son. pt very tearful and anxious.given emotional support and informed of plan of care.\n\na/p: s/p fall.pending ct scan and mri results.clear spine.provide pain control.d/c solumedrol gtt at 1700.\n"
}
] |
21,853 | 109,025 | This is a 58-year-old right-handed woman with metastatic breast cancer to , , here with new seizures, presumably from disease progression. She was transferred to for further care given that her oncology care is here. She was intially confused on overnight and was less so during . She continued to recieve Benadryl prn and in addition received ranitidine, Zyrtec, and Ativan. On the evening of , she became increasingly confused and agitated requiring restraints and a sitter and she was then no longer able to be managed on the floor. She denied dysuria, cough, subj fever, pain. She was noted to have some phlebitis on her left arm at the site of a prior IV and her husband noted an increase in her urinary urgency. She had no chest pain, shortness of breath, N/V/D. Her agitation was possibly due to Benadryl given that she had a similar reaction in the past to phenobarbitol. Most likely etiology was polypharmacy - she has had steroids, multiple anticholinergics (Benadryl, ranitidine, Zyrtec), and Ativan. Also on ddx was non-convulsive status, infection (? UTI, ? cellulitis at old IV site), primary effect of metastases. Her Zyrtec and Benadryl were discontinued. She was monitored in the ICU over the next 48 hrs and was transferred back to the floor after her mental status had drastically improved with the d/c of anticholinergics. | NO STOOL THIS SHIFT.SKIN: INTACT.PLAN: CONT WITH Q2HR NEURO CHECKS. On the postcontrast sequence in today's examination, the previously noted temporal lobe enhancing lesions can be discerned. Comparison was made with the previous MRI of . T1 sagittal, axial and coronal images were obtained following the administration of gadolinium. Will imform team and leave it out for now.Access: Her #22 peripheral IV in intact but blood draws are difficult. The immediate prior MRI was limited by motion. Some clots passed possibly d/t trauma from pt pulling on cath earlier. A small focus of enhancement is again seen adjacent to the occipital of the right lateral ventricle. IMPRESSION: Overall, no significant interval change compared to the previous MRI of . Awaiting full results.Cardiac: ST w/o ectopy possibly d/t agitation, HR 99-120, SBP unable to attain d/t frequent movements, unable to keep pt still for proper . NARRATIVE NOTE:PT WAS DOWN FROM 11R AFTER INCREASED AGITATION AND RESTLESSNESS FOR Q2HR NEURO CHECKS. NORMAL STRENGTH AND SENSATION.RESP: R/A NO SOB NOTED. Nursing Progress Note 0700-1100*Full Code*Access: PIV L ant*Allergies: Fosphenytoin, Codeine, Morphine, Vicodin, ?TapeNeuro: Neuro checks Q2H, no change thus far. PT WAXES AND WANES ON MENTAL STATUS. MONITOR VS AS ABLE AND LABS AND REPLENISH LYTES AS NEEDED. An additional small focus of enhancement is seen adjacent to the occipital of the right lateral ventricle. IMPRESSION: Markedly limited study due to patient motion. There is moderate ventriculomegaly which could be related to atrophy. IVT called and has applied a different clear dressing which is not irritating her skin. REASON FOR THIS EXAMINATION: eval mets, first MRI with motion artifact No contraindications for IV contrast FINAL REPORT EXAM: MRI brain. However, compared on the sagittal and coronal images it remains unchanged. RESTRAINTS REMOVED BUT PT IS CLOSELY WATCHED. FINDINGS: All of the sequences with the exception of the axial FLAIR sequence are so severely limited by patient motion as to be practically diagnostically useless. HAS HX OF BREAST CA WITH METS TO THE BRAIN AND BONE.CV: B/P HAS RANGED FROM 116/67-139-89. Family has been in to visit and say that she is improved from las tnight but still way off her baseline. The left frontal and temporal enhancing lesions are again seen with surrounding edema. On the FLAIR sequence, the extensive white matter edema in the periventricular regions and the left temporal lobe are identified and are similar to the previous examination. Attempted to flush cath w/ 50cc, remains patent. Pt pulled out her foley at . FINDINGS: Again, two small enhancing lesions are seen in the left frontal cortical and subcortical region with mild surrounding edema. Compared to theprevious tracing no significant change. Non-specific ST-T wave changes. PPP BILAT.RESP: ON R/A SAO298-100%. PO pills swallowed also without difficulty.GU: UO adequate via foley. PT PULLED FOLEY CATH OUT YESTERDAY. MICU NPN 11AM-11PM:Neuro: Pt remains with periods of restlessness, agitation, pulls off monitors/equipment at any chance. EEG done this AM w/ nurse stating that she did not see anything significant at first glance. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained before gadolinium. PPP BILAT.NEURO: NO SEIZURE ACT NOTED SINCE ADM TO MICU. Diffuse periventricular and subcortical hyperintensities are seen on the FLAIR and T2-weighted images which could be related to small vessel disease and/or radiation therapy. Hct stable @ 32.7.Resp: LS CTA, O2sat checked periodically @ 98-100% on RA.GI/GU: Foley patent, amber/clear urine 25-240cc/hr. Diffuse hyperintensities in the white matter are again noted which could be related to small vessel disease or radiation therapy. On kepra as ordered.CV: Difficult to get BP due to pt tensing up with the BP cuff inflation. ABD SOFT WITH + BS. No PO food yet, just meds w/ water, tolerated well.ID: Temp 98.0, WBC 5.2, being treated for possible UTI.Psychosocial: husband will be in this afternoon to visit, MD.Dispo: cont to monitor neuro status, and provided ICU treatment as ordered. HAS CT AND LP PENDING. Sinus rhythm. BP 130-150/ 90-100 HR 90-110 sinus rhythm.Resp: O2 sat good on RA, 98%/ Lungs clear. PT WILL HAVE CT READ TODAY WHICH WAS DONE YESTERDAY AND HAVE LP DONE DEPENDING ON RESULTS OF CT. UPDATE FAMILY ON ANY CHANGES IN PT CONDITION. URINE CLEAR YELLOW.GI: ABD SOFT WITH + BS. A&O x3, follows commands, MAE, PERL 3mm/brisk. CSF clear. Exam was compared to prior study of . This lesion on axial images appears slightly larger compared to the prior study. 4 POINT RESTRAINTS, (SOFT) APPLIED AT 0400 AND PT HAS A CONSTANT SITTER IN THE ROOM.GU: FOLEY CATH WAS PLACED WITH NO DIFFICULTY NOTED. DENIES PAIN. UNABLE TO OBTAIN HOURLY B/P AS PT BECOMES VERY AGITATED WITH CUFF AND TENSES ARM RESULTING IN FALSE HIGH OR PULLES CUFF OFF. Persistent white matter abnormal signal and enhancing focus in the left temporal lobe. P0T PULLED MONITOR LEADS OFF NUMEROUS TIMES EVEN WITH RESTRAINTS. FOLLOWS COMMANDS. HAS BEEN INCONT OF URINE SEVERAL TIMES.SKIN: PT IS ALLERGIC TO ADHESIVES AND HAS A SPECIAL DSG FROM THE IV TEAM ON HER POC.PLAN: PT WILL PROBABLY BE CALLED OUT TODAY. FOLLOWS SIMPLE COMMANDS. Urine was bloody due to agitation then pt pulled out her foley. NO SOB NOTED.RR 15-32 DEPENDING ON LEVEL OF AGITATION.NEURO: ALERT ORIENTED TO PERSON/PLACE/TIME BUT IS ALSO VERY CONFUSED AND RESTLESS AND AGITATED.YELLING OUT TO FAMILY MEMBERS. MRI OF THE BRAIN WITH GADOLINIUM. There are no other definite areas of abnormal parenchymal or meningeal enhancement seen. UPDATE HUSBAND ON ANY CHANGES IN PT CONDITION. NO LONGER YELLING OUT OR TRYING TO CLIMB OOB. No seizures noted. LUNGS CLEAR. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2182-04-25 00:00:00.000",
"description": "Report",
"row_id": 1548731,
"text": "NARRATIVE NOTE:\n\nPT WAS DOWN FROM 11R AFTER INCREASED AGITATION AND RESTLESSNESS FOR Q2HR NEURO CHECKS. HAS HX OF BREAST CA WITH METS TO THE BRAIN AND BONE.\n\nCV: B/P HAS RANGED FROM 116/67-139-89. UNABLE TO OBTAIN MANY ACCURATE B/P'S AS PT TOO AGITATED AND TENSING ARMS, ATTEMPTED TO GET B/P ON CALF BUT NOT ABLE. SR/ST WITH HR RANGING FROM 88-125. P0T PULLED MONITOR LEADS OFF NUMEROUS TIMES EVEN WITH RESTRAINTS. PPP BILAT.\n\nRESP: ON R/A SAO298-100%. LUNGS CLEAR THROUGHOUT. NO SOB NOTED.RR 15-32 DEPENDING ON LEVEL OF AGITATION.\n\nNEURO: ALERT ORIENTED TO PERSON/PLACE/TIME BUT IS ALSO VERY CONFUSED AND RESTLESS AND AGITATED.YELLING OUT TO FAMILY MEMBERS. PULLING AT ALL LINES AND CLOTHES. DENIES PAIN. FOLLOWS SIMPLE COMMANDS. IS ABLE TO LIFT AND HOLD ALL EXTREMITIES. PT HAS ATTEMPTED TO HIT AND KICK AT STAFF. PT TRIED TO CLIMB OVER THE BED RAILS SEVERAL TIMES. 4 POINT RESTRAINTS, (SOFT) APPLIED AT 0400 AND PT HAS A CONSTANT SITTER IN THE ROOM.\n\nGU: FOLEY CATH WAS PLACED WITH NO DIFFICULTY NOTED. URINE CLEAR YELLOW.\n\nGI: ABD SOFT WITH + BS. NO STOOL THIS SHIFT.\n\nSKIN: INTACT.\n\nPLAN: CONT WITH Q2HR NEURO CHECKS. MONITOR VS AS ABLE AND LABS AND REPLENISH LYTES AS NEEDED. PT WILL HAVE CT READ TODAY WHICH WAS DONE YESTERDAY AND HAVE LP DONE DEPENDING ON RESULTS OF CT. UPDATE FAMILY ON ANY CHANGES IN PT CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-25 00:00:00.000",
"description": "Report",
"row_id": 1548732,
"text": "Nursing Progress Note 0700-1100\n*Full Code\n\n*Access: PIV L ant\n\n*Allergies: Fosphenytoin, Codeine, Morphine, Vicodin, ?Tape\n\nNeuro: Neuro checks Q2H, no change thus far. Pt remains agitated in bed in 4 pt restraints, attempts to get out of bed and remove IV and Foley. A&O x3, follows commands, MAE, PERL 3mm/brisk. EEG done this AM w/ nurse stating that she did not see anything significant at first glance. Awaiting full results.\n\nCardiac: ST w/o ectopy possibly d/t agitation, HR 99-120, SBP unable to attain d/t frequent movements, unable to keep pt still for proper . Hct stable @ 32.7.\n\nResp: LS CTA, O2sat checked periodically @ 98-100% on RA.\n\nGI/GU: Foley patent, amber/clear urine 25-240cc/hr. Some clots passed possibly d/t trauma from pt pulling on cath earlier. Attempted to flush cath w/ 50cc, remains patent. Lg brown loose stool this AM. No PO food yet, just meds w/ water, tolerated well.\n\nID: Temp 98.0, WBC 5.2, being treated for possible UTI.\n\nPsychosocial: husband will be in this afternoon to visit, MD.\n\nDispo: cont to monitor neuro status, and provided ICU treatment as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-25 00:00:00.000",
"description": "Report",
"row_id": 1548733,
"text": "MICU NPN 11AM-11PM:\nNeuro: Pt remains with periods of restlessness, agitation, pulls off monitors/equipment at any chance. Oriented to name all of the time and orientation to place and time comes and goes. Speech clear. Pt asked for ativan .5mg and was given this PO once at 7PM. LP was performed without incident. CSF clear. Family has been in to visit and say that she is improved from las tnight but still way off her baseline. Pt pulled out her foley at . Will leave it out for now. No seizures noted. On kepra as ordered.\n\nCV: Difficult to get BP due to pt tensing up with the BP cuff inflation. BP 130-150/ 90-100 HR 90-110 sinus rhythm.\n\nResp: O2 sat good on RA, 98%/ Lungs clear. RR 20.\n\nID: afebrile. On cephalexin PO for UTI.\n\nGI: Tolerating small amts PO and taking drinks without difficulty. PO pills swallowed also without difficulty.\n\nGU: UO adequate via foley. Urine was bloody due to agitation then pt pulled out her foley. Will imform team and leave it out for now.\n\nAccess: Her #22 peripheral IV in intact but blood draws are difficult. No BP/IV/Blood draws from her right arm due to old radical mastectomy. POC accessed by RN late this afternoon for meds/IVF and blood draws. Pt immediately became agitated with the pain of the dressing over the insertion site and site became red/imflammed. IVT called and has applied a different clear dressing which is not irritating her skin. Extra dressing are in the room and the IVT will come by to see her tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-26 00:00:00.000",
"description": "Report",
"row_id": 1548734,
"text": "NARRATIVE NOTE:\n\nCV: NSR WITH HR RANGING FROM 85-103.B/P 141/57. UNABLE TO OBTAIN HOURLY B/P AS PT BECOMES VERY AGITATED WITH CUFF AND TENSES ARM RESULTING IN FALSE HIGH OR PULLES CUFF OFF. TEAM IS AWARE. PPP BILAT.\n\nNEURO: NO SEIZURE ACT NOTED SINCE ADM TO MICU. ALERT AND ORIENTED TO 2. PT WAXES AND WANES ON MENTAL STATUS. ANSWERS QUESTIONS APPROPRIATELY BUT WILL ALSO MAKE INAPPROPRIATE STATEMENT. NO LONGER YELLING OUT OR TRYING TO CLIMB OOB. RESTRAINTS REMOVED BUT PT IS CLOSELY WATCHED. FOLLOWS COMMANDS. NORMAL STRENGTH AND SENSATION.\n\nRESP: R/A NO SOB NOTED. LUNGS CLEAR. RR 15-22.\n\nGU/GI: PT ATE PIZZA WITH HUSBAND YESTERDAY WITH NO N/V NOTED. DRINKING WATER WITH NO DIFFICULTY. ABD SOFT WITH + BS. PT PULLED FOLEY CATH OUT YESTERDAY. HAS BEEN INCONT OF URINE SEVERAL TIMES.\n\nSKIN: PT IS ALLERGIC TO ADHESIVES AND HAS A SPECIAL DSG FROM THE IV TEAM ON HER POC.\n\nPLAN: PT WILL PROBABLY BE CALLED OUT TODAY. UPDATE HUSBAND ON ANY CHANGES IN PT CONDITION. HAS CT AND LP PENDING.\n"
},
{
"category": "ECG",
"chartdate": "2182-04-29 00:00:00.000",
"description": "Report",
"row_id": 120045,
"text": "Sinus rhythm. Late transitio. Non-specific ST-T wave changes. Compared to the\nprevious tracing no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-24 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 910523,
"text": " 1:51 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please eval for interval change in brain mets, evidence of r\n Admitting Diagnosis: BREAST CANCER;BRAIN METS;SEIZURE\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with met breast cancer to brain presents s/p grand mal\n seizure\n REASON FOR THIS EXAMINATION:\n please eval for interval change in brain mets, evidence of radiation necrosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Metastatic breast cancer to brain with grand mal\n seizure.\n\n MRI OF THE BRAIN WITH GADOLINIUM.\n\n Exam was compared to prior study of .\n\n FINDINGS: All of the sequences with the exception of the axial FLAIR sequence\n are so severely limited by patient motion as to be practically diagnostically\n useless. On the FLAIR sequence, the extensive white matter edema in the\n periventricular regions and the left temporal lobe are identified and are\n similar to the previous examination. On the postcontrast sequence in today's\n examination, the previously noted temporal lobe enhancing lesions can be\n discerned. It cannot be compared adequately.\n\n IMPRESSION: Markedly limited study due to patient motion. Persistent white\n matter abnormal signal and enhancing focus in the left temporal lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 910833,
"text": " 5:28 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: eval mets, first MRI with motion artifact\n Admitting Diagnosis: BREAST CANCER;BRAIN METS;SEIZURE\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with metastatic breast CA and known mets.\n REASON FOR THIS EXAMINATION:\n eval mets, first MRI with motion artifact\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with metastatic breast cancer and known\n metastasis, for further evaluation. The immediate prior MRI was limited by\n motion.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were obtained before gadolinium. T1 sagittal, axial\n and coronal images were obtained following the administration of gadolinium.\n Comparison was made with the previous MRI of .\n\n FINDINGS: Again, two small enhancing lesions are seen in the left frontal\n cortical and subcortical region with mild surrounding edema. Additionally,\n there is an approximately 15 mm enhancing lesion seen in the left temporal\n lobe with a small adjacent enhancing nodule. This lesion on axial images\n appears slightly larger compared to the prior study. However, compared on the\n sagittal and coronal images it remains unchanged. Therefore, the differences\n on the axial images could be due to slice selection. An additional small\n focus of enhancement is seen adjacent to the occipital of the right\n lateral ventricle. Diffuse periventricular and subcortical hyperintensities\n are seen on the FLAIR and T2-weighted images which could be related to small\n vessel disease and/or radiation therapy. There is no mass effect or midline\n shift seen. There is moderate ventriculomegaly which could be related to\n atrophy. There are no other definite areas of abnormal parenchymal or\n meningeal enhancement seen.\n\n IMPRESSION: Overall, no significant interval change compared to the previous\n MRI of . The left frontal and temporal enhancing lesions are again seen\n with surrounding edema. A small focus of enhancement is again seen adjacent\n to the occipital of the right lateral ventricle. Diffuse\n hyperintensities in the white matter are again noted which could be related to\n small vessel disease or radiation therapy.\n\n\n"
}
] |
78,388 | 101,052 | This is a 72-year-old female with a history of non-small cell lung cancer (diagnosed in ), non-massive hemoptysis (s/p right fifth posterior intercostal artery embolization on ), and recent admission for weakness ( to ). . #. Hypoxia: Most likely related to new LLL infiltrate on chest xray, though other possibilities include aspiration event or health-care associated/community acquired PNA. As such, Ms. was covered broadly with vancomycin/zosyn/levofloxacin. She was also treated for influenza with oseltamivir given her poor pulmonary reserve. A DFA for flu and urine legionella antigen were sent. However, despite the antibiotics and IVF, Ms. continued to be hypoxic. She was given maximal 02 with venti mask, but still had increased work of breathing. After long discussions with family, it was decided to make patient DNR/DNI and not place invasive central venous catheters for pressure support. Throughout the night on patient had increasingly labored breathing and the family was called to the bedside. Ms. eventually passed surrounded by family. . #. Hypotension: This was concerning for sepsis, even though Ms. was initially fluid responsive. She was continued on fluids (as her 02 sats tolerated) and antibiotics. Moreover, she developed a pronounced cardiac arrhythmia toward the end of her life, which also contributed to her poor cardiac output. . #. Urinary tract infection: UTI on admission might also be contributing to septic picture and altered mental status. Again, antibiotic coverage with Vancomycin, Zosyn, Levofloxacin. . #. Somnolence: Multifactorial, with etiologies including sepsis, hypotension, hypoxia, and hypercarbia. An ABG in ED showed respiratory acidosis at 7.30/59/215. Patient was ventilated maximally with venti mask, though no invasive ventilation pursued as above. . #. NSCLC: Patient has survived well beyond the documented expectations of her physicians. Most recently has had course complicated by non-massive hemoptysis s/p embolization. She has been on home hospice for approximately a year. Family understood gravity of the situation and Ms. strength thus far, but still hoped for a miracle. | Placed on NRB with sats in 90s and transferred to for further management on Hypoxemia Assessment: CXR ~ new LLL infiltrate. Placed on NRB with sats in 90s and transferred to for further management on Hypoxemia Assessment: CXR ~ new LLL infiltrate. Placed on NRB with sats in 90s and transferred to for further management on Hypoxemia Assessment: CXR ~ new LLL infiltrate. WBC 7.1 lactate 1.2( from EW) Action: 1L NS bolus given, ABX ASDIR. Hypoxemia Assessment: CXR ~ new LLL infiltrate. WBC 7.1 lactate 1.2( from EW) Action: 1.5L NS bolus given, ABX ASDIR. Status post 1 cycle of carboplatin & gemcitabine9. Status post 1 cycle of carboplatin & gemcitabine9. O2 sats 96% rr~ 20s lungs with rhonchi Action: H flu ruled out, pt with new LLL infiltrate, on antibx` Levofloxacin, Vanco, Zosyn Response: Plan: Lung sounds RLL Lung Sounds: Rhonchi RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Rhonchi Secretions Sputum color / consistency: Tan / Thick Sputum source/amount: Nasotrachial Suction / Small Plan Comments: Pt arrived from on NRBM BS coarse rhonchi all fields with right slightly diminished. Most recently has had course comlicated by non-massive hemoptysis s/p embolization. Assessment and Plan 72 yo female with stg IV NSCLCa with R mainstem bronchus, recent episode of non massive hemoptysis admitted with acute respiratory distress/hypoxia with new LLL PNA. Assessment and Plan 72 yo female with stg IV NSCLCa with R mainstem bronchus, recent episode of non massive hemoptysis admitted with acute respiratory distress/hypoxia with new LLL PNA. - IVF boluses until BP not responsive - Follow UOP - Consider stress dose steroids if hypotension not fluid responsive in initial period given patient's chronic prednisone use #. Hold antihypertensives ICU Care Nutrition: Glycemic Control: Lines / Intubation: 20 Gauge - 02:04 AM 22 Gauge - 02:07 AM Comments: Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: ICU Total time spent: 45 minutes Patient is critically illReferences 1. javascript:command('LHBC','expand') 2. LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE PITUITARY TSH [20] 04:45AM 43* THYROID T3 [21] 04:45AM 73* Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat Comment [22] 11:29PM ART 215* 59* 7.30* 30 1 NOT INTUBA[1] GREEN TOP 1. | 14 | [
{
"category": "Physician ",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 714919,
"text": "Chief Complaint: malaise\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72 yo female with NSCLCa, recent non massive hemoptysis requiring\n \n Hospice for past year\n Today, became acutely ill 2-3 hours after taking new dose of synthroid,\n with production of white frothy secretiions and sats of 50% RA by VNA\n EMS-->99% on NRB, IVF given due to BP 80/palp\n ED: 99.8, P84, 109/60 initially but systolic 70\ns later, P16, 75% RA\n WBC 8, BUN 40\n CXR with new LLL infiltrate\n Received 2 liters IVF, levaquin/zosyn\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 02:02 AM\n Piperacillin/Tazobactam (Zosyn) - 02:02 AM\n Vancomycin - 03:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n prednisone, amiodarone, toprol, pravastatin, morphine SR, fentanyl\n patch, levothyroxine, lasix, ASA\n Past medical history:\n Family history:\n Social History:\n NSCLCa\n 1. Status post thoracotomy with biopsy and partial resection in \n2. Status post radiotherapy to right chest wall + mediastinum\n\n3. Status post 6 cycles of carboplatin/gemcitabine or\ncisplatin/paclitaxel between and \n4. Status post 2 cycles of possible vinorelbine in \n5. Status post 6 cycles of pemetrexed 500 mg/m2 in \n6. Status post erlotinib 150 mg/day .\n7. Status post 2 cycles of docetaxel and cetuximab\nbetween and \n8. Status post 1 cycle of carboplatin & gemcitabine\n9. Status post palliative chest radiotherapy to cGy\n completed in ()\n *R mainstem stent, extrinsic tumor compression by bronch, no obvious\n explanation for mediastinal air\n Pericardial tamponade s/p drainage \n weakness hospitalized 12/14-18/09\n Non massive hemoptysis\n HTN\n GERD\n Hypothyroidism\n Hypercholestolemia\n no hx lung cancer\n Occupation:\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: Fromn , in US since \n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, (+) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:59 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 83 (81 - 83) bpm\n BP: 106/52(65) {106/52(65) - 112/57(71)} mmHg\n RR: 19 (19 - 21) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 59 Inch\n Total In:\n 2,417 mL\n PO:\n TF:\n IVF:\n 417 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,817 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG:7.3/59/215 on NRB\n Physical Examination\n General Appearance: No acute distress, Thin, No(t) Anxious, No(t)\n Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n significant decreased breath sounds on right, coarse with rhonchi/rales\n at left base\n Skin: normal turgor no rashes\n Ext: no peripheral edema, bilateral boots, +clubbing\n Neurologic: Follows simple commands, Responds to: Tactile stimuli,\n Movement: Purposeful, Tone: normal\n Labs / Radiology\n 108\n 41\n [image002.jpg]\n Hematology\n [1][image003.gif] COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [2] 11:25PM\n 8.9\n 3.91*\n 10.4*\n 33.2*\n 85\n 26.5*\n 31.2\n 17.9*\n 358\n [3] 06:15AM\n 8.2\n 3.76*\n 9.9*\n 30.8*\n 82\n 26.4*\n 32.3\n 18.4*\n 319\n [4] 06:40AM\n 7.5\n 3.63*\n 9.6*\n 29.6*\n 82\n 26.4*\n 32.3\n 18.3*\n 312\n [5] 06:10AM\n 8.4\n 3.68*\n 9.6*\n 29.1*\n 79*\n 26.0*\n 33.0\n 17.8*\n 284\n DIFFERENTIAL\n Neuts\n Bands\n Lymphs\n Monos\n Eos\n Baso\n Atyps\n Metas\n [6] 11:25PM\n 84.8*\n 10.8*\n 3.7\n 0.4\n 0.3\n [7][image004.gif] BASIC COAGULATION (PT, PTT, PLT, INR)\n PT\n PTT\n Plt Ct\n INR(PT)\n [8] 11:25PM\n 358\n [9] 11:25PM\n 13.4\n 27.7\n 1.1\n Chemistry\n [10][image004.gif] RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [11] 11:25PM\n 108*\n 40*\n 1.0\n 135\n 5.2*\n 101\n 25\n 14\n ESTIMATED GFR (MDRD CALCULATION)\n estGFR\n [12] 11:25PM\n Using this[1]\n 1. Using this patient's age, gender, and serum creatinine value\n of 1.0,\n Estimated GFR = 55 if non African-American (mL/min/1.73 m2)\n Estimated GFR = 66 if African-American (mL/min/1.73 m2)\n For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2)\n GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [13] 11:25PM\n 196*\n CPK ISOENZYMES\n CK-MB\n cTropnT\n [14] 11:25PM\n <0.01[1]\n [15] 11:25PM\n 2\n 1. <0.01\n CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI\n [16][image004.gif] CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n Cholest\n [17] 06:15AM\n 7.9*\n 3.3\n 2.0\n DIABETES MONITORING\n %HbA1c\n [18] 06:10AM\n 6.4*[1]\n 1. RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS\n THERAPEUTIC ACTION\n LIPID/CHOLESTEROL\n Cholest\n Triglyc\n HDL\n CHOL/HD\n LDLcalc\n [19] 06:10AM\n 181\n 80[1]\n 46\n 3.9\n 119\n 1. LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE\n PITUITARY\n TSH\n [20] 04:45AM\n 43*\n THYROID\n T3\n [21] 04:45AM\n 73*\n Blood Gas\n BLOOD GASES\n Type\n Temp\n Rates\n Tidal V\n PEEP\n FiO2\n O2 Flow\n pO2\n pCO2\n pH\n calTCO2\n Base XS\n Intubat\n Comment\n [22] 11:29PM\n ART\n 215*\n 59*\n 7.30*\n 30\n 1\n NOT INTUBA[1]\n GREEN TOP\n 1. NOT INTUBATED\n WHOLE BLOOD, MISCELLANEOUS CHEMISTRY\n Glucose\n Lactate\n Na\n K\n Cl\n calHCO3\n [23] 11:29PM\n 106*\n 1.2\n 136\n 5.3\n 103\n 28\n Miscellaneous\n T4, FREE, DIRECT DIALYSIS\n [24] 04:45AM\n PND\n Urine\n Hematology\n GENERAL URINE INFORMATION\n Type\n Color\n Appear\n Sp \n [25] 11:30PM\n Yellow\n Clear\n 1.015\n DIPSTICK URINALYSIS\n Blood\n Nitrite\n Protein\n Glucose\n Ketone\n Bilirub\n Urobiln\n pH\n Leuks\n [26] 11:30PM\n NEG\n NEG\n 30\n NEG\n NEG\n NEG\n 0.2\n 7.0\n MOD\n MICROSCOPIC URINE EXAMINATION\n RBC\n WBC\n Bacteri\n Yeast\n Epi\n TransE\n RenalEp\n [27] 11:30PM\n 0\n \n MOD\n NONE\n 0\n [28] 11:30PM\n Other labs: Band:85\n Bronch : left bronchial tree patent, bleeding from underneath\n right main stem bronchus\n CXR: RML/RLL collapse (chronic), new LLL infiltrate\n Chest CT :\n 1. Slight progressive increase in mediastinal emphysema presumably due\n to\n broncho-mediastinal communication associated with the indwelling right\n bronchial stent. No mediastinal abscess or pleural effusion.\n 2. Right bronchial stent is intact and unchanged in position but\n remains\n narrowed by tumor ingrowth or retained secretions, and is the only\n portion of\n the right bronchial tree which is patent. Right upper and/or middle\n lobes\n remain collapsed, infiltrated by tumor from right hilar mass and\n inseparable\n from pleural tumor contiguous with mild invasion of the anterior chest\n wall.\n Extensive sclerosis and smaller regions of lysis in the ribs of the\n right\n chest wall, predominantly anteriorly, could be due to stable treated\n metastases and/or radiation necrosis, particularly in light of severe\n extensive radiation fibrosis and bronchiectasis in the right lung.\n 3. Stable tumor infiltration of minimally aerated right lower lobe. A\n handful of subcentimeter left lung nodules, presumably metastases, are\n either\n stable or only slowly enlarging.\n Assessment and Plan\n 72 yo female with stg IV NSCLCa with R mainstem bronchus, recent\n episode of non massive hemoptysis admitted with acute respiratory\n distress/hypoxia with new LLL PNA. Could represent CAP/HCAP vs\n aspiration. Lack of leukocytosis/left shift might favor the latter.\n Possible impending SIRS physiology with decreased urine\n output/hypotension, unless related to decreased po intake. Plans:\n 1. Broad coverage with vanc/zosyn /levaquin\n 2. Fluid resuscitation to maintain MAP>60, consider stress dose\n steroids\n 3. Could consider CVL if remains persistently hypotensive without\n adequate response to fluids\n 4. Supplemental oxygen\n 5. Hold antihypertensives\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 02:04 AM\n 22 Gauge - 02:07 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n ------ Protected Section ------\n Pt seen and examined on MICU rounds this morning. She required 3.5\n liters fluid resuscitation over the past few hours for hypotension, and\n on repeat physical exam appears more tachypneic, with labored\n breathing, rhonchi and accessory muscle use. Minimal urine output,\n though Cr unchanged.\n Remains on broad abx with vanc/zosyn/levaquin, though MS too poor for\n ostelamavir. Cultures and nasal swab pending. Increase to stress dose\n steroids.\n Interpreter scheduled for this morning to talk to son further pt\n poor outlook and prognosis and goals of care.\n Pt is critically ill.\n An additional 30 minutes critical care time spent.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:04 ------\nReferences\n 1. javascript:command('LHBC','expand')\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_4%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_5%22);\n 7. javascript:command('LHBI','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_6%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_7%22);\n 10. javascript:command('LCBA','expand')\n 11. JavaScript:parent.POPUP(self,%22_WEBTAG=_8%22);\n 12. JavaScript:parent.POPUP(self,%22_WEBTAG=_9%22);\n 13. JavaScript:parent.POPUP(self,%22_WEBTAG=_10%22);\n 14. JavaScript:parent.POPUP(self,%22_WEBTAG=_11%22);\n 15. JavaScript:parent.POPUP(self,%22_WEBTAG=_12%22);\n 16. javascript:command('LCBI','expand')\n 17. JavaScript:parent.POPUP(self,%22_WEBTAG=_13%22);\n 18. JavaScript:parent.POPUP(self,%22_WEBTAG=_14%22);\n 19. JavaScript:parent.POPUP(self,%22_WEBTAG=_15%22);\n 20. JavaScript:parent.POPUP(self,%22_WEBTAG=_16%22);\n 21. JavaScript:parent.POPUP(self,%22_WEBTAG=_17%22);\n 22. JavaScript:parent.POPUP(self,%22_WEBTAG=_18%22);\n 23. JavaScript:parent.POPUP(self,%22_WEBTAG=_19%22);\n 24. JavaScript:parent.POPUP(self,%22_WEBTAG=_20%22);\n 25. JavaScript:parent.POPUP(self,%22_WEBTAG=_21%22);\n 26. JavaScript:parent.POPUP(self,%22_WEBTAG=_22%22);\n 27. JavaScript:parent.POPUP(self,%22_WEBTAG=_23%22);\n 28. JavaScript:parent.POPUP(self,%22_WEBTAG=_24%22);\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 714888,
"text": "Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Nasotrachial Suction / Small\n Plan\n Comments: Pt arrived from on NRBM BS coarse rhonchi all fields with\n right slightly diminished. Placed on .95% high flow with 5L n/c for\n sats of 94%. Nasal swab for flu sent\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714891,
"text": "72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n Today after taking meds developed SOB and frothy white secretions.\n Became lethargic. EMS called sats on RA 50-60%, B/P 80\n In EW B/P in 70\ns, received 2 L NS and started on IV levoquin and\n zosyn. Placed on NRB with sats in 90\ns and transferred to for\n further management.\n Hypoxia\n Assessment:\n Received patient from EW on NRB with sats at mid 90\ns. B/L LS\n rhonchorous. Suctioned for small amnt of tan secretions. Most likely\n related to new LLL infiltrate on chest xray\n Action:\n Placed on NC and high flow neb at 95%, - Influenza DFA sent to rule out\n influenza and empirically started on oseltamivir pending DFA result.\n Started on levoquin/vanc/zosyn for HAP/CAP\n Response:\n Sats remain >90.\n Plan:\n Continue to monitor patients resp status, f/u cx data\n Hypotension\n Assessment:\n Received patient after 2 L NS bolus with B/P 110\ns however shortly\n after b/p in the 80\ns. UOP about 40cc/hr. HR in 80\ns SR no VEA noted.\n No peripheral edema. WBC 7.1 lactate 1.2( from EW)\n Action:\n 1.5L NS bolus given, ABX ASDIR. BC X1 sent\n Response:\n Ongoing\n Plan:\n Continue to monitor patient hemodynamic status, IVF if needed.\n Neuro; patient is Cantonese speaking; however from son the patient is\n currently more awake, oriented and able to communicate her needs.\n Follows commands and tries to help with turns.\n GI: abd soft non tender although the son states that she feels\ntight\n around the waist s/p embolization. NPO for now. Denies nausea/vomiting.\n GU: yellow urine w/sediment via Foley about 40 cc/hr\n Social: per son (HCP) patient is a DNI. ??? DNR. Will need\n interpreter in AM to clarify the status.\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714880,
"text": "72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n Today after taking meds developed SOB and frothy white secretions.\n Became lethargic. EMS called sats on RA 50-60%, B/P 80\n In EW B/P in 70\ns, received 2 L NS and started on IV levoquin and\n zosyn. Placed on NRB with sats in 90\ns and transferred to for\n further management.\n Hypoxia\n Assessment:\n Received patient from EW on NRB with sats at mid 90\ns. B/L LS\n rhonchorous. Suctioned for small amnt of tan secretions. Most likely\n related to new LLL infiltrate on chest xray\n Action:\n Placed on NC and high flow neb at 95%, - Influenza DFA sent to rule out\n influenza and empirically started on oseltamivir pending DFA result.\n Started on levoquin/vanc/zosyn for HAP/CAP\n Response:\n Sats remain >90.\n Plan:\n Continue to monitor patients resp status, f/u cx data\n Hypotension\n Assessment:\n Received patient after 2 L NS bolus with B/P 110\ns however shortly\n after b/p in the 80\ns. UOP about 40cc/hr. HR in 80\ns SR no VEA noted.\n No peripheral edema. WBC 7.1 lactate 1.2( from EW)\n Action:\n 1L NS bolus given, ABX ASDIR. BC X1 sent\n Response:\n Ongoing\n Plan:\n Continue to monitor patient hemodynamic status, IVF if needed.\n Neuro; patient is Cantonese speaking; however from son the patient is\n currently more awake, oriented and able to communicate her needs.\n Follows commands and tries to help with turns.\n GI: abd soft non tender although the son states that she feels\ntight\n around the waist s/p embolization. NPO for now. Denies nausea/vomiting.\n GU: yellow urine w/sediment via Foley about 40 cc/hr\n Social: per son (HCP) patient is a DNI. ??? DNR. Will need\n interpreter in AM to clarify the status.\n"
},
{
"category": "Physician ",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 714874,
"text": "Chief Complaint: Hypoxia\n HPI:\n 72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ). She presents from home today following\n dyspnea at home. Patient reportedly had been found to be confused at\n home with with O2Sat 50% on room air, which then came up to 99% on NRB.\n In the field, intial BP was 80/palp, so patient receive 200 mL NS\n enroute to the ED. son is concerned that patient's new\n medication, levothyroxine, is the reason for presentation since the\n patient became acutely ill 2 hours following the first time she took\n the medicine the morning prior to presentation. Patient was reportedly\n doing well and had breakfast without difficulty, though after taking\n her medication with Ensure was found to have white frothy secretions.\n Vitals upon presentation to the ED were: T 99.8, HR 84, BP 109/60, RR\n 16, O2Sat 75% RA. Patient was given levofloxacin and Zosyn. Family\n refusing translator in the ED. Patient is DNI, though family was not\n ready to have CMO discussion according to ED resident. Prior to\n transfer to the unit, vitals were: T 99.9, HR 73, BP 77/47, RR 12,\n O2Sat 100% NRB.\n REVIEW OF SYSTEMS:\n (+)ve: dyspnea, fatigue, confusion, LE weakness, vomiting\n (-)ve: fever, chills, night sweats, loss of appetite, chest pain,\n palpitations, rhinorrhea, nasal congestion, cough, sputum production,\n hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, nausea, diarrhea,\n constipation, hematochezia, melena, dysuria, urinary frequency, urinary\n urgency, focal numbness, focal weakness, myalgias, arthralgias\n Allergies:\n No Known Drug Allergies\n MEDICATIONS:\n *per discharge on *\n 1) Acetaminophen 325-650 mg PO Q6H:PRN pain\n 2) Amiodarone 200 mg PO DAILY\n 3) Prednisone 5 mg PO DAILY\n 4) Metoprolol Succinate 25 mg PO DAILY\n 5) Pantoprazole 40 mg PO Q24H\n 6) Pravastatin 40 mg PO DAILY\n 7) Ranitidine HCl 150 mg PO HS\n 8) Morphine SR 15 mg PO Q12H\n 9) Docusate Sodium 100 mg PO BID\n 10) Multivitamin PO DAILY\n 11) Aspirin 81 mg PO DAILY\n 12) Ibuprofen 400 mg PO Q8H:PRN pain\n 13) Fentanyl 50 mcg/hr Patch Transdermal Q72H\n 14) Lasix 20 mg PO DAILY\n 15) Levothyroxine 100 mcg PO DAILY\n 17) Potassium Chloride PO\n Past medical history:\n Social History:\n 1) Stage IV NSCLC\n - thoracotomy with biopsy and partial resection ()\n - XRT to right chest wall + mediastinum ()\n - 6 cycles of carboplatin/gemcitabine or cisplatin/paclitaxel (between\n and )\n - 2 cycles of possible vinorelbine ()\n - 6 cycles of pemetrexed 500 mg/m2 ()\n - erlotinib 150 mg/day ( to )\n - 2 cycles of docetaxel 35 mg/m2 and cetuximab 250 mg/m2 weekly between\n and \n - 1 cycle of carboplatin 5 AUC D1 and gemcitabine 1000 mg/m2 D1 of 21\n day cycle in ()\n - palliative chest radiotherapy to cGy completed ()\n 2) Hypertension\n 3) GERD\n 4) Anxiety\n 5) Palpitations\n 6) Hypothyroidism\n 7) Hypercholesterolemia\n 8) s/p resection of colonic polyps\n The patient is originally from . She has been in the United\n States since /. She denies exposure to heavy chemicals of\n asbestos.\n Tobacco: Denies, though was exposed to fumes during her work as a cook\n back in .\n EtOH: Denies\n Illicits: Denies\n Family history:\n non-contributory\n Physical Examination\n VS: T 97.1, HR 81, BP 112/57, RR 21, O2Sat 94% on 95% facemask with 5L\n NC\n GEN: Somnolent\n HEENT: PERRL, EOMI, oral mucosa slightly dry\n NECK: Supple, no \n PULM: Minimal breath sound on right, left side with coarse breath\n sounds and basilar crackles\n CARD: RR, nl S1, nl S2, no M/R/G\n ABD: BS+, soft, NT, ND, non-tympanitic\n EXT: no peripheral edema, significant clubbing of bilateral fingernails\n SKIN: no rashes\n NEURO: Oriented x 3, somnolent, difficult to perform full neuro exam in\n setting of language barrier and somnolence\n Labs / Radiology\n [1][image001.gif] COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [2] 11:25PM\n 8.9\n 3.91*\n 10.4*\n 33.2*\n 85\n 26.5*\n 31.2\n 17.9*\n 358\n [3][image001.gif] DIFFERENTIAL\n Neuts\n Bands\n Lymphs\n Monos\n Eos\n Baso\n Atyps\n Metas\n [4] 11:25PM\n 84.8*\n 10.8*\n 3.7\n 0.4\n 0.3\n [5][image001.gif] BASIC COAGULATION (PT, PTT, PLT, INR)\n PT\n PTT\n Plt Ct\n INR(PT)\n [6] 11:25PM\n 13.4\n 27.7\n 1.1\n [7][image001.gif] RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [8] 11:25PM\n 108*\n 40*\n 1.0\n 135\n 5.2*\n 101\n 25\n 14\n BLOOD GASES\n Type\n pO2\n pCO2\n pH\n [9] 11:29PM\n ART\n 215*\n 59*\n 7.30*\n CT CHEST W/CONTRAST :\n IMPRESSION:\n 1. Slight progressive increase in mediastinal emphysema presumably due\n to broncho-mediastinal communication associated with the indwelling\n right bronchial stent. No mediastinal abscess or pleural effusion.\n 2. Right bronchial stent is intact and unchanged in position but\n remains narrowed by tumor ingrowth or retained secretions, and is the\n only portion of the right bronchial tree which is patent. Right upper\n and/or middle lobes remain collapsed, infiltrated by tumor from right\n hilar mass and inseparable from pleural tumor contiguous with mild\n invasion of the anterior chest wall. Extensive sclerosis and smaller\n regions of lysis in the ribs of the right chest wall, predominantly\n anteriorly, could be due to stable treated metastases and/or radiation\n necrosis, particularly in light of severe extensive radiation fibrosis\n and bronchiectasis in the right lung.\n 3. Stable tumor infiltration of minimally aerated right lower lobe. A\n handful of subcentimeter left lung nodules, presumably metastases, are\n either stable or only slowly enlarging.\n CHEST (PORTABLE AP) Study Date of :\n *my read*\n Interval development of left lower lobe opacity.\n Assessment and Plan\n 72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n #. Hypoxia:\n Most likely related to new LLL infiltrate on chest xray. Possible that\n it is from an aspiration event given history of patient having acute\n decompensation shortly after meal at home prior to presentation.\n Additionally, could be a pneumonia given her multiple presentations to\n health care in the recent past. She should be covered for both HAP and\n CAP. Unlikely to be influenza; however, given her poor pulmonary\n reserve, is reasonable to treat empirically and rule out flu with a\n DFA.\n - Sputum gram stain and culture\n - Check legionella urinary antigen\n - Influenza DFA to rule out influenza\n - Treat empirically with oseltamivir pending DFA result\n - Treat broadly with Vancomycin, Zosyn, Levofloxacin given recent\n healthcare exposure as well as risk of community acquired pathogen\n #. Hypotension:\n Potenial component of hypovolemia, though more concerning for sepsis.\n - IVF boluses until BP not responsive\n - Follow UOP\n - Consider stress dose steroids if hypotension not fluid responsive in\n initial period given patient's chronic prednisone use\n #. Urinary tract infection:\n Patient with mental status changes and a positive U/A for WBCs and\n leukocyte esterase. Should be well-covered with Vancomycin, Zosyn,\n Levofloxacin as above.\n - Follow-up urine culture\n #. Somnolence:\n Most likely related to her hypercarbia as evidenced by ABG in ED\n showing respiratory acidosis with measure of 7.30/59/215.\n - Repeat ABG if acute change in mental status; however, patient's son\n is very clear that they would not want mechanical ventilation\n #. NSCLC:\n Patient has survived well beyond the documented expectations of her\n physicians. Most recently has had course comlicated by non-massive\n hemoptysis s/p embolization. She has been on home hospice for\n approximately a year.\n - Interpreter services to assist in discussion of goals of care and\n code status\n - Contact patient's primary oncologist to inform of her hospitalization\n - Social work consult\n - Contact palliative care ( saw patient in )\n ICU Care\n Nutrition: NPO for now\n Lines:\n 20 Gauge - 02:04 AM\n 22 Gauge - 02:07 AM\n Prophylaxis:\n -DVT ppx with heparin subcutaneous\n -Bowel regimen with colace and senna\n -Pain management with fentanyl patch and MS-contin\n Communication: son, \n status: DNI, though would want attempted CPR.\n Disposition: ICU\nReferences\n 1. javascript:command('LHBC','expand')\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 3. javascript:command('LHBD','expand')\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_4%22);\n 5. javascript:command('LHBI','expand')\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_8%22);\n 7. javascript:command('LCBA','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_10%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_16%22);\n"
},
{
"category": "Physician ",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 714866,
"text": "Chief Complaint: malaise\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72 yo female with NSCLCa, recent non massive hemoptysis requiring\n \n Hospice for past year\n Today, became acutely ill 2-3 hours after taking new dose of synthroid,\n with production of white frothy secretiions and sats of 50% RA by VNA\n EMS-->99% on NRB, IVF given due to BP 80/palp\n ED: 99.8, P84, 109/60 initially but systolic 70\ns later, P16, 75% RA\n WBC 8, BUN 40\n CXR with new LLL infiltrate\n Received 2 liters IVF, levaquin/zosyn\n Patient admitted from: ER\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 02:02 AM\n Piperacillin/Tazobactam (Zosyn) - 02:02 AM\n Vancomycin - 03:17 AM\n Infusions:\n Other ICU medications:\n Other medications:\n prednisone, amiodarone, toprol, pravastatin, morphine SR, fentanyl\n patch, levothyroxine, lasix, ASA\n Past medical history:\n Family history:\n Social History:\n NSCLCa\n 1. Status post thoracotomy with biopsy and partial resection in \n2. Status post radiotherapy to right chest wall + mediastinum\n\n3. Status post 6 cycles of carboplatin/gemcitabine or\ncisplatin/paclitaxel between and \n4. Status post 2 cycles of possible vinorelbine in \n5. Status post 6 cycles of pemetrexed 500 mg/m2 in \n6. Status post erlotinib 150 mg/day .\n7. Status post 2 cycles of docetaxel and cetuximab\nbetween and \n8. Status post 1 cycle of carboplatin & gemcitabine\n9. Status post palliative chest radiotherapy to cGy\n completed in ()\n *R mainstem stent, extrinsic tumor compression by bronch, no obvious\n explanation for mediastinal air\n Pericardial tamponade s/p drainage \n weakness hospitalized 12/14-18/09\n Non massive hemoptysis\n HTN\n GERD\n Hypothyroidism\n Hypercholestolemia\n no hx lung cancer\n Occupation:\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: Fromn , in US since \n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, (+) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:59 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 36.2\nC (97.1\n HR: 83 (81 - 83) bpm\n BP: 106/52(65) {106/52(65) - 112/57(71)} mmHg\n RR: 19 (19 - 21) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 59 Inch\n Total In:\n 2,417 mL\n PO:\n TF:\n IVF:\n 417 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,817 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG:7.3/59/215 on NRB\n Physical Examination\n General Appearance: No acute distress, Thin, No(t) Anxious, No(t)\n Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n significant decreased breath sounds on right, coarse with rhonchi/rales\n at left base\n Skin: normal turgor no rashes\n Ext: no peripheral edema, bilateral boots, +clubbing\n Neurologic: Follows simple commands, Responds to: Tactile stimuli,\n Movement: Purposeful, Tone: normal\n Labs / Radiology\n 108\n 41\n [image002.jpg]\n Hematology\n [1][image003.gif] COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [2] 11:25PM\n 8.9\n 3.91*\n 10.4*\n 33.2*\n 85\n 26.5*\n 31.2\n 17.9*\n 358\n [3] 06:15AM\n 8.2\n 3.76*\n 9.9*\n 30.8*\n 82\n 26.4*\n 32.3\n 18.4*\n 319\n [4] 06:40AM\n 7.5\n 3.63*\n 9.6*\n 29.6*\n 82\n 26.4*\n 32.3\n 18.3*\n 312\n [5] 06:10AM\n 8.4\n 3.68*\n 9.6*\n 29.1*\n 79*\n 26.0*\n 33.0\n 17.8*\n 284\n DIFFERENTIAL\n Neuts\n Bands\n Lymphs\n Monos\n Eos\n Baso\n Atyps\n Metas\n [6] 11:25PM\n 84.8*\n 10.8*\n 3.7\n 0.4\n 0.3\n [7][image004.gif] BASIC COAGULATION (PT, PTT, PLT, INR)\n PT\n PTT\n Plt Ct\n INR(PT)\n [8] 11:25PM\n 358\n [9] 11:25PM\n 13.4\n 27.7\n 1.1\n Chemistry\n [10][image004.gif] RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [11] 11:25PM\n 108*\n 40*\n 1.0\n 135\n 5.2*\n 101\n 25\n 14\n ESTIMATED GFR (MDRD CALCULATION)\n estGFR\n [12] 11:25PM\n Using this[1]\n 1. Using this patient's age, gender, and serum creatinine value\n of 1.0,\n Estimated GFR = 55 if non African-American (mL/min/1.73 m2)\n Estimated GFR = 66 if African-American (mL/min/1.73 m2)\n For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2)\n GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure\n ENZYMES & BILIRUBIN\n ALT\n AST\n LD(LDH)\n CK(CPK)\n AlkPhos\n Amylase\n TotBili\n DirBili\n [13] 11:25PM\n 196*\n CPK ISOENZYMES\n CK-MB\n cTropnT\n [14] 11:25PM\n <0.01[1]\n [15] 11:25PM\n 2\n 1. <0.01\n CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI\n [16][image004.gif] CHEMISTRY\n TotProt\n Albumin\n Globuln\n Calcium\n Phos\n Mg\n UricAcd\n Iron\n Cholest\n [17] 06:15AM\n 7.9*\n 3.3\n 2.0\n DIABETES MONITORING\n %HbA1c\n [18] 06:10AM\n 6.4*[1]\n 1. RECOMMENDATIONS:; <7% GOAL OF THERAPY; >8% WARRANTS\n THERAPEUTIC ACTION\n LIPID/CHOLESTEROL\n Cholest\n Triglyc\n HDL\n CHOL/HD\n LDLcalc\n [19] 06:10AM\n 181\n 80[1]\n 46\n 3.9\n 119\n 1. LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE\n PITUITARY\n TSH\n [20] 04:45AM\n 43*\n THYROID\n T3\n [21] 04:45AM\n 73*\n Blood Gas\n BLOOD GASES\n Type\n Temp\n Rates\n Tidal V\n PEEP\n FiO2\n O2 Flow\n pO2\n pCO2\n pH\n calTCO2\n Base XS\n Intubat\n Comment\n [22] 11:29PM\n ART\n 215*\n 59*\n 7.30*\n 30\n 1\n NOT INTUBA[1]\n GREEN TOP\n 1. NOT INTUBATED\n WHOLE BLOOD, MISCELLANEOUS CHEMISTRY\n Glucose\n Lactate\n Na\n K\n Cl\n calHCO3\n [23] 11:29PM\n 106*\n 1.2\n 136\n 5.3\n 103\n 28\n Miscellaneous\n T4, FREE, DIRECT DIALYSIS\n [24] 04:45AM\n PND\n Urine\n Hematology\n GENERAL URINE INFORMATION\n Type\n Color\n Appear\n Sp \n [25] 11:30PM\n Yellow\n Clear\n 1.015\n DIPSTICK URINALYSIS\n Blood\n Nitrite\n Protein\n Glucose\n Ketone\n Bilirub\n Urobiln\n pH\n Leuks\n [26] 11:30PM\n NEG\n NEG\n 30\n NEG\n NEG\n NEG\n 0.2\n 7.0\n MOD\n MICROSCOPIC URINE EXAMINATION\n RBC\n WBC\n Bacteri\n Yeast\n Epi\n TransE\n RenalEp\n [27] 11:30PM\n 0\n \n MOD\n NONE\n 0\n [28] 11:30PM\n Other labs: Band:85\n Bronch : left bronchial tree patent, bleeding from underneath\n right main stem bronchus\n CXR: RML/RLL collapse (chronic), new LLL infiltrate\n Chest CT :\n 1. Slight progressive increase in mediastinal emphysema presumably due\n to\n broncho-mediastinal communication associated with the indwelling right\n bronchial stent. No mediastinal abscess or pleural effusion.\n 2. Right bronchial stent is intact and unchanged in position but\n remains\n narrowed by tumor ingrowth or retained secretions, and is the only\n portion of\n the right bronchial tree which is patent. Right upper and/or middle\n lobes\n remain collapsed, infiltrated by tumor from right hilar mass and\n inseparable\n from pleural tumor contiguous with mild invasion of the anterior chest\n wall.\n Extensive sclerosis and smaller regions of lysis in the ribs of the\n right\n chest wall, predominantly anteriorly, could be due to stable treated\n metastases and/or radiation necrosis, particularly in light of severe\n extensive radiation fibrosis and bronchiectasis in the right lung.\n 3. Stable tumor infiltration of minimally aerated right lower lobe. A\n handful of subcentimeter left lung nodules, presumably metastases, are\n either\n stable or only slowly enlarging.\n Assessment and Plan\n 72 yo female with stg IV NSCLCa with R mainstem bronchus, recent\n episode of non massive hemoptysis admitted with acute respiratory\n distress/hypoxia with new LLL PNA. Could represent CAP/HCAP vs\n aspiration. Lack of leukocytosis/left shift might favor the latter.\n Possible impending SIRS physiology with decreased urine\n output/hypotension, unless related to decreased po intake. Plans:\n 1. Broad coverage with vanc/zosyn /levaquin\n 2. Fluid resuscitation to maintain MAP>60, consider stress dose\n steroids\n 3. Could consider CVL if remains persistently hypotensive without\n adequate response to fluids\n 4. Supplemental oxygen\n 5. Hold antihypertensives\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 02:04 AM\n 22 Gauge - 02:07 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\nReferences\n 1. javascript:command('LHBC','expand')\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_2%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_3%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_4%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_5%22);\n 7. javascript:command('LHBI','expand')\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_6%22);\n 9. JavaScript:parent.POPUP(self,%22_WEBTAG=_7%22);\n 10. javascript:command('LCBA','expand')\n 11. JavaScript:parent.POPUP(self,%22_WEBTAG=_8%22);\n 12. JavaScript:parent.POPUP(self,%22_WEBTAG=_9%22);\n 13. JavaScript:parent.POPUP(self,%22_WEBTAG=_10%22);\n 14. JavaScript:parent.POPUP(self,%22_WEBTAG=_11%22);\n 15. JavaScript:parent.POPUP(self,%22_WEBTAG=_12%22);\n 16. javascript:command('LCBI','expand')\n 17. JavaScript:parent.POPUP(self,%22_WEBTAG=_13%22);\n 18. JavaScript:parent.POPUP(self,%22_WEBTAG=_14%22);\n 19. JavaScript:parent.POPUP(self,%22_WEBTAG=_15%22);\n 20. JavaScript:parent.POPUP(self,%22_WEBTAG=_16%22);\n 21. JavaScript:parent.POPUP(self,%22_WEBTAG=_17%22);\n 22. JavaScript:parent.POPUP(self,%22_WEBTAG=_18%22);\n 23. JavaScript:parent.POPUP(self,%22_WEBTAG=_19%22);\n 24. JavaScript:parent.POPUP(self,%22_WEBTAG=_20%22);\n 25. JavaScript:parent.POPUP(self,%22_WEBTAG=_21%22);\n 26. JavaScript:parent.POPUP(self,%22_WEBTAG=_22%22);\n 27. JavaScript:parent.POPUP(self,%22_WEBTAG=_23%22);\n 28. JavaScript:parent.POPUP(self,%22_WEBTAG=_24%22);\n"
},
{
"category": "Social Work",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 714950,
"text": "Social Work\n SW consult request rec\nd via POE and page from RN to assist pt\ns family\n w/coping and end of life issues.\n Pt\ns 72 y/o Cantonese only speaking female whose medical health has\n declined in the recent yrs. Currently pt\ns on DNI/DNR and not able to\n communicate w/this writer.\n Met w/pt\ns son. Provided emotional support and answered questions about\n end of life issues. Their primary concern was receiving assistance\n finding a funeral home. Provided a list of funeral homes in the area of\n where family lives and informed that SW will cont to be avail\n as needed. Family appeared to be supporting each other well.\n Will attempt to f/u w/pt\ns son on . For urgent matters please page\n on-call SW.\n Rohila, LCSW\n #\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714969,
"text": "72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n Today after taking meds developed SOB and frothy white secretions.\n Became lethargic. EMS called sats on RA 50-60%, B/P 80\n In EW B/P in 70\ns, received 2 L NS and started on IV levoquin and\n zosyn. Placed on NRB with sats in 90\ns and transferred to for\n further management on \n Hypoxemia\n Assessment:\n CXR ~ new LLL infiltrate. Possible from an aspiration event given\n history of pt having acute decompensation shortly after a meal at\n home. H Flu ruled out\n pt off precautions. Pt on 95% Hi Flow,\n and 5 liters n/c. O2 sats 96% rr~ 20\ns lungs with rhonchi\n Action:\n H flu ruled out, pt with new LLL infiltrate, on antibx~\n Levofloxacin, Vanco, Zosyn pt did not tolerate CPT.\n Response:\n Pulm status tenious\n Plan:\n Continue with Hi Flow O2, monitor O2 sats, continue antibx, pt\n turned q 2 hours.\n Hypotension (not Shock)\n Assessment:\n Bp labile\ns pt received one 500 cc NS bolus. Bp currently\n 86-94/40-55\n Action:\n Received one 500 cc bolus NS\n Response:\n Pt continues with labile bp\n Plan:\n Careful with IVF, secondary to pt\ns pulmonary status.\n SOCIAL: family meeting held with son/other relatives, \n speaking intrepretor in meeting, discussed pt\ns condition.\n Pt remains DNR/DNI, continue with antibx, steroids.\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714966,
"text": "72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n Today after taking meds developed SOB and frothy white secretions.\n Became lethargic. EMS called sats on RA 50-60%, B/P 80\n In EW B/P in 70\ns, received 2 L NS and started on IV levoquin and\n zosyn. Placed on NRB with sats in 90\ns and transferred to for\n further management.\n Hypoxemia\n Assessment:\n CXR ~ new LLL infiltrate. Possible from an aspiration event given\n history of pt having acute decompensation shortly after a meal at\n home. H Flu ruled out\n pt off precautions. Pt on 95% Hi Flow,\n and 5 liters n/c. O2 sats 96% rr~ 20\ns lungs with rhonchi\n Action:\n H flu ruled out, pt with new LLL infiltrate, on antibx`\n Levofloxacin, Vanco, Zosyn\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715016,
"text": "Pt. significantly hypotensive and hypoxic at start of shift despite\n fluid boluses and increased O2. Multiple meetings with family\n throughout start of shift regarding pt. progress. Many family members\n in. At 00:30 pt. in junctional rhythm with SBP in the 40\ns. Sat 80. Pt.\n expired at 00:50- Asystole. Pronounced.\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714996,
"text": "72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n Today after taking meds developed SOB and frothy white secretions.\n Became lethargic. EMS called sats on RA 50-60%, B/P 80\n In EW B/P in 70\ns, received 2 L NS and started on IV levoquin and\n zosyn. Placed on NRB with sats in 90\ns and transferred to for\n further management on \n Hypoxemia\n Assessment:\n CXR ~ new LLL infiltrate. Possible from an aspiration event given\n history of pt having acute decompensation shortly after a meal at\n home. H Flu ruled out\n pt off precautions. Pt on 95% Hi Flow,\n and 5 liters n/c. O2 sats 96% rr~ 20\ns lungs with rhonchi\n Action:\n H flu ruled out, pt with new LLL infiltrate, on antibx~\n Levofloxacin, Vanco, Zosyn pt did not tolerate CPT.\n Response:\n Pulm status labile\n Plan:\n Continue with Hi Flow O2, monitor O2 sats, continue antibx, pt\n turned q 2 hours.\n Hypotension (not Shock)\n Assessment:\n Bp labile\ns pt received one 500 cc NS bolus. Bp currently\n 86-94/40-55 at 5 pm\n pt with runs V-Tach, EKG done\n cardiology\n called\n family called - lytes sent, lactate~ 4 grams Magnesium\n Sulfate given, bp dropping. -\n Action:\n Received two 500 cc bolus NS , awaiting cardiology consult/family to\n come in.\n Response:\n Pt continues with labile bp, runs of V-tach\n Plan:\n Careful with IVF, secondary to pt\ns pulmonary status. Await input\n from attending, cardiology, meet with family\n update pt\n condition. Repeat lytes,\n SOCIAL: family meeting held with son/other relatives, \n speaking intrepretor in meeting, discussed pt\ns condition.\n Pt remains DNR/DNI, continue with antibx, steroids.\n Cardiology thought pt in RBBB, repeat lytes BUN 41, crt 1.2, K 5.6,\n NA 138, lactate 2.9, CPK\ns added\n pt with poor urine output. O2\n sats dropping 88, pt medicated with 0.5 mg IV Morphine x1. family in\n and updated on pt\ns condition. Pt remains DNR/DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 714989,
"text": "72 yo F with history of non-small cell lung cancer (diagnosed in ),\n non-massive hemoptysis (s/p right fifth posterior intercostal artery\n embolization on ), and recent admission for weakness\n ( to ).\n Today after taking meds developed SOB and frothy white secretions.\n Became lethargic. EMS called sats on RA 50-60%, B/P 80\n In EW B/P in 70\ns, received 2 L NS and started on IV levoquin and\n zosyn. Placed on NRB with sats in 90\ns and transferred to for\n further management on \n Hypoxemia\n Assessment:\n CXR ~ new LLL infiltrate. Possible from an aspiration event given\n history of pt having acute decompensation shortly after a meal at\n home. H Flu ruled out\n pt off precautions. Pt on 95% Hi Flow,\n and 5 liters n/c. O2 sats 96% rr~ 20\ns lungs with rhonchi\n Action:\n H flu ruled out, pt with new LLL infiltrate, on antibx~\n Levofloxacin, Vanco, Zosyn pt did not tolerate CPT.\n Response:\n Pulm status labile\n Plan:\n Continue with Hi Flow O2, monitor O2 sats, continue antibx, pt\n turned q 2 hours.\n Hypotension (not Shock)\n Assessment:\n Bp labile\ns pt received one 500 cc NS bolus. Bp currently\n 86-94/40-55 at 5 pm\n pt with runs V-Tach, EKG done\n cardiology\n called\n family called - lytes sent, lactate~ 4 grams Magnesium\n Sulfate given\n Action:\n Received two 500 cc bolus NS , awaiting cardiology consult/family to\n come in.\n Response:\n Pt continues with labile bp, runs of V-tach\n Plan:\n Careful with IVF, secondary to pt\ns pulmonary status. Await input\n from attending, cardiology, meet with family\n update pt\n condition. Repeat lytes,\n SOCIAL: family meeting held with son/other relatives, \n speaking intrepretor in meeting, discussed pt\ns condition.\n Pt remains DNR/DNI, continue with antibx, steroids.\n"
},
{
"category": "ECG",
"chartdate": "2191-01-22 00:00:00.000",
"description": "Report",
"row_id": 206214,
"text": "The rhythm may be sinus but consider also ectopic atrial rhythm. Wide complex\npremature beats including a six beat run of tachycardia which may be\nsypraventricular with aberrant conduction. Incomplete right bundle-branch\nblock. Indeterminate axis. QTc interval may be prolonged but it is difficult\nto measure. Since the previous tracing of change in P wave morphology\nsuggests ectopic atrial rhythm and wide complex beats as outlined are now\npresent.\n\n"
},
{
"category": "ECG",
"chartdate": "2191-01-21 00:00:00.000",
"description": "Report",
"row_id": 206215,
"text": "Sinus rhythm. Minor inferior ST-T wave abnormalities. Compared to the previous\ntracing of there is no significant change.\n\n"
}
] |
32,082 | 154,926 | 88 yo M with CAD, chronic diastolic CHF and HTN with cholangitis and E Coli bacteremia. Cholangitis and E Coli bacteremia. Pt presented with nausea, chest pain, fever and was found to have transaminitis and hyperbilirubinemia. His blood cultures from were positive for E.Coli sensitive to levofloxacin. He was transferred from and underwent ERCP with stone/sludge removed. He had a sphincterotomy with stent placement. He had findings of a biliary vs abscess in the right intrahepatic system. He was placed on cipro/flagyl with resolution of clinical symptoms and normalization of LFT's and bilirubin. He will complete 2 total weeks of antibiotics. His home simvastatin and acetaminophen were held due to LFTs and can be restarted 4 days after discharge. For recurrent fevers he should have an U/S or MRI of the liver to rule out abscess. He needs a f/u ERCP for stent removal in weeks. The patient did not have gallbladder stones on RUQ U/S done at and based upon the ERCP report, this seems mostly to have been sludge mediated. For now he appears to have adequate biliary drainage and there is no plan for cholecystectomy. HTN, CAD. The patient presented with chest pain complaints. He had no ECG changes and normal cardiac enzymes. He continues on his home medication regimen except statin which can be restarted 4 days after discharge. Dysphagia. The patient complained of intermittent dysphagia. Speech and swallow eval was within normal limits. He can continue on a regular diet. | T wave abnormalities are lessprominent. Minor inferolateral T wave abnormalities. Since the previoustracing of the rate is slower. | 1 | [
{
"category": "ECG",
"chartdate": "2115-07-05 00:00:00.000",
"description": "Report",
"row_id": 228271,
"text": "Sinus rhythm. Minor inferolateral T wave abnormalities. Since the previous\ntracing of the rate is slower. T wave abnormalities are less\nprominent.\n\n"
}
] |
73,280 | 103,060 | 72 year old male with history of type 2 diabetes mellitus who presented with hyperglycemia, hypernatremia, hypertension and seizures. He was originally admitted to the MICU and once stabilized, was transferred to the floor. | Hyperglycemia Assessment: Received pt AA&Ox3. Hyperglycemia Assessment: Received pt AA&Ox3. Hyperglycemia Assessment: Received pt AA&Ox3. Hyperglycemia Assessment: Received pt AA&Ox3. # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration, can restart if s/s of volume overload . # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration, can restart if s/s of volume overload . # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration, can restart if s/s of volume overload . FeNa/Fe Urea c/w prerenal this AM. FeNa/Fe Urea c/w prerenal this AM. FeNa/Fe Urea c/w prerenal this AM. # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . #dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration . # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration . Hypertension, benign Assessment: Pt received with systolic BPs 180s-190s after having received 20mg IV hydral and 10mg IV labetalol. Hypertension, benign Assessment: Pt received with systolic BPs 180s-190s after having received 20mg IV hydral and 10mg IV labetalol. HYPERTENSION, BENIGN: Holding bblocker, and minoxidiol, and monitoring BP, contniue clonidine, and valsartan. HYPERTENSION, BENIGN: Holding bblocker, and minoxidiol, and monitoring BP, contniue clonidine, and valsartan. # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration, can restart if s/s of volume overload . # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration, can restart if s/s of volume overload . SEIZURE, WITHOUT STATUS EPILEPTICUS: likely in setting of metabolic abnormality from HONK + old seizure focus, f/u EEG, f/u MRI/MRA today. SEIZURE, WITHOUT STATUS EPILEPTICUS: likely in setting of metabolic abnormality from HONK + old seizure focus, f/u EEG, f/u MRI/MRA today. # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration . # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . # Prophylaxis: Subcutaneous heparin . # Gout : stable - continue allopurinol . # Gout : stable - continue allopurinol . # Gout : stable - continue allopurinol . Hyperglycemia Assessment: Received pt AA&Ox3. Hyperglycemia Assessment: Received pt AA&Ox3. Hyperglycemia Assessment: Pt continues to be moderately hyperglycemic. AM BP meds given early elevated SBP >180 Hyperglycemia Assessment: Received pt AA&Ox3. AM BP meds given early elevated SBP >180 Hyperglycemia Assessment: Received pt AA&Ox3. # dCHF: Volume down currently - Continue metoprolol, valsartan - Hold torsemide given dehydration, can restart if s/s of volume overload . Hypertension, benign Assessment: Pt received with systolic BPs 180s-190s after having received 20mg IV hydral and 10mg IV labetalol. Hypertension, benign Assessment: Pt received with systolic BPs 180s-190s after having received 20mg IV hydral and 10mg IV labetalol. Hyperglycemia Assessment: Received pt AA&Ox3. # Prophylaxis: Subcutaneous heparin . FeNa/Fe Urea c/w prerenal this AM. FeNa/Fe Urea c/w prerenal this AM. Hyperglycemia Assessment: Pt continues to be moderately hyperglycemic. # Gout : stable - continue allopurinol . CAP - may be more likely aspiration from seizure ICU Care Nutrition: Glycemic Control: Comments: titrating diabetes regimen Lines / Intubation: 18 Gauge - 05:19 AM Comments: Prophylaxis: DVT: SQ UF Heparin Stress ulcer: Not indicated Comments: seizure precautions Communication: Comments: Code status: Full code Disposition: ICU Total time spent: Response: Plan: Hypertension, benign Assessment: Mild hypertension noted this am. EEG negativeAmbulation: consult PT RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): resolved back at baseline. EEG negativeAmbulation: consult PT RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): resolved back at baseline. Hyperglycemia Assessment: Received pt AA&Ox3. Response: Plan: Hypertension, benign Assessment: Mild hypertension noted this am, sbp 140s. FINDINGS: The previously seen retrocardiac opacity is largely resolved and therefore I suspect it was atelectasis. Got decadron, CTX, vanc. Hyperglycemia Assessment: Pt continues to be moderately hyperglycemic. Hyperglycemia Assessment: Action: Response: Plan: Hypertension, benign Assessment: Action: Response: Plan: Action: Scheduled po meds admin. Action: Scheduled po meds admin. Action: Scheduled po meds admin. Action: Scheduled po meds admin. Action: Scheduled po meds admin. Action: Pt cont on qid humalog scale and hs lantus dose. COMPARISON: MRI and MRA dated . Assessment and Plan 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure, mental status improving. FeNa/Fe Urea c/w prerenal this AM. Visualized portion of paranasal sinuses and mastoid air cells is within normal limits. Hypertension, benign Assessment: Mild hypertension noted this am, sbp 140s. | 63 | [
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485175,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Vitals- BP: 198/108 P: 108 R: 16 100% RA\n Gen- AOx 2 says that year is , well appearing, well nourished,\n NAD\n HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No tongue\n lesions noted.\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly, negative sign\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently, but only intermittently following commands.\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n # ? L facial droop: Unsure if new or not.\n - Neuro following\n - MRI/MRA today\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then night prior UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings improved today, afebrile,\n no coughing\n - d/c ceftriaxone/azithro\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: ICU for now, likely transfer to floor once UO improves\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484607,
"text": "Pt is a 72yo male admitted to MICU 7 via ED with Hyperglycemia and\n Seizures. Pt presented to ED from home after having witnessed seizure\n while in bed. On arrival to pt was post-ictal and was being ruled\n out for CVA---Head Ct was negative. Upon returning to the ED from CT\n scan pt had another seizure and was treated with IV Ativan. Blood\n sugar on admission was 653 and Lactate level was 9.3. Pt received 1.7\n liters of IVF and 10 units IV insulin, IV rocephin and IV Vanco. LP\n was done and was reported as neg. Pt being admitted to MICU for\n management of hyperglycemia and seizure workup with Neuro following.\n Other PMH sig for DM, HTN, Gout, CRI, Neuropathy, colon Ca ---s/p\n resection, cataracts, mild diastolic dysfunction. Pt with an allergy\n to enalapril.\n Events:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Critical Care Staff",
"row_id": 484602,
"text": "TITLE: Critical Care\n 72M DM2 presented to ED via EMS s/p seizure witnessed by wife at home.\n Hypertensive, tachy on presentation. Head CT negative. On way back\n from scan another seizure. Glucose noted to be critically high.\n Decadron, CTX, Vanc, LP performed prelim 2wbc. Neuro consulted\n feel\n that is hyperglycemic seizure. Insulin given with good improvement of\n glucose.\n Cont seizure precautions, aggressive management of electrolytes.\n Follow-up LP data to help exclude infection as source. Evaluate other\n potential etiologies. Neuro following.\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 484696,
"text": "TITLE:\n Chief Complaint: siezure, hyperglycemic hyperosmotic syndrome\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72yo M with PMH DMT2, chronic renal insufficiency, hypertension and\n mild diastolic dysfunction who was brought in with seizure. Was in\n usual state of health until Thursday when he noticed some shakiness in\n his L hand, then last night had increased fatigue and lethargy and was\n found to be seizing by his wife. with seizure, given ativan 2mg\n and seizure activity broke. In the ED was sent to head CT, which\n showed old L frontal infarct but nothing acute, and had repeat GTC\n seizure that broke again with 2mg ativan. Labs revealed BS of >600 and\n he was given insulin IV and then gtt, and IVF (total 2.5L). No sodium\n was checked at that time, and the patient was then transferred to the\n ICU. He also had an LP that showed no evidence of infection. Sodium\n just prior to transfer was 147, lactate 12.1. Following transfer, the\n patient was found to have BS of 170s and insulin drip was\n discontinued. He was noted to be slightly lethargic and delirious.\n The patient's wife reports that he has been very adherent to his\n diabetes regimen, that he has never been hospitalized for his blood\n sugars before. Of note, patient was recently given prednisone for a\n gout flare. He has no known history of seizure activity.\n History obtained from Patient, limited by somnolence\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 05:25 AM\n Labetalol - 05:40 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DMt2, on Lantus 9u daily at home\n Chronic renal insufficiency\n Gout\n Hypertension\n Secondary hyperparathyroidism\n H/o Colon cancer, s/p cancer\n No family history of seizures\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 84 (84 - 109) bpm\n BP: 146/83(97) {146/83(97) - 209/124(135)} mmHg\n RR: 16 (14 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,169 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,049 mL\n Blood products:\n Total out:\n 0 mL\n 620 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 549 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, somnolent\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:3.4 mmol/L\n Assessment and Plan\n Seizure: ? secondary to hyperosmotic state with prior stroke as\n trigger focus\n - ongoing change in mental status ? secondary to ativan v. post-ictal\n v. status\n - per neuro, EEG this morning to r/o further seizure activity\n - for MRI in the future\n - checking CK given prolonged seizure\n Hyperglcemia\n - improved, will manage with subcutaneous insulin\n - start NPH 5u and checking blood sugars q2h\n - re-check electrolytes now\n - will give more IVF if urine output drops to <50cc/hr\nHypertension\n - SBP was >200 in the ED, now improved s/p hydralazine and labetalol\n - restarting home meds today, SBP now 140s\n ? Pneumonia: focal consolidtion on cxr\n - will start ceftriaxone/azithromycin for ? CAP\n - may be aspiration from seizure\n ICU Care\n Nutrition:\n Glycemic Control: Comments: titrating diabetes regimen\n Lines / Intubation:\n 18 Gauge - 05:19 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments: seizure precautions\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 484698,
"text": "TITLE:\n Chief Complaint:\n HPI:\n 72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n .\n In the ED, initial vs were: T P 98 BP 177/95 R O2 sat 100% 4L.\n .\n On the floor, he is following commands, but still lethargic and\n delerious.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 05:25 AM\n Labetalol - 05:40 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n -Allopurinol 300 mg once a day on Mon, Wed, Fri and 200mg qd on other\n days\n -Clonidine 0.3 mg Tablet 1 Tablet(s) by mouth once a day\n -Insulin Glargine 9 units at bedtime\n -Insulin Lispro\n -Metoprolol Tartrate 50 mg Tablet 1 Tablet(s) by mouth twice a day\n -Minoxidil 10 mg Tablet 1 Tablet(s) by mouth twice a day\n -Paricalcitol 4 mcg Capsule 1 Capsule(s) once a day\n -Simvastatin 20 mg Tablet once a day \\\n -Torsemide [Demadex] 20 mg Tablet once a day\n -Valsartan 160 mg Tablet q day\n -Ascorbic Acid 500 mg Tablet once a day\n -Aspirin 81 mg Tablet, once a day (OTC)\n -Multivitamin with Iron-Mineral once a day\n Past medical history:\n Family history:\n Social History:\n - Diabetes mellitus type II, dx'ed 15-20 years ago, followed at\n \n - Chronic renal insufficiency, Cr baseline 1.8-2.2\n - Hypertension, patient states BPs in 130s/70s\n - Colon cancer, s/p resection\n - Gout (proven with joint fluid analysis)\n - Cataracts\n - Secondary hyperparathyroidism\n - Cholelithiasis\n - Mild Diastolic Dysfunction\n Family hx of hypertension. Pt denies family hx of CAD, stroke,\n cancer\n Originally from , the patient has lived in for 40+\n years. He retired as a CPA, and lives at home with his wife. His\n children are grown. He manages his ADLS. He used tobacco for 5\n years many years ago, occasional social alcohol, no IVDU.\n Review of systems:\n Flowsheet Data as of 10:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 84 (84 - 109) bpm\n BP: 146/83(97) {146/83(97) - 209/124(135)} mmHg\n RR: 16 (14 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,174 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,054 mL\n Blood products:\n Total out:\n 0 mL\n 654 mL\n Urine:\n 254 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 520 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Vitals- BP: 198/108 P: 108 R: 16 100% RA\n Gen- AOx 2 says that year is , well appearing, well nourished,\n NAD\n HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No tongue\n lesions noted.\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly, negative sign\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently, but only intermittently following commands.\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:3.4 mmol/L\n CSF;SPINAL FLUID GRAM STAIN-PENDING; FLUID CULTURE-PENDING\n INPATIENT\n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY \n Images:\n CT head\n No acute hemmorhage. MRI is more senitive for acute ishemia.\n .\n CXR\n Mild volume overload\n .\n EKG: NSR, LAA\n Assessment and Plan\n Assessment and Plan: This is a 72 yo M w/ hyperglycemia,\n hypernatremia, hypertension and seizure.\n .\n #Seizure: Would be strange to be caused by hyperglycemia alone. CSF w/\n 2 WBCs and 1 RBC so does not appear meningitis/encephalitis. Tox screen\n negative. Could be secondary to hyperosmolality w/\n hypernatremia/hyperglycemia which are now improving. His altered mental\n status is likely ativan vs. post ictal but seems to be clearing.\n - Continue IVF D51/2NS with 20 meqK\n - D/c'd Insulin drip\n - Dilantin 1g loading dose if seizes again\n - Consider MRI eventually\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG\n -\n .\n #HTN: Urgency on arrival to the ICU. ? whether HTN event caused Sz as\n pt. was also very HTN on admission. His somnolence seemed to improve w/\n treatment of BP. Likely that he missed a dose or two of his home meds.\n He is on minoxidil so likely very poorly controlled HTN at baseline.\n - Restarted home meds\n - EKG\n .\n # Hyperglycemia: HSS, improving significantly with hydration.\n - Insulin Q2 with finger sticks\n - NPH as long acting\n .\n #dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration\n .\n .\n #Gout continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-30 00:00:00.000",
"description": "MICU Resident Progress Note",
"row_id": 484912,
"text": "TITLE: Resident Progress Note\n Chief Complaint: \n - Had decreased UO throughout the day, gave 500ml IVF x 3, also had LR\n x 1 liter at 200/hr, later in night still low UO, gave 1 liter over 2\n hours\n - ordered MRA/MRI per neuro\n - advanced to regular diet\n - BS improved to 100-200\n - EEG done\n 24 Hour Events:\n EEG - At 12:00 PM\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 65 (64 - 99) bpm\n BP: 118/49(64) {94/39(60) - 177/124(135)} mmHg\n RR: 15 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,733 mL\n 1,695 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 4,133 mL\n 1,575 mL\n Blood products:\n Total out:\n 1,161 mL\n 70 mL\n Urine:\n 761 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,572 mL\n 1,625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 127 K/uL\n 9.1 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 36 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n WBC\n 7.0\n Hct\n 27.7\n Plt\n 127\n Cr\n 2.1\n 2.1\n 2.4\n Glucose\n 293\n 99\n 150\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n HYPERGLYCEMIA\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 72 yo M w/ hyperglycemia, hypernatremia, hypertension and\n seizure.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds\n - EKG\n .\n # Hyperglycemia/Diabetes: HSS, improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then overnight UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS.\n - IVF this AM\n - PM renal function\n - monitor UO\n - hold diuretics\n - will check urine lytes\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: ICU for now, likely transfer to floor once UO improves\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: no ppi needed\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now, likely transfer to floor once UO improves\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484768,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n .\n In the ED, initial vs were: T P 98 BP 177/95 R O2 sat 100% 4L.\n .\n On the floor, he is following commands, but still lethargic and\n delerious.\n Hypertension, benign\n Assessment:\n Pt received with systolic BPs 180s-190s after having received 20mg IV\n hydral and 10mg IV labetalol.\n Action:\n Pt given home dose BP meds (metoprolol, clonidine) @ 08. Then received\n other home dose meds (valsartan, minoxidil) @ 12.\n Response:\n BP down to 140s-150s post 0800 meds. Post 1200 meds, BP down to\n 120s-130s.\n Plan:\n Cont with home dose BP meds.\n Hyperglycemia\n Assessment:\n BS @ 0900 post 1L 1/2NS 301, rechecked @ 10 for 318.\n Action:\n BS monitored Q2 but with Q4 insulin coverage. Pt given 8 units Humalog\n to cover BS of 318 @ 10. Fixed insulin dose changed to 5 units of NPH @\n breakfast, 4 units NPH @ bedtime. 5 units NPH given @ 11. FSBS\n rechecked @ 12 for 284, pt given 1x dose of 3 units Humalog. At 1600\n pt\ns BS 181 and pt given 2 units Humalog.\n Response:\n 1800 BS\n Plan:\n Cont to monitor Q2 hr BS and provide SS insulin coverage Q4hrs. Cont\n fixed dose insulin.\n Seizure, without status epilepticus\n Assessment:\n Pt admitted s/p 2 long lasting tonic clonic seizures. No seizure\n activity noted this shift. Pt A&Ox3, pupils equal/reactive, \n strength in all extremities, extremely somnolent/lethargic.\n Action:\n Seizure pads on bed. Pt seen by neuro and had EEG. Team thinks likely\n cause of seizures is hyperosmolar hyperglycemic syndrome.\n Response:\n Neuro with no plan for putting patient\ns on anti seizure meds.\n Plan:\n F/U EEG results, neuro recs. Cont to monitor neuro status.\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 485219,
"text": "Chief Complaint: Hyperosmolar hyperglycemic state, seizure.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Agitation sundowning overnight. EEG and MRI read pending.\n History obtained from Patient\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 12:50 AM\n Heparin Sodium (Prophylaxis) - 08:11 AM\n Other medications:\n MVI, ASA 81, vitaminC, valsartan, simvastatin, mioxidil, colace,\n glargine, HISS.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 73 (63 - 98) bpm\n BP: 137/66(83) {92/40(57) - 189/88(104)} mmHg\n RR: 15 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 840 mL\n PO:\n 1,080 mL\n 840 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.9 g/dL\n 158 K/uL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: EEG negative for epileptic activity\n MRI/MRA motion limited chronic vascular infarcts and microvascular\n changes otherwise stable.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF):\n Stable creatinine at baseline. Keep fluid balance even\n ACUTE CONFUSION:\n resolving, alert and oriented x3 now. EEG iwth no seizure, MRI iwth no\n acute event, likely post ictal state, benzodiazepine effect.\n HYPERGLYCEMIA:\n Sugar in better control, restarted on glargine, continue HISS.\nSundowning: behavioral control, prn haldol\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n ------ Protected Section ------\n Exam not entered above exam findings:\n Oriented x3, awake alert, lungs clear heart regular, abdomen soft LE,\n with no edema.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:52 ------\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484821,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n Hypertension, benign\n Assessment:\n Pt received with systolic BPs 180s-190s after having received 20mg IV\n hydral and 10mg IV labetalol.\n Action:\n Pt given home dose BP meds (metoprolol, clonidine) @ 08. Then received\n other home dose meds (valsartan, minoxidil) @ 12.\n Response:\n BP down to 140s-150s post 0800 meds. Post 1200 meds, BP down to\n 120s-130s.\n Plan:\n Cont with home dose BP meds.\n Hyperglycemia\n Assessment:\n BS @ 0900 post 1L 1/2NS 301, rechecked @ 10 for 318.\n Action:\n BS monitored Q2 but with Q4 insulin coverage. Pt given 8 units Humalog\n to cover BS of 318 @ 10. Fixed insulin dose changed to 5 units of NPH @\n breakfast, 4 units NPH @ bedtime. 5 units NPH given @ 11. FSBS\n rechecked @ 12 for 284, pt given 1x dose of 3 units Humalog. At 1600\n pt\ns BS 181 and pt given 2 units Humalog.\n Response:\n 1800 BS 139.\n Plan:\n Cont to monitor Q2 hr BS and provide SS insulin coverage Q4hrs. Cont\n fixed dose insulin.\n Seizure, without status epilepticus\n Assessment:\n Pt admitted s/p 2 long lasting tonic clonic seizures. No seizure\n activity noted this shift. Pt A&Ox3, pupils equal/reactive, \n strength in all extremities, extremely somnolent/lethargic.\n Action:\n Seizure pads on bed. Pt seen by neuro and had EEG. Team thinks likely\n cause of seizures is hyperosmolar hyperglycemic syndrome.\n Response:\n Neuro with no plan for putting patient\ns on anti seizure meds.\n Plan:\n F/U EEG results, neuro recs. Cont to monitor neuro status.\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484882,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 146 @ change of shift.\n Action:\n BS monitored Q2-4 w/ Q4 insulin (Humalog) coverage. BS ranging 146-260.\n (please see Metavision/med sheets for respective amts) Pt also received\n NPH 5 units @ 2200. LR 500cc x 2 for decreased UOP w/ additional liter\n initiated @ 0530\n Response:\n BS improving. Neuro team relating sz activity to hyperosmolar\n hyperglycemic syndrome (HHS) UOP remains poor.\n Plan:\n Titrate sliding scale if needed. Transition pt to Q6hr coverage\n (consult if remains problem)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received pt w/ poor UOP. 25-40cc/hr. BUN/Cr 32/2.1. UOP trending down\n 0-30 throughout the night. (Dr. aware. Na @ 1900 146\n Action:\n LR 500cc X 2. Additional liter over 2 hrs started @ 0530 for increasing\n BUN/Cr of 36/2.4 & minimal improvement in UOP. Pt did eat dinner @\n . Encouragement of PO intake for free water.\n Response:\n Ongoing. AM Na improved 144. Tolerating diet/PO\ns well.\n Plan:\n Cont to bolus pt w/ fluid HHS. Original plan was to assess\n hydration status via UOP (goal >/= 50cc/hr) which has been\n unsuccessful. ? need to dextrose infusion (which would require tight SS\n coverage) vs.\n NS. Cont to encourage PO intake to obtain free water.\n EVENTS:\n Wife in to visit pt last evening and updated by this RN.\n PIV x 2.\n Pt does need MRI today which has been ordered as routine.\n ? c/o to medical floor.\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485211,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n HEENT- NC/AT, EOMI, PERRL,\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly,\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently,\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n # ? L facial droop: MRI no new acute events.\n - Neuro following\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then night prior UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings improved today, afebrile,\n no coughing\n - d/c ceftriaxone/azithro\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: called out to the floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 485212,
"text": "Chief Complaint: Hyperosmolar hyperglycemic state, seizure.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Agitation sundowning overnight. EEG and MRI read pending.\n History obtained from Patient\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 12:50 AM\n Heparin Sodium (Prophylaxis) - 08:11 AM\n Other medications:\n MVI, ASA 81, vitaminC, valsartan, simvastatin, mioxidil, colace,\n glargine, HISS.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 73 (63 - 98) bpm\n BP: 137/66(83) {92/40(57) - 189/88(104)} mmHg\n RR: 15 (14 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 840 mL\n PO:\n 1,080 mL\n 840 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.9 g/dL\n 158 K/uL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: EEG negative for epileptic activity\n MRI/MRA motion limited chronic vascular infarcts and microvascular\n changes otherwise stable.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF):\n Stable creatinine at baseline. Keep fluid balance even\n ACUTE CONFUSION:\n resolving, alert and oriented x3 now. EEG iwth no seizure, MRI iwth no\n acute event, likely post ictal state, benzodiazepine effect.\n HYPERGLYCEMIA:\n Sugar in better control, restarted on glargine, continue HISS.\nSundowning: behavioral control, prn haldol\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485064,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS:\n MRI/A completed\n PIV x 2\n Full Code\n No contact w/ family O/N by this RN.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 196 @ MN.\n Action:\n BS checks changed to QIDACHS. Glargine 9 units given @ 2200 (pt\ns home\n dose). Pt has also been eating since evening of .\n Response:\n Neuro team relating seizure activity to hyperosmolar hyperglycemic\n syndrome (HHS). Blood sugars improving. Humalog sliding scale coverage\n provided as needed. (please see Metavision/ for UTD information)\n Plan:\n Titrate sliding scale if needed. Patient called out.\n Renal failure, acute on chronic\n Assessment:\n Pt with h/o baseline CRI with fluctuating Cr. UOP has improved O/N.\n 20-40cc/hr.\n Action:\n UOP improving. No further need to bolus @ this time per MICU team.\n Response:\n Per patient, he usually voids small amts 5 times daily, so most likely\n dose not make large amt at urine at baseline. Improved PO intake.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time per team, so will not bolus further.\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485065,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS:\n MRI/A completed\n PIV x 2\n Full Code\n No contact w/ family O/N by this RN.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 196 @ MN.\n Action:\n BS checks changed to QIDACHS. Glargine 9 units given @ 2200 (pt\ns home\n dose). Pt has also been eating since evening of .\n Response:\n Neuro team relating seizure activity to hyperosmolar hyperglycemic\n syndrome (HHS). Blood sugars improving. Humalog sliding scale coverage\n provided as needed. (please see Metavision/ for UTD information)\n Plan:\n Titrate sliding scale if needed. Patient called out.\n Renal failure, acute on chronic\n Assessment:\n Pt with h/o baseline CRI with fluctuating Cr. UOP has improved O/N.\n 20-40cc/hr.\n Action:\n UOP improving. No further need to bolus @ this time per MICU team.\n Response:\n Per patient, he usually voids small amts 5 times daily, so most likely\n dose not make large amt at urine at baseline. Improved PO intake.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time per team, so will not bolus further.\n Acute Confusion\n Assessment:\n Pt has become increasingly restless O/N. Remains A&Ox3 but is\n frequently pulling @ and trying to remove lines/tubes. Pt has become\n entangled in cardiac wires (around neck) more than once.\n Action:\n Frequent orientation/reinforcement (~ Q20min) Haldol 0.5mg IV x 1.\n (attempting to avoid chemical restraint admission hx of HHS w/ sz\n activity) 4 side rails up. Bed alarm. Bilateral wrist restraints\n applied for safety.\n Response:\n Pt has remained somewhat calm since initiation of wrist restraints.\n Plan:\n Cont to monitor MS. (per wife, pt is often agitated & restless @ home\n as well) Remove restraints when pt can demonstrate improved safety.\n Avoid chemical restraint.\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485061,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS:\n MRI/A completed\n PIV x 2\n Full Code\n No contact w/ family O/N by this RN.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 129 @ 08a.\n Action:\n Pt given am dose of NPH, no SS coverage necessary for BS 129. BS checks\n changed to QIDACHS and pt placed back on home dose standing glargine at\n bedtime. Pt started eating.\n Response:\n Post starting to eat, BS 263, 264 which were covered appropriately with\n 6 units humalog each time. BS more under control. Neuro team relating\n seizure activity to hyperosmolar hyperglycemic syndrome (HHS).\n Plan:\n Titrate sliding scale if needed. Patient called out.\n Renal failure, acute on chronic\n Assessment:\n Pt with poor UOP (approx 15cc/hr) with am BUN/Cr 36/2.4. Pt with h/o\n baseline CRI with fluctuating Cr.\n Action:\n Pt bolused with 1L LR this am.\n Response:\n Urine output with minimal improvement post bolus. Per patient, he\n usually voids small amts 5 times daily, so most likely dose not make\n large amt at urine at baseline.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time per team, so will not bolus further. Pt called out.\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485207,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n HEENT- NC/AT, EOMI, PERRL,\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly,\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently,\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n # ? L facial droop: Unsure if new or not.\n - Neuro following\n - MRI/MRA today\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then night prior UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings improved today, afebrile,\n no coughing\n - d/c ceftriaxone/azithro\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: ICU for now, likely transfer to floor once UO improves\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485583,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications. Zemplar still on hold.\n Transfer to floor. Had PT eval today. Steady on his feet this am.\n Possible discharge home . Foley dc\nd 1200, dtv 2000hrs.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERGLYCEMIA,SEIZURES\n Code status:\n Full code\n Height:\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CRI, Colon Ca---s/p resection, gout, cataracts,\n mild diasolic dysfunction\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:59\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 420 mL\n 24h total out:\n 335 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:45 AM\n Potassium:\n 4.2 mEq/L\n 04:45 AM\n Chloride:\n 116 mEq/L\n 04:45 AM\n CO2:\n 23 mEq/L\n 04:45 AM\n BUN:\n 34 mg/dL\n 04:45 AM\n Creatinine:\n 2.3 mg/dL\n 04:45 AM\n Glucose:\n 101 mg/dL\n 04:45 AM\n Hematocrit:\n 29.2 %\n 04:45 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n #18g L AC \n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry:\n Transferred from: micu 782\n Transferred to: cc712\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2150-08-30 00:00:00.000",
"description": "MICU Resident Progress Note",
"row_id": 484945,
"text": "TITLE: Resident Progress Note\n Chief Complaint: \n - Had decreased UO throughout the day, gave 500ml IVF x 3, also had LR\n x 1 liter at 200/hr, later in night still low UO, gave 1 liter over 2\n hours\n - ordered MRA/MRI per neuro\n - advanced to regular diet\n - BS improved to 100-200\n - EEG done\n 24 Hour Events:\n EEG - At 12:00 PM\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 65 (64 - 99) bpm\n BP: 118/49(64) {94/39(60) - 177/124(135)} mmHg\n RR: 15 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,733 mL\n 1,695 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 4,133 mL\n 1,575 mL\n Blood products:\n Total out:\n 1,161 mL\n 70 mL\n Urine:\n 761 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,572 mL\n 1,625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 127 K/uL\n 9.1 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 36 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n WBC\n 7.0\n Hct\n 27.7\n Plt\n 127\n Cr\n 2.1\n 2.1\n 2.4\n Glucose\n 293\n 99\n 150\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n HYPERTENSION, BENIGN\n HYPERGLYCEMIA\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n This is a 72 yo M w/ hyperglycemia, hypernatremia, hypertension and\n seizure.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds\n - EKG\n .\n # Hyperglycemia/Diabetes: HSS, improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then overnight UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS.\n - IVF this AM\n - PM renal function\n - monitor UO\n - hold diuretics\n - will check urine lytes\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: ICU for now, likely transfer to floor once UO improves\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: no ppi needed\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now, likely transfer to floor once UO improves\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 485025,
"text": "Chief Complaint: HHS, seizures, lactic acidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Intermittently decreased urine output received additional 2.5L fluid\n challenge with little response of his urine output. Creatinine baseline\n about 2.2. EEG performed. MRi/MRA scheduled for noon today.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n , 81, vitamin C, valsartan, simvastatin, minoxidil, lopressor,\n clonidine, insulin 5NPH , sliding scale, colace , ceftriaxone,\n azithromycin, ceftriaxone.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 63 (63 - 81) bpm\n BP: 129/70(84) {94/39(60) - 159/84(99)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,733 mL\n 2,842 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 4,133 mL\n 2,602 mL\n Blood products:\n Total out:\n 1,161 mL\n 190 mL\n Urine:\n 761 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,572 mL\n 2,652 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed, vitiligo anterior chest\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal, left facial droop\n Labs / Radiology\n 9.1 g/dL\n 127 K/uL\n 150 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 36 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n WBC\n 7.0\n Hct\n 27.7\n Plt\n 127\n Cr\n 2.1\n 2.1\n 2.4\n Glucose\n 293\n 99\n 150\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR resolved atelectasis in the LLL.\n Microbiology: Culture no growth to date.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF):\n Baseline creatinine about 2.2, urine output borderline many be simply\n secondary to his Chronic renal insufficiency, yet still prerenal by\n FEUN, but failed fluid challenge. Will allow him to reequilibrate and\n follow up creatinine. HOld off onhome torsemide for now. No current\n signs of volume overload.\n HYPERTENSION, BENIGN:\n Holding bblocker, and minoxidiol, and monitoring BP, contniue\n clonidine, and valsartan.\n HYPERGLYCEMIA;\n HONK to prednisone, improved on NPH. Will readjust to home dose\n once diet is well estabilished wtih lantus qhs.\n SEIZURE, WITHOUT STATUS EPILEPTICUS:\n likely in setting of metabolic abnormality from HONK + old seizure\n focus, f/u EEG, f/u MRI/MRA today. Hold off on further anti-seizure\n medications for now. Neuro following.\nMental status improved: ? related to ativan, f/u CSF culture data\nPNA: no signs of this, CXR clear today, will stop ceftriazxone and\n azithro.\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU after MRI/MRA can transfer to floor if mental status\n improved.\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485031,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 129 @ 08a.\n Action:\n Pt given am dose of NPH, no SS coverage necessary for BS 129. BS checks\n changed to QIDACHS and pt placed back on home dose standing glargine at\n bedtime. Pt started eating.\n Response:\n Post starting to eat, BS 263, 264 which were covered appropriately with\n 6 units humalog each time. Neuro team relating seizure activity to\n hyperosmolar hyperglycemic syndrome (HHS).\n Plan:\n Titrate sliding scale if needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received pt w/ poor UOP. 25-40cc/hr. BUN/Cr 32/2.1. UOP trending down\n 0-30 throughout the night. (Dr. aware. Na @ 1900 146\n Action:\n LR 500cc X 2. Additional liter over 2 hrs started @ 0530 for increasing\n BUN/Cr of 36/2.4 & minimal improvement in UOP. Pt did eat dinner @\n . Encouragement of PO intake for free water.\n Response:\n Ongoing. AM Na improved 144. Tolerating diet/PO\ns well.\n Plan:\n Cont to bolus pt w/ fluid HHS. Original plan was to assess\n hydration status via UOP (goal >/= 50cc/hr) which has been\n unsuccessful. ? need to dextrose infusion (which would require tight SS\n coverage) vs.\n NS. Cont to encourage PO intake to obtain free water.\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485032,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS: Pt had MRI/MRA. Pt A&Ox3 when asked questions, but seems\n slightly confused as evidenced by pulling of wires at times.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 129 @ 08a.\n Action:\n Pt given am dose of NPH, no SS coverage necessary for BS 129. BS checks\n changed to QIDACHS and pt placed back on home dose standing glargine at\n bedtime. Pt started eating.\n Response:\n Post starting to eat, BS 263, 264 which were covered appropriately with\n 6 units humalog each time. BS more under control. Neuro team relating\n seizure activity to hyperosmolar hyperglycemic syndrome (HHS).\n Plan:\n Titrate sliding scale if needed. Patient called out.\n Renal failure, acute on chronic\n Assessment:\n Pt with poor UOP (approx 15cc/hr) with am BUN/Cr 36/2.4. Pt with h/o\n baseline CRI with fluctuating Cr.\n Action:\n Pt bolused with 1L LR this am.\n Response:\n Urine output with minimal improvement post bolus. Per patient, he\n usually voids small amts 5 times daily, so most likely dose not make\n large amt at urine at baseline.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time per team, so will not bolus further. Pt called out.\n"
},
{
"category": "Rehab Services",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 485575,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / 345.9\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt. is 72 y.o. male\n presents s/p tonic-clonic seizure observed by wife. During, neuro eval\n in ED, had another seizure. Head CT and EEG were normal suspect seizure\n related to severe hyperglycemia.\n Past Medical / Surgical History: Diabetes mellitus, type 2,\n Hypertension, Renal insufficiency, Colon cancer, s/p resection, Gout ,\n cataracts, Secondary hyperparathyroidism\n Cholelithiasis, Mild diastolic dysfunction\n Medications: Aspirin, Simvastatin, Valsartan, Metoprolol, Minoxidil,\n CloniDINE\n Radiology: MR : No acute infarction. New chronic microvascular\n infarcts since ,\n Labs:\n 29.2\n 9.4\n 125\n 3.8\n [image002.jpg]\n Other labs:\n Activity Orders: As tolerated\n Social / Occupational History: Denies alcohol, cigarettes, IV drug use.\n Married. Lives with wife. Originally from \n Living Environment: + stairs, 1 level home\n Prior Functional Status / Activity Level: PTA\n Objective Test\n Arousal / Attention / Cognition / Communication: A&O x 3, pleasant and\n cooperative\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 58\n 111/58\n 14\n 100 on RA\n Sit\n /\n Activity\n 67\n 124/58\n Stand\n /\n Recovery\n 60\n 157/64\n 15\n 100 on RA\n Total distance walked:\n Minutes:\n Pulmonary Status: BS CTA\n Integumentary / Vascular: L UE PIV\n Sensory Integrity: no c/o parethesias\n Pain / Limiting Symptoms: no c/o pain\n Posture: WNL\n Range of Motion\n Muscle Performance\n Bilat. UEs/LES: WFL throughout\n bilat. UEs/LES: > throughout\n Motor Function: no abnormal movement patterns noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt. amb. 200 ft , no gait deviations noted.\n Rolling:\n Received in sitting\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n T\n\n\n\n\n\n Ambulation:\n T\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: no LOB during ambulation. neg. rhomberg, able to maintain\n upright postures with perturbations\n Education / Communication: Pt. edu re: Role of PT, , d/c plan to\n rehab, RN comm re: pt. status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Knowledge, Impaired\n Clinical impression / Prognosis: Pt. is 72 y.o. male s/p tonic-clonic\n seizures, likely hyperglycemia that p/w above impairments\n associated with increased risk to fall. Pt. appears to be functiioning\n close to baseline and has met all STGs, therefore anticipate d/c home\n once medically stable. No further acute PT needs.\n Goals\n Time frame: met on eval\n 1.\n sit to stand .\n 2.\n Amb. 200 ft. .\n 3.\n Verbalize understanding of Role of PT\n 4.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration:\n d/c acute PT\n Nsg recs: Encourage ambulation 3x/day\n Face time: 14:05-14:33\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-30 00:00:00.000",
"description": "MICU Resident Progress Note",
"row_id": 484947,
"text": "TITLE: Resident Progress Note\n Chief Complaint: \n - Had decreased UO throughout the day, gave 500ml IVF x 3, also had LR\n x 1 liter at 200/hr, later in night still low UO, gave 1 liter over 2\n hours\n - ordered MRA/MRI per neuro\n - advanced to regular diet\n - BS improved to 100-200\n - EEG done\n 24 Hour Events:\n EEG - At 12:00 PM\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.1\nC (97\n HR: 65 (64 - 99) bpm\n BP: 118/49(64) {94/39(60) - 177/124(135)} mmHg\n RR: 15 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,733 mL\n 1,695 mL\n PO:\n 600 mL\n 120 mL\n TF:\n IVF:\n 4,133 mL\n 1,575 mL\n Blood products:\n Total out:\n 1,161 mL\n 70 mL\n Urine:\n 761 mL\n 70 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,572 mL\n 1,625 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n Vitals- BP: 198/108 P: 108 R: 16 100% RA\n Gen- AOx 2 says that year is , well appearing, well nourished,\n NAD\n HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No tongue\n lesions noted.\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly, negative sign\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently, but only intermittently following commands.\n Labs / Radiology\n 127 K/uL\n 9.1 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 36 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n WBC\n 7.0\n Hct\n 27.7\n Plt\n 127\n Cr\n 2.1\n 2.1\n 2.4\n Glucose\n 293\n 99\n 150\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n CXR:\n FINDINGS: There is a retrocardiac opacification, with loss of medial\n diaphragm, concerning for consolidation. Hila prominent bilaterally\n with some\n prominent vasculature, which could be due to fluid overload. No pleural\n effusion or pneumothorax.\n IMPRESSION: Left retrocardiac opacification, concerning for pneumonia\n with\n some associated volume loss.\n Please follow-up by CXR in weeks after therapy for resolution to\n exclude a\n postobstructive process.\n CT HEAD:\n FINDINGS: There is no acute hemorrhage, large acute territorial\n infarction,\n or large masses. There is no shift of midline structures. Ventricles\n and\n sulci are normal in size and configuration. There are subcortical\n hypodensities, likely due to chronic small vessel ischemic changes.\n There is\n no evidence of hydrocephalus. Ventricles and sulci are prominent,\n likely age\n related. There is no evidence of fracture. Visualized portion of\n paranasal\n sinuses and mastoid air cells is within normal limits.\n IMPRESSION: No acute intracranial hemorrhage. Please note that MRI is\n more\n sensitive for acute ischemia, if there is clinical concern.\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n # ? L facial droop: Unsure if new or not.\n - Neuro following\n - MRI/MRA today\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then overnight UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - IVF this AM\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings today, afebrile, no\n coughing\n - d/c ceftriaxone/azithro\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: ICU for now, likely transfer to floor once UO improves\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: hep sc\n Stress ulcer: no ppi needed\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now, likely transfer to floor once UO improves\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 484948,
"text": "Chief Complaint: HHS, seizures, lactic acidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n Intermittently decreased urine output received additional 2.5L fluid\n challenge with little response of his urine output. Creatinine baseline\n about 2.2. EEG performed. MRi/MRA scheduled for noon today.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:30 AM\n Other medications:\n , 81, vitamin C, valsartan, simvastatin, minoxidil, lopressor,\n clonidine, insulin 5NPH , sliding scale, colace , ceftriaxone,\n azithromycin, ceftriaxone.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 63 (63 - 81) bpm\n BP: 129/70(84) {94/39(60) - 159/84(99)} mmHg\n RR: 14 (10 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 4,733 mL\n 2,842 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 4,133 mL\n 2,602 mL\n Blood products:\n Total out:\n 1,161 mL\n 190 mL\n Urine:\n 761 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,572 mL\n 2,652 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed, vitiligo anterior chest\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, Tone: Normal, left facial droop\n Labs / Radiology\n 9.1 g/dL\n 127 K/uL\n 150 mg/dL\n 2.4 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 36 mg/dL\n 113 mEq/L\n 144 mEq/L\n 27.7 %\n 7.0 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n WBC\n 7.0\n Hct\n 27.7\n Plt\n 127\n Cr\n 2.1\n 2.1\n 2.4\n Glucose\n 293\n 99\n 150\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Imaging: CXR resolved atelectasis in the LLL.\n Microbiology: Culture no growth to date.\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF):\n Baseline creatinine about 2.2, urine output borderline many be simply\n secondary to his Chronic renal insufficiency, yet still prerenal by\n FEUN, but failed fluid challenge. Will allow him to reequilibrate and\n follow up creatinine. HOld off onhome torsemide for now. No current\n signs of volume overload.\n HYPERTENSION, BENIGN:\n Holding bblocker, and minoxidiol, and monitoring BP, contniue\n clonidine, and valsartan.\n HYPERGLYCEMIA;\n HONK to prednisone, improved on NPH. Will readjust to home dose\n once diet is well estabilished wtih lantus qhs.\n SEIZURE, WITHOUT STATUS EPILEPTICUS:\n likely in setting of metabolic abnormality from HONK + old seizure\n focus, f/u EEG, f/u MRI/MRA today. Hold off on further anti-seizure\n medications for now. Neuro following.\nMental status improved: ? related to ativan, f/u CSF culture data\nPNA: no signs of this, CXR clear today, will stop ceftriazxone and\n azithro.\n ICU Care\n Nutrition:\n Comments: po diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU after MRI/MRA can transfer to floor if mental status\n improved.\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485251,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n HEENT- NC/AT, EOMI, PERRL,\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly,\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently,\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n # ? L facial droop: MRI no new acute events.\n - Neuro following\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then night prior UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings improved today, afebrile,\n no coughing\n - d/c ceftriaxone/azithro\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: called out to the floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:30 ------\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484643,
"text": "Pt is a 72yo male admitted to MICU 7 via ED with Hyperglycemia and\n Seizures. Pt presented to ED from home after having witnessed seizure\n while in bed. On arrival to pt was post-ictal and was being ruled\n out for CVA---Head Ct was negative. Upon returning to the ED from CT\n scan pt had another seizure and was treated with IV Ativan. Blood\n sugar on admission was 653 and Lactate level was 9.3. Pt received 1.7\n liters of IVF and 10 units IV insulin, IV rocephin and IV Vanco. LP\n was done and was reported as neg. Pt being admitted to MICU for\n management of hyperglycemia and seizure workup with Neuro following.\n Other PMH sig for DM, HTN, Gout, CRI, Neuropathy, colon Ca ---s/p\n resection, cataracts, mild diastolic dysfunction. Pt with an allergy\n to enalapril.\n Events: Arrived via stretcher from ED on cardiac monitor, transferred\n into bed and oriented to MICU environment, wife visited and provided\n additional information, BP on arrival to MICU 209/109, fingerstick 182.\n Hyperglycemia\n Assessment:\n Blood sugar on admission to Ed=686----received 10 units IV regular\n insulin as per report, received 1.7 liters of IV NS, insulin gtt IV\n started briefly (approx. 10 min) in ED but placed on hold when blood\n sugar was 200.\n Action:\n Fingersticks Q 1hr\n Response:\n Improved blood sugar since admission\n Plan:\n Awaiting orders for sliding scale insulin coverage, continue\n fingersticks Q 1hr for now\n Seizure, without status epilepticus\n Assessment:\n Alert and oriented, lethargic but easily arouseable, opens eyes to\n stimulation, PEARL, moving all extremities, mildly restless, following\n all commands, mildly confused to the year but oriented to person and\n date, speech clear but slow, smile symmetrical and tongue midline,\n equal grasps all extremities, lytes WNL, blood glucose <250, no gap, no\n evidence of seizures at present\n Action:\n Freq. neuro checks, seizure precautions, oral airway at bedside, 02 at\n 2 L NC\n Response:\n Remains lethargic from earlier doses of ativan, no seizure activity\n noted\n Plan:\n Continue freq. safety checks, freq. neuro checks, if has another\n seizure then load with 1 gm Dilantin as per Neuro.\n Hypertension, benign\n Assessment:\n Denies H/A, no pain, BP on arrival 209/109, received hydralazine 10 mg\n IV x 2 with slight improvement and BP down to 190\ns/ 100\ns. Received\n 10 mg IV Labetolol with BP down to 160/80\n Action:\n BP treated with hydralzine and labetolol\n Response:\n Good effect from both antihypertensives\n Plan:\n Restart pt on oral meds this am, may give another dose of labetolol 10\n mg if needed\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484645,
"text": "Pt is a 72yo male admitted to MICU 7 via ED with Hyperglycemia and\n Seizures. Pt presented to ED from home after having witnessed seizure\n while in bed. On arrival to pt was post-ictal and was being ruled\n out for CVA---Head Ct was negative. Upon returning to the ED from CT\n scan pt had another seizure and was treated with IV Ativan. Blood\n sugar on admission was 653 and Lactate level was 9.3. Pt received 1.7\n liters of IVF and 10 units IV insulin, IV rocephin and IV Vanco. LP\n was done and was reported as neg. Pt being admitted to MICU for\n management of hyperglycemia and seizure workup with Neuro following.\n Other PMH sig for DM, HTN, Gout, CRI, Neuropathy, colon Ca ---s/p\n resection, cataracts, mild diastolic dysfunction. Pt with an allergy\n to enalapril.\n Events: Arrived via stretcher from ED on cardiac monitor, transferred\n into bed and oriented to MICU environment, wife visited and provided\n additional information, BP on arrival to MICU 209/109, fingerstick 182.\n Hyperglycemia\n Assessment:\n Blood sugar on admission to Ed=686----received 10 units IV regular\n insulin as per report, received 1.7 liters of IV NS, insulin gtt IV\n started briefly (approx. 10 min) in ED but placed on hold when blood\n sugar was 200.\n Action:\n Fingersticks Q 1hr\n Response:\n Improved blood sugar since admission\n Plan:\n Awaiting orders for sliding scale insulin coverage, continue\n fingersticks Q 1hr for now\n Seizure, without status epilepticus\n Assessment:\n Alert and oriented, lethargic but easily arouseable, opens eyes to\n stimulation, PEARL, moving all extremities, mildly restless, following\n all commands, mildly confused to the year but oriented to person and\n date, speech clear but slow, smile symmetrical and tongue midline,\n equal grasps all extremities, lytes WNL, blood glucose <250, no gap, no\n evidence of seizures at present\n Action:\n Freq. neuro checks, seizure precautions, oral airway at bedside, 02 at\n 2 L NC\n Response:\n Remains lethargic from earlier doses of ativan, no seizure activity\n noted\n Plan:\n Continue freq. safety checks, freq. neuro checks, if has another\n seizure then load with 1 gm Dilantin as per Neuro.\n Hypertension, benign\n Assessment:\n Denies H/A, no pain, BP on arrival 209/109, received hydralazine 10 mg\n IV x 2 with slight improvement and BP down to 190\ns/ 100\ns. Received\n 10 mg IV Labetolol with BP down to 160/80\n Action:\n BP treated with hydralzine and labetolol\n Response:\n Good effect from both antihypertensives\n Plan:\n Restart pt on oral meds this am, may give another dose of labetolol 10\n mg if needed\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Critical Care Staff",
"row_id": 484650,
"text": "TITLE: Critical Care\n 72M DM2 presented to ED via EMS s/p seizure witnessed by wife at home.\n Hypertensive, tachy on presentation. Head CT negative. On way back\n from scan another seizure. Glucose noted to be critically high.\n Decadron, CTX, Vanc, LP performed prelim 2wbc. Neuro consulted\n feel\n that is hyperglycemic seizure. Insulin given with good improvement of\n glucose.\n Cont seizure precautions, aggressive management of electrolytes.\n Follow-up LP data to help exclude infection as source. Evaluate other\n potential etiologies. Neuro following.\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484761,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n .\n In the ED, initial vs were: T P 98 BP 177/95 R O2 sat 100% 4L.\n .\n On the floor, he is following commands, but still lethargic and\n delerious.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485354,
"text": "Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Acute Confusion\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485357,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. His hyperglycemia is currently being\n treated with fixed and sliding scale insulin coverage. He has had no\n repeat seizure activity since the day of his admission on . He is\n called out and awaiting bed availability.\n .\n Hypertension, benign\n Assessment:\n Pt initially hypertensive to sbp ~180 last evening. He received all\n scheduled antihypertensive medications with significant improvement in\n his blood pressure.\n Action:\n Received oral antihypertensives.\n Response:\n SBP ranging 110-140\ns overnight.\n Plan:\n Monitor hemodynamic status closely; give oral antihypertensives per\n schedule and parameters.\n Hyperglycemia\n Assessment:\n Pt continues to be moderately hyperglycemic. FS @hs was 292; pt\n received lantus and insulin per hiss. He is receiving diet.\n Action:\n In addition to his daily lantus dose, pt received another 6 units\n Humalog insulin per sliding scale parameters @2200.\n Response:\n Plan:\n Continue to monitor fs qid with sliding scale coverage prior to meals\n and @hs.\n Acute Confusion\n Assessment:\n No evidence of seizure activity. Pt has remained calm and oriented x3\n throughout the night. Although his bed alarm is turned on, he has made\n no attempt to get oob and has been unrestrained. No evidence of acute\n agitation or inappropriate behavior.\n Action:\n None; no evidence of\nsun downing\n behavior overnight.\n Response:\n Oriented; appropriate.\n Plan:\n Monitor mental status, evidence of acute change, agitation.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley is patent and intact, draining clear, yellow urine. UOP\n ~20-50cc/hr.\n Action:\n Pt making marginal amounts of urine at times; micu resident is aware\n and will continue to monitor output.\n Response:\n Unchanged.\n Plan:\n Monitor serial bun/creat results, uop.\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485403,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. His hyperglycemia is currently being\n treated with fixed and sliding scale insulin coverage. He has had no\n repeat seizure activity since the day of his admission on . He is\n called out and awaiting bed availability.\n .\n Hypertension, benign\n Assessment:\n Pt initially hypertensive to sbp ~180 last evening. He received all\n scheduled antihypertensive medications with significant improvement in\n his blood pressure.\n Action:\n Received oral antihypertensives.\n Response:\n SBP ranging 110-140\ns overnight.\n Plan:\n Monitor hemodynamic status closely; give oral antihypertensives per\n schedule and parameters.\n Hyperglycemia\n Assessment:\n Pt continues to be moderately hyperglycemic. FS @hs was 292; pt\n received lantus and insulin per hiss. He is receiving diet.\n Action:\n In addition to his daily lantus dose, pt received another 6 units\n Humalog insulin per sliding scale parameters @2200.\n Response:\n Plan:\n Continue to monitor fs qid with sliding scale coverage prior to meals\n and @hs.\n Acute Confusion\n Assessment:\n No evidence of seizure activity. Pt has remained calm and oriented x3\n throughout the night. Although his bed alarm is turned on, he has made\n no attempt to get oob and has been unrestrained. No evidence of acute\n agitation or inappropriate behavior.\n Action:\n None; no evidence of\nsun downing\n behavior overnight.\n Response:\n Oriented; appropriate.\n Plan:\n Monitor mental status, evidence of acute change, agitation.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley is patent and intact, draining clear, yellow urine. UOP\n ~20-50cc/hr.\n Action:\n Pt making marginal amounts of urine at times; micu resident is aware\n and will continue to monitor output.\n Response:\n Unchanged.\n Plan:\n Monitor serial bun/creat results, uop.\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485409,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. His hyperglycemia is currently being\n treated with fixed and sliding scale insulin coverage. He has had no\n repeat seizure activity since the day of his admission on . He is\n called out and awaiting bed availability.\n .\n Hypertension, benign\n Assessment:\n Pt initially hypertensive to sbp ~180 last evening. He received all\n scheduled antihypertensive medications with significant improvement in\n his blood pressure.\n Action:\n Received oral antihypertensives.\n Response:\n SBP ranging 110-140\ns overnight.\n Plan:\n Monitor hemodynamic status closely; give oral antihypertensives per\n schedule and parameters.\n Hyperglycemia\n Assessment:\n Pt continues to be moderately hyperglycemic. FS @hs was 292; pt\n received lantus and insulin per hiss. He is receiving diet.\n Action:\n In addition to his daily lantus dose, pt received another 6 units\n Humalog insulin per sliding scale parameters @2200.\n Response:\n Plan:\n Continue to monitor fs qid with sliding scale coverage prior to meals\n and @hs.\n Acute Confusion\n Assessment:\n No evidence of seizure activity. Pt has remained calm and oriented x3\n throughout the night. Although his bed alarm is turned on, he has made\n no attempt to get oob and has been unrestrained. No evidence of acute\n agitation or inappropriate behavior.\n Action:\n None; no evidence of\nsun downing\n behavior overnight.\n Response:\n Oriented; appropriate.\n Plan:\n Monitor mental status, evidence of acute change, agitation.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley is patent and intact, draining clear, yellow urine. UOP\n ~20-50cc/hr.\n Action:\n Pt making marginal amounts of urine at times; micu resident is aware\n and will continue to monitor output.\n Response:\n Unchanged.\n Plan:\n Monitor serial bun/creat results, uop.\n"
},
{
"category": "Physician ",
"chartdate": "2150-09-01 00:00:00.000",
"description": "MICU Resident Progress Note",
"row_id": 485487,
"text": "MICU Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n No overnight events. Still awaiting bed assignment on floor.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:14 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98\n HR: 61 (60 - 82) bpm\n BP: 152/64(84) {102/47(61) - 177/76(95)} mmHg\n RR: 17 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,440 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,055 mL\n 160 mL\n Urine:\n 1,055 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n -160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 125 K/uL\n 9.4 g/dL\n 101 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 116 mEq/L\n 147 mEq/L\n 29.2 %\n 3.8 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n 04:45 AM\n WBC\n 7.0\n 6.6\n 3.8\n Hct\n 27.7\n 34.4\n 29.2\n Plt\n 127\n 158\n 125\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n 101\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n # ? L facial droop: MRI no new acute events.\n - Neuro following\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then night prior UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings improved today, afebrile,\n no coughing\n - d/c ceftriaxone/azithro\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n # Gout : stable\n - continue allopurinol\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals 18g x2\n # Code: Confirmed full\n # Communication: Wife \n # Disposition: called out to the floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-29 00:00:00.000",
"description": "MICU Fellow Progress Note",
"row_id": 484733,
"text": "TITLE:\n Chief Complaint: seizure, hyperglycemic hyperosmotic syndrome\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72yo M with PMH DMT2, chronic renal insufficiency, hypertension and\n mild diastolic dysfunction who was brought in with seizure. Was in\n usual state of health until Thursday when he noticed some shakiness in\n his L hand, then last night had increased fatigue and lethargy and was\n found to be seizing by his wife. with seizure, given ativan 2mg\n and seizure activity broke. In the ED was sent to head CT, which\n showed old L frontal infarct but nothing acute, and had repeat GTC\n seizure that broke again with 2mg ativan. Labs revealed BS of >600 and\n he was given insulin IV and then gtt, and IVF (total 2.5L). No sodium\n was checked at that time, and the patient was then transferred to the\n ICU. He also had an LP that showed no evidence of infection. Sodium\n just prior to transfer was 147, lactate 12.1. Following transfer, the\n patient was found to have BS of 170s and insulin drip was\n discontinued. He was noted to be slightly lethargic and delirious.\n The patient's wife reports that he has been very adherent to his\n diabetes regimen, that he has never been hospitalized for his blood\n sugars before. Of note, patient was recently given prednisone for a\n gout flare. He has no known history of seizure activity. Patient\n denies any pain, including no headache, no abdominal pain, no cough, no\n fevers/chills at home.\n History obtained from Patient, limited by somnolence\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 05:25 AM\n Labetalol - 05:40 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DMt2, on Lantus 9u daily at home\n Chronic renal insufficiency\n Gout\n Hypertension\n Secondary hyperparathyroidism\n H/o Colon cancer, s/p cancer\n No family history of seizures\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 84 (84 - 109) bpm\n BP: 146/83(97) {146/83(97) - 209/124(135)} mmHg\n RR: 16 (14 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,169 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,049 mL\n Blood products:\n Total out:\n 0 mL\n 620 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 549 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, somnolent\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:3.4 mmol/L\n Assessment and Plan\n Seizure: ? secondary to hyperosmotic state with prior stroke as\n trigger focus\n - ongoing change in mental status ? secondary to ativan v. post-ictal\n v. status\n - per neuro, EEG this morning to r/o further seizure activity\n - for MRI in the future\n - checking CK given prolonged seizure\n Hyperglcemia\n - improved, will manage with subcutaneous insulin\n - start NPH 5u and checking blood sugars q2h\n - re-check electrolytes now\n - will give more IVF if urine output drops to <50cc/hr\nHypertension\n - SBP was >200 in the ED, now improved s/p hydralazine and labetalol\n - restarting home meds today, SBP now 140s\n ? Pneumonia: focal consolidtion on cxr\n - will start ceftriaxone/azithromycin for ? CAP\n - may be more likely aspiration from seizure\n ICU Care\n Nutrition:\n Glycemic Control: Comments: titrating diabetes regimen\n Lines / Intubation:\n 18 Gauge - 05:19 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n Comments: seizure precautions\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484791,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n .\n In the ED, initial vs were: T P 98 BP 177/95 R O2 sat 100% 4L.\n .\n On the floor, he is following commands, but still lethargic and\n delerious.\n Hypertension, benign\n Assessment:\n Pt received with systolic BPs 180s-190s after having received 20mg IV\n hydral and 10mg IV labetalol.\n Action:\n Pt given home dose BP meds (metoprolol, clonidine) @ 08. Then received\n other home dose meds (valsartan, minoxidil) @ 12.\n Response:\n BP down to 140s-150s post 0800 meds. Post 1200 meds, BP down to\n 120s-130s.\n Plan:\n Cont with home dose BP meds.\n Hyperglycemia\n Assessment:\n BS @ 0900 post 1L 1/2NS 301, rechecked @ 10 for 318.\n Action:\n BS monitored Q2 but with Q4 insulin coverage. Pt given 8 units Humalog\n to cover BS of 318 @ 10. Fixed insulin dose changed to 5 units of NPH @\n breakfast, 4 units NPH @ bedtime. 5 units NPH given @ 11. FSBS\n rechecked @ 12 for 284, pt given 1x dose of 3 units Humalog. At 1600\n pt\ns BS 181 and pt given 2 units Humalog.\n Response:\n 1800 BS 139.\n Plan:\n Cont to monitor Q2 hr BS and provide SS insulin coverage Q4hrs. Cont\n fixed dose insulin.\n Seizure, without status epilepticus\n Assessment:\n Pt admitted s/p 2 long lasting tonic clonic seizures. No seizure\n activity noted this shift. Pt A&Ox3, pupils equal/reactive, \n strength in all extremities, extremely somnolent/lethargic.\n Action:\n Seizure pads on bed. Pt seen by neuro and had EEG. Team thinks likely\n cause of seizures is hyperosmolar hyperglycemic syndrome.\n Response:\n Neuro with no plan for putting patient\ns on anti seizure meds.\n Plan:\n F/U EEG results, neuro recs. Cont to monitor neuro status.\n ------ Protected Section ------\n Team wants UOP to be atleast 50cc/hr HHS as they feel pt was\n extremely volume depleted on admission and they are using UOP to\n monitor fluid status.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:44 ------\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485146,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS:\n MRI/A completed\n PIV x 2\n Full Code\n Wife updated this am by this RN.\n AM BP meds given early elevated SBP >180\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 196 @ MN.\n Action:\n BS checks changed to QIDACHS. Glargine 9 units given @ 2200 (pt\ns home\n dose). Pt has also been eating since evening of .\n Response:\n Neuro team relating seizure activity to hyperosmolar hyperglycemic\n syndrome (HHS). Blood sugars improving. Humalog sliding scale coverage\n provided as needed. (please see Metavision/ for UTD information)\n Plan:\n Titrate sliding scale if needed. Patient called out.\n Renal failure, acute on chronic\n Assessment:\n Pt with h/o baseline CRI with fluctuating Cr. UOP has improved O/N.\n 20-50cc/hr. AM Cr 2.3 (yesterday 2.4)\n Action:\n UOP improving. No further need to bolus @ this time per MICU team.\n Response:\n Per patient, he usually voids small amts 5 times daily, so most likely\n dose not make large amt at urine at baseline. Improved PO intake.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time per team, so will not bolus further.\n Acute Confusion\n Assessment:\n Pt has become increasingly restless O/N. Remains A&Ox3 but is\n frequently pulling @ and trying to remove lines/tubes. Pt has become\n entangled in cardiac wires (around neck) more than once.\n Action:\n Frequent orientation/reinforcement (~ Q20min) Haldol 0.5mg IV x 1.\n (attempting to avoid chemical restraint admission hx of HHS w/ sz\n activity) 4 side rails up. Bed alarm. Bilateral wrist restraints\n applied for safety.\n Response:\n Pt has had cont periods of agitation but remains A&Ox3. Waist belt\n applied this am.\n Plan:\n Cont to monitor MS. (per wife, pt is often agitated & restless @ home\n as well) Remove restraints when pt can demonstrate improved safety.\n Avoid chemical restraint.\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485153,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE CONFUSION\n HYPERGLYCEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485154,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Vitals- BP: 198/108 P: 108 R: 16 100% RA\n Gen- AOx 2 says that year is , well appearing, well nourished,\n NAD\n HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No tongue\n lesions noted.\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly, negative sign\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently, but only intermittently following commands.\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ACUTE CONFUSION\n HYPERGLYCEMIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 485155,
"text": "Chief Complaint:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:30 PM\n - less somnolent today\n - MRI/MRA completed with no acute infarction; new chronic microvascular\n infarcts since \n - d/c'ed ceftriaxon and azithro\n - changed insulin regimen to glargine\n - urine lytes c/w prerenal\n - neuro recs: hold off on starting AEDs for now and follow him\n clinically. Would also advise him not to drive for 6 months given his\n diabetes and recent seizures. Should follow up in epilepsy clinic.\n - EEG: no seizures per neuro attdg\n - hypertensive in the late afternoon, gave home bp meds and improved\n - agitated overnight, needed redirection several times, given haldol\n 0.5 mg x 1, and restrained as pulling off leads, gown.\n - called out but no bed\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Haloperidol (Haldol) - 12:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.2\nC (97.1\n HR: 92 (63 - 98) bpm\n BP: 189/70(97) {92/40(57) - 189/88(104)} mmHg\n RR: 16 (13 - 20) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,770 mL\n 600 mL\n PO:\n 1,080 mL\n 600 mL\n TF:\n IVF:\n 2,690 mL\n Blood products:\n Total out:\n 557 mL\n 325 mL\n Urine:\n 557 mL\n 325 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,213 mL\n 275 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Vitals- BP: 198/108 P: 108 R: 16 100% RA\n Gen- AOx 2 says that year is , well appearing, well nourished,\n NAD\n HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No tongue\n lesions noted.\n Neck: supple, JVP not elevated\n Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT\n pulses\n Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular\n or subcostal retractions\n Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no\n organomegaly, negative sign\n Skin- no rashes, lesions\n Extremities/Spine: extremities warm and well perfused, no clubbing,\n cyanosis, trace lower extremity edema\n Neurologic: no focal deficits, CN II-XII intact, moving all 4\n extremities independently, but only intermittently following commands.\n Labs / Radiology\n 158 K/uL\n 10.9 g/dL\n 117 mg/dL\n 2.3 mg/dL\n 22 mEq/L\n 3.6 mEq/L\n 33 mg/dL\n 109 mEq/L\n 144 mEq/L\n 34.4 %\n 6.6 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n WBC\n 7.0\n 6.6\n Hct\n 27.7\n 34.4\n Plt\n 127\n 158\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.5 mg/dL, Mg++:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n .\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but seems to be clearing.\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - MRI/MRA to look for CVA\n - F/u CSF cultures\n - F/u Neuro recs\n - EEG f/u result\n .\n # ? L facial droop: Unsure if new or not.\n - Neuro following\n - MRI/MRA today\n .\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - Restarted home meds, but with holding parameters\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - NPH as long acting \n start glargine tonight\n - FS QIDACHS\n .\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then overnight UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - IVF this AM\n - PM renal function\n - monitor UOP\n - hold diuretics\n # Pneumonia: Less likely given CXR findings today, afebrile, no\n coughing\n - d/c ceftriaxone/azithro\n .\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n .\n # Gout : stable\n - continue allopurinol\n .\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n .\n # Access: peripherals 18g x2\n .\n # Code: Confirmed full\n .\n # Communication: Wife \n .\n # Disposition: ICU for now, likely transfer to floor once UO improves\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485580,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications. Zemplar still on hold.\n Transfer to floor. Had PT eval today. Steady on his feet this am.\n Possible discharge home . Foley dc\nd 1200, dtv 2000hrs.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERGLYCEMIA,SEIZURES\n Code status:\n Full code\n Height:\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CRI, Colon Ca---s/p resection, gout, cataracts,\n mild diasolic dysfunction\n :\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:58\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 58 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 120 mL\n 24h total out:\n 335 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:45 AM\n Potassium:\n 4.2 mEq/L\n 04:45 AM\n Chloride:\n 116 mEq/L\n 04:45 AM\n CO2:\n 23 mEq/L\n 04:45 AM\n BUN:\n 34 mg/dL\n 04:45 AM\n Creatinine:\n 2.3 mg/dL\n 04:45 AM\n Glucose:\n 101 mg/dL\n 04:45 AM\n Hematocrit:\n 29.2 %\n 04:45 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: none\n Transferred from: MICU 792\n Transferred to: CC 712\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2150-08-29 00:00:00.000",
"description": "MICU Fellow Progress Note",
"row_id": 484740,
"text": "TITLE:\n Chief Complaint: seizure, hyperglycemic hyperosmotic syndrome\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 72yo M with PMH DMT2, chronic renal insufficiency, hypertension and\n mild diastolic dysfunction who was brought in with seizure. Was in\n usual state of health until Thursday when he noticed some shakiness in\n his L hand, then last night had increased fatigue and lethargy and was\n found to be seizing by his wife. with seizure, given ativan 2mg\n and seizure activity broke. In the ED was sent to head CT, which\n showed old L frontal infarct but nothing acute, and had repeat GTC\n seizure that broke again with 2mg ativan. Labs revealed BS of >600 and\n he was given insulin IV and then gtt, and IVF (total 2.5L). No sodium\n was checked at that time, and the patient was then transferred to the\n ICU. He also had an LP that showed no evidence of infection. Sodium\n just prior to transfer was 147, lactate 12.1. Following transfer, the\n patient was found to have BS of 170s and insulin drip was\n discontinued. He was noted to be slightly lethargic and delirious.\n The patient's wife reports that he has been very adherent to his\n diabetes regimen, that he has never been hospitalized for his blood\n sugars before. Of note, patient was recently given prednisone for a\n gout flare. He has no known history of seizure activity. Patient\n denies any pain, including no headache, no abdominal pain, no cough, no\n fevers/chills at home.\n History obtained from Patient, limited by somnolence\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 05:25 AM\n Labetalol - 05:40 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DMt2, on Lantus 9u daily at home\n Chronic renal insufficiency\n Gout\n Hypertension\n Secondary hyperparathyroidism\n H/o Colon cancer, s/p cancer\n No family history of seizures\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 10:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 84 (84 - 109) bpm\n BP: 146/83(97) {146/83(97) - 209/124(135)} mmHg\n RR: 16 (14 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,169 mL\n PO:\n 120 mL\n TF:\n IVF:\n 1,049 mL\n Blood products:\n Total out:\n 0 mL\n 620 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 549 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, somnolent\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:3.4 mmol/L\n Assessment and Plan\n Seizure: ? secondary to hyperosmotic state with prior stroke as\n trigger focus\n - ongoing change in mental status ? secondary to ativan v. post-ictal\n v. status\n - per neuro, EEG this morning to r/o further seizure activity\n - for MRI in the future\n - checking CK given prolonged seizure\n Hyperglcemia\n - improved, will manage with subcutaneous insulin\n - start NPH 5u and checking blood sugars q2h\n - re-check electrolytes now\n - will give more IVF if urine output drops to <50cc/hr\nHypertension\n - SBP was >200 in the ED, now improved s/p hydralazine and labetalol\n - restarting home meds today, SBP now 140s\n ? Pneumonia: focal consolidtion on cxr\n - will start ceftriaxone/azithromycin for ? CAP\n - may be more likely aspiration from seizure\n ICU Care\n Nutrition:\n Glycemic Control: Comments: titrating diabetes regimen\n Lines / Intubation:\n 18 Gauge - 05:19 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n Comments: seizure precautions\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 72M with DM recently placed on prednisone for gout\n presents with 2\n seizures, 1 with high glucose and the second as glucose was falling\n quickly. Now sleepy but arousable. He has been treated for\n hyperglycemia. No anti-seizure meds have been started.\n Exam notable for Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 84 (84 - 109) bpm\n BP: 146/83(97) {146/83(97) - 209/124(135)} mmHg\n RR: 16 (14 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Sleepy but arousable, following simple commands, moving all 4\n extremities\n Neck supple\n Hrt rrr\n Lungs clear\n Abd benign\n Extreme no edema\n Labs reviewed and recorded in housestaff note\n Imaging: CXR ? retrocardic infiltrate\n Problems: seizure, hyperglycemia, gout, ? pna, HTN\n Agree with plan to follow neuro exam, continue insulin, cont abx, cont\n anti-hypertensives\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 14:36 ------\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484783,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n .\n In the ED, initial vs were: T P 98 BP 177/95 R O2 sat 100% 4L.\n .\n On the floor, he is following commands, but still lethargic and\n delerious.\n Hypertension, benign\n Assessment:\n Pt received with systolic BPs 180s-190s after having received 20mg IV\n hydral and 10mg IV labetalol.\n Action:\n Pt given home dose BP meds (metoprolol, clonidine) @ 08. Then received\n other home dose meds (valsartan, minoxidil) @ 12.\n Response:\n BP down to 140s-150s post 0800 meds. Post 1200 meds, BP down to\n 120s-130s.\n Plan:\n Cont with home dose BP meds.\n Hyperglycemia\n Assessment:\n BS @ 0900 post 1L 1/2NS 301, rechecked @ 10 for 318.\n Action:\n BS monitored Q2 but with Q4 insulin coverage. Pt given 8 units Humalog\n to cover BS of 318 @ 10. Fixed insulin dose changed to 5 units of NPH @\n breakfast, 4 units NPH @ bedtime. 5 units NPH given @ 11. FSBS\n rechecked @ 12 for 284, pt given 1x dose of 3 units Humalog. At 1600\n pt\ns BS 181 and pt given 2 units Humalog.\n Response:\n 1800 BS 139.\n Plan:\n Cont to monitor Q2 hr BS and provide SS insulin coverage Q4hrs. Cont\n fixed dose insulin.\n Seizure, without status epilepticus\n Assessment:\n Pt admitted s/p 2 long lasting tonic clonic seizures. No seizure\n activity noted this shift. Pt A&Ox3, pupils equal/reactive, \n strength in all extremities, extremely somnolent/lethargic.\n Action:\n Seizure pads on bed. Pt seen by neuro and had EEG. Team thinks likely\n cause of seizures is hyperosmolar hyperglycemic syndrome.\n Response:\n Neuro with no plan for putting patient\ns on anti seizure meds.\n Plan:\n F/U EEG results, neuro recs. Cont to monitor neuro status.\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 484973,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 146 @ change of shift.\n Action:\n BS monitored Q2-4 w/ Q4 insulin (Humalog) coverage. BS ranging 146-260.\n (please see Metavision/med sheets for respective amts) Pt also received\n NPH 5 units @ 2200. LR 500cc x 2 for decreased UOP w/ additional liter\n initiated @ 0530\n Response:\n BS improving. Neuro team relating sz activity to hyperosmolar\n hyperglycemic syndrome (HHS) UOP remains poor.\n Plan:\n Titrate sliding scale if needed. Transition pt to Q6hr coverage\n (consult if remains problem)\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Received pt w/ poor UOP. 25-40cc/hr. BUN/Cr 32/2.1. UOP trending down\n 0-30 throughout the night. (Dr. aware. Na @ 1900 146\n Action:\n LR 500cc X 2. Additional liter over 2 hrs started @ 0530 for increasing\n BUN/Cr of 36/2.4 & minimal improvement in UOP. Pt did eat dinner @\n . Encouragement of PO intake for free water.\n Response:\n Ongoing. AM Na improved 144. Tolerating diet/PO\ns well.\n Plan:\n Cont to bolus pt w/ fluid HHS. Original plan was to assess\n hydration status via UOP (goal >/= 50cc/hr) which has been\n unsuccessful. ? need to dextrose infusion (which would require tight SS\n coverage) vs.\n NS. Cont to encourage PO intake to obtain free water.\n EVENTS:\n"
},
{
"category": "Nursing",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485149,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS:\n MRI/A completed\n PIV x 2\n Full Code\n Wife updated this am by this RN.\n AM BP meds given early elevated SBP >180\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 196 @ MN.\n Action:\n BS checks changed to QIDACHS. Glargine 9 units given @ 2200 (pt\ns home\n dose). Pt has also been eating since evening of .\n Response:\n Neuro team relating seizure activity to hyperosmolar hyperglycemic\n syndrome (HHS). Blood sugars improving. Humalog sliding scale coverage\n provided as needed. (please see Metavision/ for UTD information)\n Plan:\n Titrate sliding scale if needed. Patient called out.\n Renal failure, acute on chronic\n Assessment:\n Pt with h/o baseline CRI with fluctuating Cr. UOP has improved O/N.\n 20-50cc/hr. AM Cr 2.3 (yesterday 2.4)\n Action:\n UOP improving. No further need to bolus @ this time per MICU team.\n Response:\n Per patient, he usually voids small amts 5 times daily, so most likely\n dose not make large amt at urine at baseline. Improved PO intake.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time per team, so will not bolus further.\n Acute Confusion\n Assessment:\n Pt has become increasingly restless O/N. Remains A&Ox3 but is\n frequently pulling @ and trying to remove lines/tubes. Pt has become\n entangled in cardiac wires (around neck) more than once.\n Action:\n Frequent orientation/reinforcement (~ Q20min) Haldol 0.5mg IV x 1.\n (attempting to avoid chemical restraint admission hx of HHS w/ sz\n activity) 4 side rails up. Bed alarm. Bilateral wrist restraints\n applied for safety.\n Response:\n Pt has had cont periods of agitation but remains A&Ox3. Waist belt\n applied this am.\n Plan:\n Cont to monitor MS. (per wife, pt is often agitated & restless @ home\n as well) Remove restraints when pt can demonstrate improved safety.\n Avoid chemical restraint\n"
},
{
"category": "ECG",
"chartdate": "2150-08-28 00:00:00.000",
"description": "Report",
"row_id": 258987,
"text": "Sinus tachycardia, rate 127. There are slight non-specific ST-T wave changes in\nleads I, II, aVF and leads V4-V6. Consider left atrial abnormality. Compared\nto the previous tracing of , except for the change in rate, no other\ndiagnostic interval change.\n\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485543,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications. Zemplar still on hold.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERGLYCEMIA,SEIZURES\n Code status:\n Full code\n Height:\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CRI, Colon Ca---s/p resection, gout, cataracts,\n mild diasolic dysfunction\n :\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:58\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 58 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 120 mL\n 24h total out:\n 335 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:45 AM\n Potassium:\n 4.2 mEq/L\n 04:45 AM\n Chloride:\n 116 mEq/L\n 04:45 AM\n CO2:\n 23 mEq/L\n 04:45 AM\n BUN:\n 34 mg/dL\n 04:45 AM\n Creatinine:\n 2.3 mg/dL\n 04:45 AM\n Glucose:\n 101 mg/dL\n 04:45 AM\n Hematocrit:\n 29.2 %\n 04:45 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: none\n Transferred from: MICU 792\n Transferred to: CC 712\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485544,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications. Zemplar still on hold.\n Transfer to floor. Due for PT eval, ordered yestereday. Steady on his\n feet this am. Possible discharge home .\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERGLYCEMIA,SEIZURES\n Code status:\n Full code\n Height:\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CRI, Colon Ca---s/p resection, gout, cataracts,\n mild diasolic dysfunction\n :\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:58\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 58 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 120 mL\n 24h total out:\n 335 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:45 AM\n Potassium:\n 4.2 mEq/L\n 04:45 AM\n Chloride:\n 116 mEq/L\n 04:45 AM\n CO2:\n 23 mEq/L\n 04:45 AM\n BUN:\n 34 mg/dL\n 04:45 AM\n Creatinine:\n 2.3 mg/dL\n 04:45 AM\n Glucose:\n 101 mg/dL\n 04:45 AM\n Hematocrit:\n 29.2 %\n 04:45 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: none\n Transferred from: MICU 792\n Transferred to: CC 712\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485551,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications. Zemplar still on hold.\n Transfer to floor. Due for PT eval, ordered yestereday. Steady on his\n feet this am. Possible discharge home . Foley dc\nd 1200, dtv\n 2000hrs.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERGLYCEMIA,SEIZURES\n Code status:\n Full code\n Height:\n Admission weight:\n 74 kg\n Daily weight:\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CRI, Colon Ca---s/p resection, gout, cataracts,\n mild diasolic dysfunction\n :\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:58\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 58 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 120 mL\n 24h total out:\n 335 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:45 AM\n Potassium:\n 4.2 mEq/L\n 04:45 AM\n Chloride:\n 116 mEq/L\n 04:45 AM\n CO2:\n 23 mEq/L\n 04:45 AM\n BUN:\n 34 mg/dL\n 04:45 AM\n Creatinine:\n 2.3 mg/dL\n 04:45 AM\n Glucose:\n 101 mg/dL\n 04:45 AM\n Hematocrit:\n 29.2 %\n 04:45 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: none\n Transferred from: MICU 792\n Transferred to: CC 712\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2150-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485316,
"text": "72 yo M w/ DMII p/w hyperglycemia, hypertension and seizure. Up until\n Thursday had been feeling well, then Thursday he noted that his R had\n was shaking. Tonight had lethargy, no focal symptoms, just not feeling\n well and ate dinner with his wife. then went went to bed. His wife\n checked on him at about 21:30 and found him in tonic-clonic seizure. .\n He was brought to the ED by EMS his VS on arrival were 98.9, 130,\n 192/122, 17 96%NRB. Got head CT and had another Sz on the way back from\n CT. Glucose critically high. Got 2mg ativan. Got 10 Units IV insulin.\n Got decadron, CTX, vanc. LP done but difficult. got 1mg more ativan. AG\n 21. Got 2.5L NS. UOP has been 500cc since 2330. Neuro saw him and felt\n most likely hyperglycemia, but checked LP and no e/o infection.\n LFTs normal. Neuro said if more sz start dilantin load 1g IV then 100mg\n TID. Goal level . Pt. was noted to be \"post-ictal\" in the ED, not\n responding to commands.\n EVENTS:\n MRI/A completed\n PIV x1\n Full Code\n Wife updated this afternoon by this RN.\n Hyperglycemia\n Assessment:\n Received pt AA&Ox3. MAE, following commands. BS 143, 12p 288, 5p 277.\n Action:\n BS checks changed to QIDACHS. Provided with sliding scale humalog 6\n units x2. Glargine 9 units at bedtime.\n Response:\n Neuro team relating seizure activity to hyperosmolar hyperglycemic\n syndrome (HHS). Blood sugars improving. Humalog sliding scale coverage\n provided as needed. (please see Metavision/ for UTD information)\n Plan:\n Titrate sliding scale if needed. Patient called out, since sunday.\n Renal failure, acute on chronic\n Assessment:\n Pt with h/o baseline CRI with fluctuating Cr. UOP has improved\n 20-50cc/hr. AM Cr 2.3 (yesterday 2.4)\n Action:\n UOP improving.\n Response:\n Per patient, he usually voids small amts 5 times daily, so most likely\n dose not make large amt at urine at baseline. Improved PO intake.\n Plan:\n Cont to monitor BUN/Cr. Pt\ns fluid status seems to be corrected at this\n time.\n Acute Confusion\n Assessment:\n Pt has been restless this morning, is frequently pulling @ and trying\n to remove lines/tubes, tries to sit on edge of bed. With questioning is\n alert and oriented, follows commands, easily redirectable. When not\n supervised resumed picking and pulling at tubes and lines. Lap belt on\n for safety, by 10 am A&O, pleasant cooperative, waist belt removed.\n Action:\n Frequent orientation/reinforcement, 4 side rails up. Bed alarm. For\n safety.\n Response:\n Mental status returned closer to baseline as day progressed.\n Plan:\n Cont to monitor MS. (per wife, pt is often agitated & restless @ home\n as well) maintain safety\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485542,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications.\n"
},
{
"category": "Physician ",
"chartdate": "2150-09-01 00:00:00.000",
"description": "MICU Resident Progress Note",
"row_id": 485535,
"text": "MICU Resident Progress Note\n 24 Hour Events:\n No overnight events. Still awaiting bed assignment on floor. No report\n of sundowning.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Azithromycin - 11:00 AM\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:14 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98\n HR: 61 (60 - 82) bpm\n BP: 152/64(84) {102/47(61) - 177/76(95)} mmHg\n RR: 17 (13 - 22) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,440 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,055 mL\n 160 mL\n Urine:\n 1,055 mL\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n -160 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 125 K/uL\n 9.4 g/dL\n 101 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 116 mEq/L\n 147 mEq/L\n 29.2 %\n 3.8 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n 04:45 AM\n WBC\n 7.0\n 6.6\n 3.8\n Hct\n 27.7\n 34.4\n 29.2\n Plt\n 127\n 158\n 125\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n 101\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n 3:00 am CSF;SPINAL FLUID TUBE 3.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n This is a concentrated smear made by cytospin method, please refer to\n hematology for a quantitative white blood cell count..\n FLUID CULTURE (Final ): NO GROWTH.\n UCx neg\n BCx NGTD\n EEG\n IMPRESSION: This is a mildly abnormal extended routine EEG due to low\n voltage of the background rhythm with diffuse beta activity. There were\n no focal, lateralized, or epileptiform features noted.\n MRI/MRA head:\n IMPRESSION:\n 1. Motion-limited head MRI and MRA.\n 2. No acute infarction. New chronic microvascular infarcts since .\n 3. Unremarkable head MRA.\n Assessment and Plan\n 72 yo M w/ hyperglycemia, hypernatremia, hypertension and seizure,\n mental status improving.\n #Seizure: Possile causes are hyperglycemia vs could be due to prior CVA\n seen on CT scan. CSF w/ 2 WBCs and 1 RBC so does not appear\n meningitis/encephalitis. Tox screen negative. His altered mental status\n is now likely post ictal vs from ativan. but clearing today. MRI/MRA\n negative for acute stroke\n - monitor glucose\n - Dilantin 1g loading dose if seizes again\n - F/u CSF cultures\n - F/u Neuro recs\n # ? L facial droop: MRI no new acute events.\n - Neuro following\n #HTN: Urgency on arrival to the ICU. HTN may have been from Sz, now\n improved. His somnolence seemed to improve w/ treatment of BP. Likely\n that he missed a dose or two of his home meds. He is on minoxidil so\n likely very poorly controlled HTN at baseline.\n - on current home regiimen\n - monitor BPs\n # Hyperglycemia/Diabetes: improved significantly with hydration.\n Likely worse due to recent prednisone use.\n - Insulin SS\n - Glargien currently\n - FS QIDACHS\n # Acute renal failure: Cr was elevated on admission, was improving with\n fluids then night prior UO decreased and Cr rose again. Concerning for\n prerenal state in setting of HHS. FeNa/Fe Urea c/w prerenal this AM.\n - monitor UOP\n - hold diuretics\n # dCHF: Volume down currently\n - Continue metoprolol, valsartan\n - Hold torsemide given dehydration, can restart if s/s of volume\n overload\n # Gout : stable\n - continue allopurinol\n # FEN: No IVF, replete electrolytes, regular diet\n .\n # Prophylaxis: Subcutaneous heparin\n # Access: peripherals 18g x2\n # Code: Confirmed full\n # Communication: Wife \n # Disposition: called out to the floor\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: HSQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 485536,
"text": "Chief Complaint: Seizures, hyperglycemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n CALLED OUT awaiting bed.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:14 PM\n Other medications:\n MVI, asa 81, Vitamin C, valsartin, simvastatin, clonidine, colace,\n HISS, lantus s/c\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 59 (55 - 82) bpm\n BP: 118/49(65) {103/47(61) - 177/76(95)} mmHg\n RR: 24 (11 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,440 mL\n 120 mL\n PO:\n 1,440 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,055 mL\n 300 mL\n Urine:\n 1,055 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal, facial droop resolved\n Labs / Radiology\n 9.4 g/dL\n 125 K/uL\n 101 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 116 mEq/L\n 147 mEq/L\n 29.2 %\n 3.8 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n 04:45 AM\n WBC\n 7.0\n 6.6\n 3.8\n Hct\n 27.7\n 34.4\n 29.2\n Plt\n 127\n 158\n 125\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n 101\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\nSeizure: neuro exam improved, MRI,. EEG negative\nAmbulation: consult PT\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF):\n resolved back at baseline.\n HYPERTENSION, BENIGN:\n continue home regimen. hold off resuming home diuretics for now given\n hypernateremia\nHypernatremia: recheck lytes, continue po diet.\n Diabetes: continue glargine\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: glargine\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 485538,
"text": "Chief Complaint: Seizures, hyperglycemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n CALLED OUT awaiting bed.\n Allergies:\n Enalapril\n Cough;\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:14 PM\n Other medications:\n MVI, asa 81, Vitamin C, valsartin, simvastatin, clonidine, colace,\n HISS, lantus s/c\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.7\nC (98.1\n HR: 59 (55 - 82) bpm\n BP: 118/49(65) {103/47(61) - 177/76(95)} mmHg\n RR: 24 (11 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 1,440 mL\n 120 mL\n PO:\n 1,440 mL\n 120 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 1,055 mL\n 300 mL\n Urine:\n 1,055 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 385 mL\n -180 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Skin: Warm\n Neurologic: Responds to: Verbal stimuli, Movement: Purposeful, Tone:\n Normal, facial droop resolved\n Labs / Radiology\n 9.4 g/dL\n 125 K/uL\n 101 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 34 mg/dL\n 116 mEq/L\n 147 mEq/L\n 29.2 %\n 3.8 K/uL\n [image002.jpg]\n 10:53 AM\n 06:33 PM\n 04:03 AM\n 04:59 AM\n 04:45 AM\n WBC\n 7.0\n 6.6\n 3.8\n Hct\n 27.7\n 34.4\n 29.2\n Plt\n 127\n 158\n 125\n Cr\n 2.1\n 2.1\n 2.4\n 2.3\n 2.3\n Glucose\n 293\n 99\n 150\n 117\n 101\n Other labs: PT / PTT / INR:13.0/34.3/1.1, CK / CKMB / Troponin-T:124//,\n Lactic Acid:3.4 mmol/L, Ca++:8.4 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\nSeizure: neuro exam improved, MRI,. EEG negative\nAmbulation: consult PT\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF):\n resolved back at baseline.\n HYPERTENSION, BENIGN:\n continue home regimen. hold off resuming home diuretics for now given\n hypernateremia\nHypernatremia: recheck lytes, continue po diet.\n Diabetes: continue glargine\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Comments: glargine\n Lines:\n 18 Gauge - 05:19 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 25 minutes\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:05 ------\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485506,
"text": "Hyperglycemia\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485507,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. His hyperglycemia is currently being\n treated with fixed and sliding scale insulin coverage. He has had no\n repeat seizure activity since the day of his admission on . He is\n called out and awaiting bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. No neuro deficits.\n Action:\n Pt cont on qid humalog scale and hs lantus dose. Neurology following.\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485509,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 485591,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. He has had no repeat seizure activity\n since the day of his admission on . He is called out and awaiting\n bed availability.\n Hyperglycemia\n Assessment:\n Blood sugars wnl this am. Hyperglycemia is currently being treated\n with fixed and sliding scale insulin coverage. No neuro deficits, no\n seizure activity.\n Action:\n QID fingersticks with coverage as ordered. Neurology following.\n Response:\n Hyperglycemia noted after meals breakfast but is easily covered w/pt\n humalog ss.\n Plan:\n Cont to monitor qid blood sugars. Cont humalog ss and lantus at HS.\n Hypertension, benign\n Assessment:\n Mild hypertension noted this am, sbp 140s. Pt on multiple po\n antihypertensives.\n Action:\n Scheduled po meds admin.\n Response:\n SB 50s w/stable BP, sbp 100-120.\n Plan:\n Resume at home medications. Zemplar still on hold.\n Transfer to floor. Had PT eval today. Steady on his feet this am.\n Possible discharge home . Foley dc\nd 1200, dtv 2000hrs.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n HYPERGLYCEMIA,SEIZURES\n Code status:\n Full code\n Admission weight:\n 74 kg\n Allergies/Reactions:\n Enalapril\n Cough;\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: CRI, Colon Ca---s/p resection, gout, cataracts,\n mild diasolic dysfunction\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:59\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 59 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 420 mL\n 24h total out:\n 335 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 04:45 AM\n Potassium:\n 4.2 mEq/L\n 04:45 AM\n Chloride:\n 116 mEq/L\n 04:45 AM\n CO2:\n 23 mEq/L\n 04:45 AM\n BUN:\n 34 mg/dL\n 04:45 AM\n Creatinine:\n 2.3 mg/dL\n 04:45 AM\n Glucose:\n 101 mg/dL\n 04:45 AM\n Hematocrit:\n 29.2 %\n 04:45 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n #18g L AC \n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry:\n Transferred from: micu 782\n Transferred to: cc712\n Date & time of Transfer: 1530\n"
},
{
"category": "Nursing",
"chartdate": "2150-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 485414,
"text": "Pt is a 72 yo man initially admitted s/p seizure activity in the\n setting of hyperglycemia, hypernatremia, and hypertension. A head ct\n also suggests that pt may have had prior cva although he does not\n appear to have any deficits. His hyperglycemia is currently being\n treated with fixed and sliding scale insulin coverage. He has had no\n repeat seizure activity since the day of his admission on . He is\n called out and awaiting bed availability.\n .\n Hypertension, benign\n Assessment:\n Pt initially hypertensive to sbp ~180 last evening. He received all\n scheduled antihypertensive medications with significant improvement in\n his blood pressure.\n Action:\n Received oral antihypertensives.\n Response:\n SBP ranging 110-140\ns overnight.\n Plan:\n Monitor hemodynamic status closely; give oral antihypertensives per\n schedule and parameters.\n Hyperglycemia\n Assessment:\n Pt continues to be moderately hyperglycemic. FS @hs was 292; pt\n received lantus and insulin per hiss. He is receiving diet.\n Action:\n In addition to his daily lantus dose, pt received another 6 units\n Humalog insulin per sliding scale parameters @2200.\n Response:\n Plan:\n Continue to monitor fs qid with sliding scale coverage prior to meals\n and @hs.\n Acute Confusion\n Assessment:\n No evidence of seizure activity. Pt has remained calm and oriented x3\n throughout the night. Although his bed alarm is turned on, he has made\n no attempt to get oob and has been unrestrained. No evidence of acute\n agitation or inappropriate behavior.\n Action:\n None; no evidence of\nsun downing\n behavior overnight.\n Response:\n Oriented; appropriate.\n Plan:\n Monitor mental status, evidence of acute change, agitation.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley is patent and intact, draining clear, yellow urine. UOP\n ~20-50cc/hr.\n Action:\n Pt making marginal amounts of urine at times; micu resident is aware\n and will continue to monitor output.\n Response:\n Unchanged.\n Plan:\n Monitor serial bun/creat results, uop.\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1098695,
"text": " 11:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: CODE STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with code stroke\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf FRI 11:33 PM\n No acute hemmorhage. MRI is more senitive for acute ishemia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 78-year-old man with \"code stroke.\" Evaluate for bleed.\n\n TECHNIQUE: CT head without contrast. Contiguous axial images were obtained\n through the brain. No intravenous contrast was administered.\n\n COMPARISON: No images for comparison at the time of dictation.\n\n FINDINGS: There is no acute hemorrhage, large acute territorial infarction,\n or large masses. There is no shift of midline structures. Ventricles and\n sulci are normal in size and configuration. There are subcortical\n hypodensities, likely due to chronic small vessel ischemic changes. There is\n no evidence of hydrocephalus. Ventricles and sulci are prominent, likely age\n related. There is no evidence of fracture. Visualized portion of paranasal\n sinuses and mastoid air cells is within normal limits.\n\n IMPRESSION: No acute intracranial hemorrhage. Please note that MRI is more\n sensitive for acute ischemia, if there is clinical concern.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-30 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 1098878,
"text": " 12:14 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W/O CONTRAST Clip # \n Reason: evaluate for infarcts\n Admitting Diagnosis: HYPERGLYCEMIA,SEIZURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with diabetes, new onset seizure, concern for prior CVA\n REASON FOR THIS EXAMINATION:\n evaluate for infarcts\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes and new onset seizure. Concern for prior infarction.\n\n COMPARISON: MRI and MRA dated . Non-contrast head CT dated\n .\n\n TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR, gradient echo,\n and diffusion-weighted images of the head. Three-dimensional time-of-flight\n MRA of the head.\n\n No intravenous contrast was utilized due to low glomerular filtration rate.\n\n FINDINGS: The MRI and MRA are both limited by motion artifacts.\n\n There is no acute infarction. There is no evidence of cerebral edema, mass\n effect, or blood products. There are foci of high T2 signal in the\n subcortical and periventricular white matter of the cerebral hemispheres, new\n since the previous study and representing chronic microvascular infarcts in a\n patient of this age. The largest lesion is located in the left superior\n frontal subcortical white matter (image 10:21). There is mild cerebral\n atrophy with associated prominence of the sulci and ventricles.\n\n Flow is visualized in the intracranial internal carotid and vertebral\n arteries, and their major branches, without evidence of hemodynamically\n significant stenoses or aneurysms.\n\n IMPRESSION:\n\n 1. Motion-limited head MRI and MRA.\n 2. No acute infarction. New chronic microvascular infarcts since .\n 3. Unremarkable head MRA.\n\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1098816,
"text": " 2:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: HYPERGLYCEMIA,SEIZURES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with sz, hyperglycemia, new PNA on left\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 05:01\n\n INDICATION: Prior left retrocardiac opacity concerning for pneumonia.\n\n COMPARISON: at 00:21.\n\n FINDINGS:\n\n The previously seen retrocardiac opacity is largely resolved and therefore I\n suspect it was atelectasis. Remainder of the lungs is clear. The cardiac and\n mediastinal contours are normal. The pulmonary vascular markings are bit less\n distended.\n\n IMPRESSION: Improved appearance of the chest with resolved opacity in the\n retrocardiac region.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1098699,
"text": " 12:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL FOR PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with FEVER\n REASON FOR THIS EXAMINATION:\n EVAL FOR PNA\n ______________________________________________________________________________\n WET READ: IPf SAT 6:28 AM\n Retrocardiac opacity concerning for infiltrate at the left lung base.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with fever. Evaluate for pneumonia.\n\n TECHNIQUE: Single portable chest radiograph.\n\n COMPARISON: Compared to chest radiograph from .\n\n FINDINGS: There is a retrocardiac opacification, with loss of medial\n diaphragm, concerning for consolidation. Hila prominent bilaterally with some\n prominent vasculature, which could be due to fluid overload. No pleural\n effusion or pneumothorax.\n\n IMPRESSION: Left retrocardiac opacification, concerning for pneumonia with\n some associated volume loss.\n\n Please follow-up by CXR in weeks after therapy for resolution to exclude a\n postobstructive process.\n\n"
}
] |
48,100 | 147,004 | 76 yo M with long hx of tobacco smoking, appendectomy, and epilepsy in youth presenting from OSH after x4 radiation treatments, 15 day Levofloxacin course for pna, and steroid taper for COPD exacerbation presenting for tracheal and esophageal stent placement for lung carcinoma. 1. Squamous cell lung carcinoma: Pt received x4 sessions of XRT at prior to transfer. During the patient's admission, he tolerated esophageal and airway stenting, but developed atrial fibrillation with RVR during his course. On discharge to Rehab, the patient will need to continue palliative XRT at under the care of , MD, who can be reached at . 2. Atrial fibrillation with RVR: Post-stenting, the patient developed AF with RVR requiring MICU transfer for diltiazem gtt. He was converted to a standing oral regimen on transfer to the general floor, and was noted to be in sinus with 1:1 conduction for the duration with intermitent episodes of rate-controlled atrial fibrillation. He will need to continue diltiazem on discharge. Given multiple recent interventions performed, aspirin therapy was deferred during his admission, but can be considered on discharge. 3. COPD exacerbation: Patient was transferred on prednisone for a presumed COPD exacerbation. His was stable from a respiratory standpoint during his admission on a baseline home oxygen requirement of 2L nc (unchanged from prior to admission), and he will be discharged on a prednisone taper. The directions for his prednisone are: Prednisone 20 mg daily for 4 days, then 10 mg daily for 4 days, then STOP 4. Urinary retention: Following tracheal stent placement, the patient developed urinary retention. A foley catheter was placed and Tamsulosin was started with successful voiding trial. 5. Pneumonia: Patient completed a 15 day course of levofloxacin during his admission. 6. Smoking cessation: Patient continued on nicotine patch during admission. 7. Hyponatremia: Patient developed hyponatremia to 130. He will have a repeat BMP as well as urine electrolytes, creatinine and osmolality checked as an outpatient to determine appropriate course of action. Ddx includes volume depletion vs. SIADH. | 13 mm semisolid left upper lobe opacity is nonspecific, and may represent aspiration, infection, or tumor. There is mild-to-moderate atherosclerotic calcification in the arch, and non-calcified eccentric atherosclerotic plaque within the descending aorta. Probable small right pleural effusion is unchanged. 13 mm left upper lobe ground glass opacity is nonspecific, and may represent aspiration, infection, or tumor. Mass effect on the right main pulmonary artery and right-sided airways is little changed. Large mediastinal/right hilar mass is unchanged, allowing for differences in technique. The left lung appears well aerated. A curvilinear course of multiple pulmonary vessels in the collapsed right lower lobe suggests rounded atelectasis. Small bilateral pleural effusions, left greater than right. Mild apical predominant centrilobular emphysema is unchanged. There remains pleural fluid along the right side as well as bronchovascular prominence at the right base. There is increased density seen within the right lung base, which was seen on prior chest radiograph and is unchanged. Limited views of the upper abdomen show unchanged atherosclerotic disease in the abdominal aorta and its branches. 7-mm nodule in the periphery of the right upper lobe (4, 62) is unchanged. Left lung is otherwise well aerated. Multilevel thoracic spine degenerative changes are stable in appearance. Small right pleural effusion little changed; pleural enhancement noted and pleural involvement by tumor cannot be excluded. Given the heterogeneous enhancement and convex margins of the right lower lobe parenchymal opacity, pleural and/or parenchymal tumor involvement in this area cannot be excluded. Scattered areas of probable atelectasis elsewhere within the right lung are not significantly changed. Slightly larger left pleural effusion and adjacent left basilar atelectasis have moderately worsened since prior CT of . PE Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) IMPRESSION: 1. There is nonspecific focus of semisolid opacity spanning a 13-mm area in the central left upper lobe (4, 63). Right pleural effusion shows pleural enhancement. (Over) 1:59 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ? (Over) 1:59 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ? Status post tracheal Y-stent, which appears patent. 1:59 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: ? Sinus rhythm with atrial premature beat. Pleural involvement with tumor in this area cannot be entirely excluded. There is a tiny subcapsular perfusion abnormality in segment VI of the liver, and probably adenomyomatosis of the gallbladder. Clinical correlation issuggested. Probable worsening of partial right lower lobe collapse since prior CT (though improved from recent radiographs), likely due to tumoral involvement of right lower lobe airways. Total fluoroscopic time is unavailable. Low QRS voltage inleads I and aVL. Atrial fibrillation. There is similar degree of mass effect on the right main pulmonary artery, but no evidence of obstruction. A well circumscribed rounded density is visualized in the midline of unclear etiology. Similar appearance of mediastinal mass, consistent with reported history of squamous cell lung cancer, allowing for differences in technique. Worsening of right lower lobe collapse and consolidation since prior CT (though improved from recent radiographs), likely due to tumoral involvement and/or secretions within right lower lobe airways. Interval placement of patent tracheal Y-stent. IMPRESSION: Fluoroscopic images obtained during placement of esophageal stent without radiologist present. PE Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE Contrast: OPTIRAY Amt: 100 FINAL REPORT (Cont) CTA CHEST: There is no pulmonary embolism. However, there remains increased opacity and right-sided pleural effusion in this location. There is more severe mass effect on right-sided airways, with narrowing of the right mainstem bronchus, bronchus intermedius, and segmental bronchi to the right upper and right middle lobes. FINDINGS: Since the previous study, there is improved aeration of the right lung status post bronchoscopy. Status post esophageal stent placement, which is collapsed at its waist, and nearly completely occluded, with air-fluid levels, proximal and distal to the waist of the stent. Residual oral contrast is seen within the stomach and distally within the descending colon. Thoracic aorta is normal in caliber and contour throughout. An esophageal stent has also been placed, but the waist of the stent is severely narrowed, and partially occluded (501B, 35). Findings are non-specific and may be within normal limits butcannot exclude possible chronic pulmonary disease. Segmental bronchi to the right lower lobe appear essentially completely occluded with dense collapse and consolidation. COMPARISON: Fluoroscopic images from and chest radiograph from . Mild-to-moderate left basilar atelectasis. ABDOMINAL RADIOGRAPH, SUPINE AND UPRIGHT VIEWS: On the upright images, there is no evidence of free air under the diaphragms. There is a 12 mm precarinal lymph node. 7 mm right upper lobe nodule. 7 mm right upper lobe nodule. Extension to mediastinum and esophagus again noted. Compared to the previous tracing of the rhythm haschanged.TRACING #1 These images show interval placement of a nasogastric tube with the tip seen in the gastric fundus. Status post esophageal stent, which is collapsed at its waist, and nearly completely occluded, with air-fluid levels, proximal and distal to the waist of the stent. | 9 | [
{
"category": "Radiology",
"chartdate": "2150-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1153021,
"text": " 10:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with squamous cell lung CA s/p bronchoscopy to try to expand\n RML, RLL.\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 76-year-old man with squamous cell cancer status post bronchoscopy\n to try to expand the right middle and right lower lobe.\n\n FINDINGS: Comparison is made to previous study from at\n 9:11 p.m.\n\n Since the previous study, there has been some improvement in the aeration at\n the right middle lobe and right base. However, there remains increased\n opacity and right-sided pleural effusion in this location. There are no signs\n for overt pulmonary edema. The left lung is clear. There are no\n pneumothoraces identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1152925,
"text": " 4:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: possible pneumonia\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n increased O2sat with sputum\n REASON FOR THIS EXAMINATION:\n possible pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Patient with possible pneumonia.\n\n FINDINGS: Comparison is made to prior study from .\n\n Since the previous study, there has been volume loss and increased\n opacification within the right lung. This may represent partial volume loss\n due to mucus plugging and collapse. Repeat images are recommended to\n resolution of this finding. There is also likely some loculated pleural fluid\n along the right posterior chest wall, which is also new since the previous\n study. The left lung appears well aerated. No pneumothoraces are identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1152969,
"text": " 8:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess forn lung re-expansion\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with right lung collapse, s/p bronchoscopy.\n REASON FOR THIS EXAMINATION:\n assess forn lung re-expansion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: Patient with right lung collapse status post bronchoscopy. Assess\n re-expansion.\n\n FINDINGS: Since the previous study, there is improved aeration of the right\n lung status post bronchoscopy. There remains pleural fluid along the right\n side as well as bronchovascular prominence at the right base. No\n pneumothoraces are seen. The left lung is clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-06 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 1153269,
"text": " 11:36 AM\n ABDOMEN (SUPINE ONLY); ABDOMINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: please review fluoroscopy images from \n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with Non small cell lung cancer with mediastinal mass causing\n esophageal compression. Evaluate for esophageal stent\n REASON FOR THIS EXAMINATION:\n please review fluoroscopy images from \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with non-small cell lung cancer and mediastinal\n mass causing esophageal compression. Evaluate fluoroscopic images from\n from esophageal stent placement.\n\n COMPARISON: None available.\n\n FINDINGS: Six fluoroscopic spot images were taken during endoscopy without\n the radiologist present. These images show interval placement of a\n nasogastric tube with the tip seen in the gastric fundus. Subsequent images\n show placement of a metallic stent in the distal esophagus. A well\n circumscribed rounded density is visualized in the midline of unclear\n etiology. Please see endoscopic note for further details. Total fluoroscopic\n time is unavailable.\n\n IMPRESSION: Fluoroscopic images obtained during placement of esophageal stent\n without radiologist present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-08 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1153039,
"text": " 1:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with lung Ca with new O2 requirement s/p bronchial stent\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd SAT 3:24 PM\n 1. No evidence of pulmonary embolism.\n\n 2. Similar appearance of mediastinal mass, consistent with reported history\n of squamous cell lung cancer, allowing for differences in technique. Mass\n effect on the right main pulmonary artery and right-sided airways is little\n changed.\n\n 3. Probable worsening of partial right lower lobe collapse since prior CT\n (though improved from recent radiographs), likely due to tumoral involvement\n of right lower lobe airways. Given the heterogeneous enhancement and convex\n margins of the right lower lobe parenchymal opacity, pleural and/or\n parenchymal tumor involvement in this area cannot be excluded.\n\n 4. Status post tracheal Y-stent, which appears patent.\n\n 5. Status post esophageal stent, which is collapsed at its waist, and nearly\n completely occluded, with air-fluid levels, proximal and distal to the waist\n of the stent.\n\n 6. Small bilateral pleural effusions, left greater than right.\n Mild-to-moderate left basilar atelectasis.\n\n 7. 13 mm semisolid left upper lobe opacity is nonspecific, and may represent\n aspiration, infection, or tumor.\n\n 8. 7 mm right upper lobe nodule.\n ______________________________________________________________________________\n FINAL REPORT\n CTA CHEST, \n\n CLINICAL HISTORY: Lung cancer, new oxygen requirement, status post bronchial\n stent. Query PE.\n\n COMPARISON: CT studies from and obtained at\n , and multiple recent chest radiographs.\n\n TECHNIQUE: Volumetric CT of the chest was performed before and after IV\n contrast administration per departmental CTA protocol. Multiplanar\n reformatted images were obtained and reviewed.\n\n (Over)\n\n 1:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CTA CHEST: There is no pulmonary embolism. Thoracic aorta is normal in\n caliber and contour throughout. There is no dissection. There is\n mild-to-moderate atherosclerotic calcification in the arch, and non-calcified\n eccentric atherosclerotic plaque within the descending aorta. There is a 12\n mm precarinal lymph node. No axillary lymphadenopathy.\n\n Large mediastinal/right hilar mass is unchanged, allowing for differences in\n technique. It is centered in the subcarinal region, measuring roughly 7.5 x\n 6.5 cm. Exact measurement is difficult due to its confluent nature, and\n adjacent lung collapse. There is similar degree of mass effect on the right\n main pulmonary artery, but no evidence of obstruction. There is more severe\n mass effect on right-sided airways, with narrowing of the right mainstem\n bronchus, bronchus intermedius, and segmental bronchi to the right upper and\n right middle lobes. Extension to mediastinum and esophagus again noted.\n Segmental bronchi to the right lower lobe appear essentially completely\n occluded with dense collapse and consolidation. A curvilinear course of\n multiple pulmonary vessels in the collapsed right lower lobe suggests rounded\n atelectasis. Right pleural effusion shows pleural enhancement. Pleural\n involvement with tumor in this area cannot be entirely excluded.\n\n Since prior exam, a tracheal Y-stent has also been placed, which extends into\n both main stem bronchi. This appears patent. An esophageal stent has also\n been placed, but the waist of the stent is severely narrowed, and partially\n occluded (501B, 35). There are air-fluid levels within the esophagus, both\n proximal and distal to the stent.\n\n Scattered areas of probable atelectasis elsewhere within the right lung are\n not significantly changed. 7-mm nodule in the periphery of the right upper\n lobe (4, 62) is unchanged. Probable small right pleural effusion is\n unchanged. Slightly larger left pleural effusion and adjacent left basilar\n atelectasis have moderately worsened since prior CT of . There\n is nonspecific focus of semisolid opacity spanning a 13-mm area in the central\n left upper lobe (4, 63). Left lung is otherwise well aerated.\n\n Mild apical predominant centrilobular emphysema is unchanged.\n\n This study is not specifically tailored for subdiaphragmatic evaluation.\n Limited views of the upper abdomen show unchanged atherosclerotic disease in\n the abdominal aorta and its branches. There is a tiny subcapsular perfusion\n abnormality in segment VI of the liver, and probably adenomyomatosis of the\n gallbladder. Adrenal glands are normal in size.\n\n There is no osseous lesion suspicious for malignancy. Multilevel thoracic\n spine degenerative changes are stable in appearance.\n\n (Over)\n\n 1:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n\n 2. Interval placement of patent tracheal Y-stent. Worsening of right lower\n lobe collapse and consolidation since prior CT (though improved from recent\n radiographs), likely due to tumoral involvement and/or secretions within right\n lower lobe airways. Similar appearance of locally invasive hilar/mediastinal\n mass, consistent with reported history of squamous cell lung cancer.\n\n 3. Increased left pleural effusion and left basilar consolidation and\n atelectasis, consistent with pneumonia and possibly aspiration. Small right\n pleural effusion little changed; pleural enhancement noted and pleural\n involvement by tumor cannot be excluded.\n\n 4. Status post esophageal stent placement, which is collapsed at its waist,\n and nearly completely occluded, with air-fluid levels, proximal and distal to\n the waist of the stent.\n\n 5. 13 mm left upper lobe ground glass opacity is nonspecific, and may\n represent aspiration, infection, or tumor. 7 mm right upper lobe nodule.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-07 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1152827,
"text": " 4:40 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: Pathology related to stenting or RUQ pathology\n Admitting Diagnosis: NON SMALL CELL LUNG CANCER;ESOPHAGEAL STRUCTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with lung cancer s/p tracheal stent and eosphageal stent on\n c/o abdominal painin RUQ\n REASON FOR THIS EXAMINATION:\n Pathology related to stenting or RUQ pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old male with past medical history of lung cancer with\n recent tracheal and esophageal stent placement. Patient now presenting with\n increasing right upper quadrant pain.\n\n COMPARISON: Fluoroscopic images from and chest radiograph\n from .\n\n ABDOMINAL RADIOGRAPH, SUPINE AND UPRIGHT VIEWS: On the upright images, there\n is no evidence of free air under the diaphragms. There is increased density\n seen within the right lung base, which was seen on prior chest radiograph and\n is unchanged. Residual oral contrast is seen within the stomach and distally\n within the descending colon. There is no evidence of dilated small bowel to\n suggest obstruction. There is mild scoliosis of the lumbar spine without\n other significant osseous abnormalities.\n\n IMPRESSION: No evidence of free air or obstruction.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2150-08-07 00:00:00.000",
"description": "Report",
"row_id": 237827,
"text": "Sinus rhythm. Compared to the previous tracing the rhythm has changed.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2150-08-06 00:00:00.000",
"description": "Report",
"row_id": 237828,
"text": "Atrial fibrillation. Compared to the previous tracing of the rhythm has\nchanged.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2150-08-04 00:00:00.000",
"description": "Report",
"row_id": 238045,
"text": "Sinus rhythm with atrial premature beat. Rightward axis. Low QRS voltage in\nleads I and aVL. Findings are non-specific and may be within normal limits but\ncannot exclude possible chronic pulmonary disease. Clinical correlation is\nsuggested. No previous tracing available for comparison.\n\n"
}
] |
26,691 | 165,460 | Patient admitted to the trauma service. Orthopedics, Plastics, Neurosurgery were consulted because of her injuries; and admitted to the Trauma ICU for close monitoring. Neurosurgery placed ICP bolt; she was loaded with Dilantin and serial head CT scans were performed. She will follow up with Neurosurgery in weeks for repeat head imaging. Her Dilantin has been discontinued. Plastics consulted because of her extensive scalp wound; she was eventually taken to the operating room on for scalp advancement and wound closure; her scalp sutures are to remain in place for 3-4 weeks at which time she will follow up with clinic. Bacitracin will need to be applied to scalp wound as directed on page 1. Orthopedics was consulted for her multiple injuries; her pelvic fracture was stabilized with closed reduction and fixation; she was later taken to the operating room on for ORIF. Her humerus was repaired on . She remained in the Trauma ICU vented; she was eventually trached and a PEG was placed for nutritional support. Her trach was eventually downsized and removed on . Her PEG remains in place and she is receiving tube feedings. Nutrition services followed patient during her hospitalization. She did require intermittent intravenous antibiotics for positive sputum and wound cultures; a PICC was placed secondary to poor venous access; this line was removed on . She is no longer on any antibiotics; most recent WBC on was 9.5. She was evaluated by Speech and Swallow for Passy Muir valve (see pertinent results section). Physical and Occupational therapy have been consulted and have recommended a rehab for patients with traumatic brain injuries. | remaines trached and vented, weaned to PSV tol ok at this time. Pboots cont.GI: Abd slightly firm. BS coarse bilaterally which clears with suctioning. L humerous remains splintedSKIN: head lac sutured w/out drainage. titrated to maintain BG < 120.ID: cont. care note - Pt. Bowel sounds hypoactive.GU: Adequate u/o via foley.ID: Febrile for most of shift despite tylenol and tepid baths. Trache care done, # 7 portex. NGT to sux for lg amts of bilious drainage d/t regurgitation noc before. Team aware, cleansed and dressed overnoc. (+)palpable DP/PT, (+)radial/ulnar pulses bilat. abd distended with normal - hyperactive bowel sounds.GU: autodiuresising. Pt cont on zosyn and gentamicin. Abd dsg D+I,JP drains scant serosang dge. BP 90s-120s/40s-60s.HEME: Sq heparin dc'd and pt started on lovenox. Hct=22(stable)Resp-Remains intubated, on CMV 14, 450/ 50%,peep8, ls sl. See Carevue for exacts. Returned to AC for brief amt of time to lower RR, then retried w/o success. Sq heparin/pboots for DVT prophylaxis.GI: Abd soft distended. BP WNL.HEME: Acceptable H/H. amts.Tx'd with albuterol prn.Plan:cont. Chest tube sites redressed. Chest tube sites redressed. Lovenox/pboots for DVT prophylaxis.GI: Small amount of bilious fluid via NGT. Lopressor QID cont.HEME: Lovenox cont. albuterol given q4h. Gluc well controlled with RISS.SKIN: Staples to abd removed and steristrips applied. Resp CarePt. nbp stable 99/50-135/90gi: us done of gall bladder. Abdomen soft/distended, +ve bowel sounds. J-tube site redressed. IVF kvo'd.ID: Tmax 101.2. venodynnes, lovenox injection.GI: Pt cont on reglan ATC and cont with loose stool. H/H acceptable.GI: NGT clamped and residuals checked q4. NGT clamped, residuals minimal Q4. No BM this shift.GU: Adequate u/o via foley.ID: Afebrile. Abdomen soft/nontender, +ve bowel sounds. Monitor resp status sux prn. ?d/c reglan brief bouts of tachypnea, relieved with suctioning. Pt with high resp when intubated. Pt placed back on assist control. R Hip dsg changed with scant drainage. Scalp laceration redressed with -to-dry. firm with hypoactive bowel sounds. Has left subclavain MML w/prox port transduced for CVP=. NGT to intermittent suction with moderate bilious output. Chest tube sites redressed. abd softly distended with + BS. +pp, lovenox as ordered. dilantin dosing cont. Scalp lac with to dry dressings TID. Pos BS.GU: u/o adeqSkin: mult brusing to exts. no residuals.Infusing well via post pyloric. ABdomen soft/distended/nontender, +ve bowel sounds. Pt annointed today.Activity: Per ortho Pt may get OOB nonweightbearing on both LEs. Please send stool for c-diff. Tachypenic when suction needed, settles quickly. NGT remains to suction with bilious output. The JP drains have put out minimal hemoserous ooze.OGT in place. While in IR post-pyloric tube removed. Resp Care Note, Pt remains on current bent settings. with restraint.CV: Hr SR-ST. Up to 110's, usually tachycardia seen more when pt is febrile. BS clear after suctioning and MDI. 3xCT to H2O , small volume of serosanguinous drainage, entrance sites redressed. ABG pH 7.31, PaO2 120, PaCO2 47, BE -2. Noting notable suctioned form ett. + peripheral pulses.Resp - Lungs coarse throughout. Abdomen firm/hypoactive bowel sounds/no BM. Pt started on Albuterol MDI. jpx2, scant serosang dge.Bladder pressures trending down, last one 8.GU- foley in place, u/o qsID- afebrile off antibxF/E/N- tf off for or today, ivf @ kvo. JP X2 with small amount of serosang drainage.Skin/Mobility: Remain in c-collar, skeletal traction, skin grossly intact, small area on labia with skin tear drainag serosang drainage.Social: Family in updated.Plan: OR in the the morning for ortho, wean vent as toleraed, cont to montior and support, follow plan of care. Resp CarePt. Petechiae to lower extremities, initially cool/pale, weak palpable pulses.Renal - UO 300-650ml/hr, 24hour balance +15500ml, currently -ve 1800ml today. Scant secretions with suctioning.CV: Swan dc'd and changed to TLCL. HISTORY: Right central venous line partially withdrawn. FINAL REPORT PORTABLE SUPINE CHEST, . Abdominal dressing reinforced, small-moderate serosanguinous drainage, 2xJP (no drainage). Lytes repleated PRN.Resp - Lungs coarse throughout, diminished at bases. ABP systolic 110-130's, CVP 5-8, P-boots.Resp: Remains intubated, lungs coarse suctioned for scant secretions. Abd firm, absent bowel sounds, PPI, NPO, Bladder pressures 15-18. ABG's and vent changes as per carevueGU/GI: Abd closed, under dressing, JPX2 with sero/sang drainage. IMPRESSION: New small left apical pneumothorax with chest tubes in place. OGT replaced by Dr. d/t improper position noted on xray. FINDINGS: The left-sided femoral catheter has been removed. Kefzol/flagyl dc'd. Non-specificST-T wave flattening. Tracheostomy tube in standard placement. The new nasogastric tube terminates in the distal esophagus. Left humerous remains in splint. CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is consolidation of the posterior lower lobes. There is a minimal right pleural effusion. Two left pleural tubes are unchanged in position. TECHNIQUE: Non-contrast head CT. A left femoral catheter is identified. INDICATION: Removal of right chest tube. FINDINGS: Again seen is a fracture of the right and left superior and inferior pubic rami as well as of the right sacral ala. Fracture fragments are unchanged in position and alignment compared to the prior study. There is a left subclavian vein central venous catheter in unchanged position with the tip in the distal SVC. A right-sided central venous catheter is partially imaged. Tip of the left subclavian line projects over the SVC, ET tube is in standard placement and nasogastric tube ends at or beyond the pylorus. Comparison to pelvis radiographs performed on and . Bilateral inferior pubic rami fractures are visualized. Bilateral inferior pubic rami fractures are visualized. FINDINGS: There is a comminuted sagittally oriented fracture through the right sacral ala. Evidence of retroperitoneal hemorrhage. Right inferior pubic ramus fracture noted. IMPRESSION: Overall unchanged appearance of the pelvis with right sacral ala and bilateral pubic rami fractures, status post fixation. AP supine chest radiograph obtained on trauma board. There is a left femoral venous catheter. As no suitable superficial veins were identified, ultrasound of the right upper extremity was performed, which demonstrated the right brachial vein to be patent and compressible. The right hemipelvis is proximally displaced with poorly assessed involvement of the right SI joint and associated fractures, right sacrum. Fracture through the right os pubis and ischium. A final limited chest radiograph confirmed placement of the tip of the catheter to be in the lower SVC at the cavoatrial junction. | 130 | [
{
"category": "Nursing/other",
"chartdate": "2145-05-22 00:00:00.000",
"description": "Report",
"row_id": 1611507,
"text": "Resp Care\n\nPt remains intubated and on full vent support. MV is being maintained in th 6-8L range. BS with occ upper lobe rhonchi and suctioning small amts of blood tinged sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-22 00:00:00.000",
"description": "Report",
"row_id": 1611508,
"text": "T/SICU Nursing Progress Note\nS/P MVC\nS: Intubated\nO: ROS Neuro: arousable to voice. Able to open her eyes. Inconstitently follows commands. Moves LE bilaterally and has purposeful movement of RUE. Limited if at all movement noted in LUE. PERRL. Remains off propofol gtt. Cont with fentanyl gtt for comfort.\n\nCV: cont to be HD stable w/out VEA noted. Palpable peripheral pulses, although LE are cool to touch. HCT stable at 22.\n\nRESP: remains intubated w/ no changes made. SPO2 > 98%. Suctioned for scan blood thick sputum. All 3 CT placed to H2O seal. CXR obtained.\n\nGI: abd remains taunt, w/ bladder pressures of approx 18-22. TF's started via OGT. -BM, -BS.\n\nGU: Foley to gravity w/ adequate u/o\n\nOrtho: R leg remains in 30 lbs of skeletal traction. L humerous remains splinted\n\nSKIN: head lac sutured w/out drainage. Perineal bruising noted.\n\nENDO: no replacement per SS\n\nFAMILY: Husband and daughter in to visit throughout the afternoon.\n\nA: HD stable, antipate return to OR on Monday for ortho repair.\n\nP: cont to support as per NCP. Provide family spoort as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-23 00:00:00.000",
"description": "Report",
"row_id": 1611509,
"text": "Nursing Progress Note\nneuro- remains sedated on Fentanyl, increased to 120mcg for presumed pain w/effect.Moves RUE well, spontaneously, reaching for ETT when lightened, wiggles toes to command, moves LUE slightly.Opens eyes to verbal stimuli, does not look to speaker, nods/shakes head slightly to simple questions\n\ncv- monitor SR no ectopy, Aline dampened, removed, restart attempted x3 by resident, left out for now. cuff pressures stable.TLC intact, cvp 12-14.pulses + but weak, boot on LLE only. Hct=22(stable)\n\nResp-Remains intubated, on CMV 14, 450/ 50%,peep8, ls sl. coarse, diminished @ bases- no weaning overnight. CT x2 on L, x1 on R to water seal, no air leak or crepitus- dsgs changed\n\nGI- TF started yesterday @10cc/hr- via OGT- clamped after 4hrs for residual>100cc. Remains clamped overnight, to be rechecked @ 0700.\nAbd firm, no bs. Abd dsg D+I,JP drains scant serosang dge. bladder pressures stable in mid teens\n\nF/E/N- as above tf off, ivf and fentanyl total 15cc/hr. K and Mg wnl. requiring no repletion.\n\n\nGU- foley patent.u/o clear/yellow, qs\n\nID- afebrile wbc 10.3 today, trending up. Finished antibx yest (kefzol)\n\nSkin- cool, dry, pale. Scalp lac sutures intact, no dge. Mult ecchymotic areas on legs, petichiae noted R thigh, unchanged over my shift. Perineal bruising noted-old. Skeletal tx pin sites clean w/out dge\n\nPlan- Wean as tolerated off vent,monitor for s+sx of further bleeding,\ntransfuse as necessary. Continue to treat pain anxiety to promote rest, optimize nutritional status. maintain joint alignment w/skeletal traction.\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-23 00:00:00.000",
"description": "Report",
"row_id": 1611510,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Currently on A/C ventilation w/ PIP/Pplat = 22/18. SpO2 remained 90s. ETT secure/patent. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-23 00:00:00.000",
"description": "Report",
"row_id": 1611511,
"text": "Resp Care\n\nPt remains intubated and on full vent support. MV is being maintained in the 6-7L range. BS with upper lobe rhonchi and suctioning small amts of tan sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-01 00:00:00.000",
"description": "Report",
"row_id": 1611546,
"text": "ASSESSMENT AS NOTED\n\nRES: ON CPAP SINCE 11PM LAST NIGHT, LS COARSE/DIM WITH FREQUENT STRONG COUGH, SUCTIONED FOR THICK YELLOW IN SM AMNTS, PSV DOWN TO 15 FROM 18\nDUE TO RES ALKALOSIS, PO2>100\n\nNEURO: OPENS EYES SPONT, DOES NOT FOLLOW, MOVES R/ARM MOSTLY, NO OR LITTLE LEG MOV., SLIGHT L/ARM MOV., STRONG COUGH,+GAG, C/COLLAR STILL ON-FLEXION/EXTENSION FILMS WERE DONE :RESULTS PENDING FOR NECK CLEARENCE\n\nCV: THACHY/NSR WITH LOPRESSOR, BP STABLE, C/LINE WAS FOUND 4AM PULLED OUT BY 10CM(HO AWARE) AND NEW PERIPHERAL IV WAS INSERTED.EDEMA ON L/ARM, +PULSES\n\nGI: TOL TF WELL AT GOAL VIA FEED TUBE, NGT WAS INSERTED DUE TO EVIDENCE OF BILE(PT REGURGITATES?) IN PT'S MOUTH LAST NIGHT EACH TIME SHE COUGHS, DRAINS SM AMNT BILE\n\nID: FEVER ON AND OFF, GOT TYLENOL, FAN IS ON, CONT ON ZOSYN, WAS SWABED FOR MRSA VRE\n\nGU: BRISK U/O\n\nLABS: HCT 22, RISS IN USE-SEE CAREVUE\n\nSKIN: SEE CAREVUE FOR DETALES\n\nSOCIAL: HUSBAND CALLED LAST NIGHT CONCERNED ABOUT PT'S NEURO STATUS, HE WAS UPDATED ON PT CONDITION\n\nPLAN: PULM TOILET, WEAN OF VENT IF TOLERATES, MONITOR NEURO,\nPULL OUT C/LINE,\nFAMILY MEETING SCHEDULE WITH S/W,\nCLEAR NECK/COLLAR,\nPEG ON WENDSDAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-01 00:00:00.000",
"description": "Report",
"row_id": 1611547,
"text": "Resp Care\nPt remains on MV, currently in PS mode as noted on Careview. PS weaned after ABG obtained by RT showed Resp Alkalosis. BBS-coarse t/o w/diminished bs, no change post BD therapy. Albuterol MDI delivered Q4 & Flovent given last night-strong, bronchspastic cough seems to have improved since previous night shift. Sx'ed freq for sm amts thick yellow secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-01 00:00:00.000",
"description": "Report",
"row_id": 1611548,
"text": "NPN: \nROS: see carevue for details\n\nNEURO: fentanyl drip dc'd this morning and patient transitioned to PO pain meds. patient continues with poor neuro exam. opens eyes spontaneously does not track. does not follow commands. moves right arm with good strength , ? if purposeful towards trach tube. left arm withdraws to pain weakly. minimal movement of lower extremities noted. dilantin re-bolused this afternoon and dose increased. cspine precautions dc'd with final read of flex-ex films. PERLA , briskly reactive.\n\nCV: HR sr 70-110s, tachycardic with stimulation and activity. BP stable. +pp. pboots on. lovenox as ordered.\n\nRESP: patient trached and ventilated on CPAP all day. periods of tachypneia (40-50s) with activity and stimulation, self limiting with RR 20-30s. O2 sat 99-100% on settings as charted in carevue. LS coarse, diminished. suctioned for small amounts of thick yellow secretion.\n\nGI: tolerating tf at goal via post pyloric feeding tube. patient also has NGT to intermittant suction after bout of regurgitation last night. NGT with bilious output. large soft BM today. abd distended with normal - hyperactive bowel sounds.\n\nGU: autodiuresising. good urine out via foley > clear yellow.\n\nENDO: Insulin drip started this morning for better BG control. titrated to maintain BG < 120.\n\nID: cont. on zosyn and gentamycin. cultures pending. tmax today 100.4.\n\nSKIN: multiple bruises, incisions and abrasions as charted in carevue. upon washing patient's hair this morning poorly closed head wound was noted. behind left ear patient has 9-10cm x3-5cm laceration, about 1-2cm deep. this laceration had been stapled upon patient's admission and was found poorly closed with a foul odor this morning. staples were removed and wound was throughly irrigated to remove left over debri. Dr. and Dr. up to evaluate wound > w>d dressing placed after irrigation. dressing to be changed TID and PRN. ? need for surgical intervention vs. closure by secondary intention.\n\nSOCIAL: husband and daughter into visit this afternoon, awaiting neuro surgery for family meeting\n\nplan: cont to wean vent as tolerated. control pain with frequent medicating. skin care. dressing changes to head as ordered. IV abx as ordered. monitor & support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-02 00:00:00.000",
"description": "Report",
"row_id": 1611549,
"text": "NPN 7pm-7am\n\nEvents of Noc- Follow-up CT\n Vent changed to AC d/t increased resp rate/drive/ tachycardia/tachypneic. Attempt to rest pt and change back to CPAP and PSUPP currently pt not able to tolerate.\n\nROS: Pls see carevue for exact data\n\nNeuro: Pt will open her eyes spont or to painful stimuli. Pt does not follow commands. No tracking noticed, pt did attempt to locate me with her eyes to the sound of my voice x2. Mae's. Purposeful with the right out of all ext's. Pt is moving LE's on bed, left LE brisker with w/drawal than right. LUE moves on bed, and RUE pt is able to lift and hold. Pupils equal and briskly reactive 3-4mm. corneals/ gag and cough. Roxicet for pain q4 hrs\n\nCV: Noticed hyperdynamic moments with HR and BP when febrile. HR cont SR-ST no ectopy. SBP 90's-110. HR 80-115. Positive pulses to LE's and LUE. Lue good, CSM, warm to touch. Lopressor TID. NS @ 10/hr\n\nRESP: Pt ventilated on Cpap and Psupp for most of noc. 11pm pt became very tired, hyperdynamic, RR 50's. Pt rested for while on AC 40% 500x14 with 5 peep. TV observed 450-500. Attempted to change back over to Cpap, but currently unable. See Carevue for exacts. LS coarse through out. Sux'd mult times for sm amts of thick yellow sputum. Lavaged with minimal help. Trache care done, # 7 portex. RR on AC 20's. Sats remain 97-100% CPT PRN. Dr to draw gas for a.m.\n\nGI: Pt cont on TF/tolerating via daubhoff (post pyloric). NGT to sux for lg amts of bilious drainage d/t regurgitation noc before. Abd soft, positive BS. No BM this shift.\n\nGU: adeq u/o. Foley to be changed d/t positive urine cult.\n\nLines: 2 Piv\n\nLytes : all wnl , repleting with 2 gm calcium\n\nEndo: Bld sugars erratic, titrate insulin prn\n\nSkin: drsg , carevue for exacts. Lg lac behind left ear open to skull. Team aware, cleansed and dressed overnoc. Pt will need ? flap.\n\nID: Tmax 101.4, per HO no need for cultures, pt cultured last noc. WBC increasing. Pt cont on zosyn and gentamicin. Will need trough before 3rd dose.\n\nHem: 22.7 HCT/ HGB 7.6 Plt 438\n\nSoc: husband called last noc, very nice and approp.\n\nA: s/p MVA with mult injuries. No drastic improvement in neuro exam, otherwise stable. Repeat CT head. Fully ventilated\n\nP: Cont wean vent as tolerated to trache collar. Monitor hemodynamics. Per H.O. CT improved. Monitor temps, cultures and tylenol PRN. Cont anbx. Plan for Rehab when afebrile. Monitor and provide support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-02 00:00:00.000",
"description": "Report",
"row_id": 1611550,
"text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. Pt changed from CPAP/PS to PS for sustained RR >40 last pm. Attempted to return to CPAP this am & pt initially did very well, but after turn/nursing care, became very tachypneic up to 60 bpm. Returned to AC for brief amt of time to lower RR, then retried w/o success. Discussed with Dr and will leave pt on AC for now, return to CPAP later then ABG to be drawn on CPAP. Pt transported to and from CT for repeat head exam w/o complications. BBS-coarse t/o. Freq sx for sm amts thick yellow secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-02 00:00:00.000",
"description": "Report",
"row_id": 1611551,
"text": "Resp. care note - Pt. remaines trached and vented, weaned to PSV tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-29 00:00:00.000",
"description": "Report",
"row_id": 1611533,
"text": "FULL CODE Universal Precautions NKDA\n\n\nNeuro: Opens eyes spont to stim, but doesn't track or startle. Withdraws w/ stim such as sx - moves R upper/lower , movement in L upper and lower . Pupils 3mm/brisk. On Dilantin - no seizure activity.\n\nCV: HR=80s, NSR, no ectopy. BP by NIBP=98-120s/50s; L DP art-line ranges from dampened waveform to 160-180/ when NIPB=110s/. +++edema, warm, Weak, but palp pulses. Draws blood back easily. Lopressor 10mg IVP q 6hr to keep HR<100. CVP=.\n\nResp: Trached yest w/ #8 portex - site clean, no bleeding; CPAP 40%. Sx thick yellow secretions via trach. RR=20-32, Vt=300-350,02sat 97-99%, ABG OK. Lungs clear bilat, diminished in the bases bilat.\n\nGI/GU: abd firm distended, Hypo BS at beginning of shift, now present and stooling copious amts liq brown stool - mushroom cath placed. TF FS Promote w/ Fiber at 10cc/hr via NGT. Pt had recieved 1000 baricat/gastrographin via NGT prior to CT at 2300. TPN also started last evening. Foley cath w/ clear yellow urine.\n\nPain: On fent gtt at 150mcg/hr for comfort.\n\nSkin: Head lacs intact - frontal w/ sutures, posterior w/ staples - no drainage; L wrist site, L hip/L knee sites draining mod amt serous drainage; Abd incision staples intact, incision is clean, no drainage. JPsx2, #1draining mod amt serosang and #2 draining nothing.\n\nID: Temp 99.8 - on gent and zosyn\n\nProcedures: Abd CT done to r/o pancreatitis.\n\nLabs: FS covered w/ RISS, K and Ca repleted.\n\nAccess: LSC TLC and L foot a-line\n\nPlan: Wean vent as tol, maintain fent gtt for comfort, mushroom cath for stool management,monitor neuro status, monitor cardiac status - lopressor as scheduled.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-29 00:00:00.000",
"description": "Report",
"row_id": 1611534,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated with 7.0 Portex Perc. Trach tube. BLBS are coarse. Sxn for moderate-large amount thick yellow secretions. Transported to CT scan and back without incident. RSBI completed on PS 5=76. Plan for IR trip today. Decreased FiO2 to 40%.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-29 00:00:00.000",
"description": "Report",
"row_id": 1611535,
"text": "Respiratory Care Note\nPt received on PSV 10/5 with VT 245-358 and RR 22-36. Pt is tachypneic at times over 40 when agitated. BS coarse bilaterally which clears with suctioning. Pt suctioned for small amts thick secretions. Pt taken to Fluroscopy for post pyloric tube placement. Plan to continue on current settings at this time. Plan to start trach mask trials as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-29 00:00:00.000",
"description": "Report",
"row_id": 1611536,
"text": "T-SICU NURSING PROGRESS NOTE\nNeuro: Opens eyes spontaneously, no tracking, not following commands. Moving right upper extremity spontaneously, ? purposeful reaching toward trach, but very weak. Withdraws right arm only to painful stimuli, no other movement noted in right leg, left leg or left arm. Pupils 3mm bilat and briskly reactive. Remains in c-collar. Fentanyl gtt weaned to 100mcg/hr. Appears comfortable.\n\nCV: HR 80s-100s, sinus rhythm, no ectopy noted. BP stable. Generalized edema, skin warm and well perfused. (+)palpable DP/PT, (+)radial/ulnar pulses bilat. Left foot aline d/c'd.\n\nResp: Remains on PSV 10/5, 40% fi02, sats 98-100%. Suctioned for small amts of thick yellow secretions. Breath sounds initially clear, now more coarse in upper lobes. ? new RML consolidation on CT scan yesterday, afebrile, follow up cxr in am. Resp rate 24-26 when calm, up to mid 30s with stimulation.\n\nGI: Abdomen distended, firm, (+)bowel sounds. Post pyloric feeding tube placed in interventional radiology, tube feeds resumed at 10cc/hr. Large amount of liquid stool this am, mushroom catheter leaking--removed.No stool x several hours, then again liquid stool at 4pm so mushroom catheter replaced. Abdominal dressing dry and intact, minimal serous drainage.\n\nGU: Clear yellow urine via foley, draining approx 100cc/hr.\n\nID: afebrile, remains on zosyn and gentamycin. Gentamycin trough pending\n\nSkin: Left hand with moderate amt of serous drainage, wound bed red, dressing changed x 3 this shift. Abdominal, right hip, right leg dressings all dry and intact from this am. Ecchymosis on right flank/back area, heels intact.\n\nEndo: covered with regular insulin per sliding scale\n\nSocial: pt's husband, son and brother in to visit, updated on pt's condition, all questions answered\n\nA: 53 yo female s/p rollover MVC with multiple ortho fx and head injury\n\nP: Wean fentanyl as tolerated, follow neuro exam, advance tube feeds as tolerated. Repeat CXR in am, trach mask trial in am. Provide support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-31 00:00:00.000",
"description": "Report",
"row_id": 1611542,
"text": "Resp Care\nPt remains on MV in AC mode as noted on Careview. No vent changes this am and RSBI pending. BBS-coarse bilat, no change in BS post BD therapy. Sx'ed freq for scant/small amts thick, yellow secretions, though a paler yellow than previous night. Pt continue to cough freq & sometimes becomes tachypneic-noted to have temp-but cough responds to BD's and/or sx. No resp distress noted this shift other than with need for sx and prn Albuterol. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-31 00:00:00.000",
"description": "Report",
"row_id": 1611543,
"text": "Resp Care\nUnable to obtain RSBI this am as pt's RR increased to >50 within 15 seconds. No desaturation or increase in HR noted. RR improved upon return to AC mode.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-31 00:00:00.000",
"description": "Report",
"row_id": 1611544,
"text": "NPN 1300-1900\nAssumed care of pt at 1300hrs.\n\nNEURO: Pt on fentanyl gtt for pain, receives no other types of sedation. Pt opens eyes occasionally but does not attempt to interact or follow commands. Does not appear to focus on speaker. RUE localizes to suctioning/mouth care. All other extremities withdraw to nailbed pressure, but no spontaneous movement observed.\n\nRESP: Pt on CPAP 18PS 5peep for approx 5-6hrs. RR varies from 10s-high 30s; tachypnea often unrelated to stimulation. Small amount of yellow secretions with suctioning. Pt has weak nonproductive congested cough. LS coarse with scattered exp wheezing. Sat WNL.\n\nCV: HR 100s ST, no ectopy noted. PO lopressor increased to 75mg TID. BP 90s-120s/40s-60s.\n\nHEME: Sq heparin dc'd and pt started on lovenox. Pboots cont.\n\nGI: Abd slightly firm. Loose BM x 2. Tolerating TF at goal. Bowel sounds hypoactive.\n\nGU: Adequate u/o via foley.\n\nID: Febrile for most of shift despite tylenol and tepid baths. Tmax 101.9. Sputum and urine samples sent for fungal culture, stool sent for c-diff.\n\nENDO: Gluc 130s-200s. RISS adjusted for tighter control.\n\nSKIN: Back/buttocks with no breakdown noted. See carevue for wound specifics.\n\nSOCIAL: Husband at bedside for most of day. Appears to be anxious in regard's to pt's clinical situation and expressed frustration that \"nothing is changing.\" POC and gravity of pt's condition discussed with husband by this RN. He appeared to be more anxious and frustrated today than previous encounters noted by this RN; could possibly benefit from a family meeting.\n\nASSESSMENT: Pt s/p MVC with multiple injuries.\n\nCurrent nsg issues:\nCont with alteration in neuro status.\nInfection/persistant fevers.\nIneffective airway clearance.\nVentilatory weaning impairment.\n\nPLAN: Cont to monitor vs, neuro checks, cont CPAP trials and wean vent as tolerated, aggressive pulmonary hygiene, monitor fever curve and follow up with culture results, arrange family meeting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-31 00:00:00.000",
"description": "Report",
"row_id": 1611545,
"text": "Respiratory Care\nPt remains trached and on vent support. Vent changes were CPAP w/PS 18/5. Pt remained on these settings for a portion of the day. Pt then had RR is high 25 - 35. Switched back to A/C to rest MD. Pt received all MDI's through vent. Flovent was ordered today. Lung sounds were course in the apical region that improved after suction. She was suctioned for small to moderate amounts of thick yellow secretions. Care plan is to wean on CPAP w/PS and remain on CPAP/PS for as long as tol. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-06 00:00:00.000",
"description": "Report",
"row_id": 1611567,
"text": "resp care\nreceived on psv mode, cuff pressure measured as>40, reduced to 25-30 range for which pt has a significant cuff leak. Dr. aware, pt may need a larger trach tube placed. placed on trach mask at 1100, tolerating very well especially since inner cannula was removed..I.D of inner cannula is only 6 mm, even her small amts of secretions were occluding the inner cannula. will place new inner cannula when placed back on psv. brief bouts of tachypnea, relieved with suctioning. albuterol given q4h. c/w trach collar, probable vent assist in psv overnoc, monitor and keep cuff pressures below 30. (8 cc's air)\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-07 00:00:00.000",
"description": "Report",
"row_id": 1611568,
"text": "RESP CARE\nPT on trach collar @ 50%. Suctioned for small amt of thick yellow secrrtions. Nebs given. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-07 00:00:00.000",
"description": "Report",
"row_id": 1611569,
"text": "T/SICU Shift Report 1900-0730\n53Year old Female NKA FULL CODE Contact Precautions\n\nAdmission - S/P Rollover MVC\n\nPMH - Nil of Note\n\nInjuries - OPen book pelvic# with pelvic hematoma\n #L Humerus\n Frontal Lobe contusions\n R Temporal Lobe Contusion\n R Temporal Lobe Subdural Hematoma\n SAH\n Interventricular Hemorrhage\n L Parietal Skull Fracture\n\nOR - - OPen abdomen\n 6/31 - Closed abdomen\n - ORIF Pelvis\n - ORIF Humerus\n - Trach\n - J-tube\n PICC\n\nReview of Systems:\n\nResp - SV on Trach mask for 17hours FiO2 50%, Spo2 98-100%, RR 20-30 while settled (25-40 while coughing/awake). Small yellow secretions cleared to tip of trach, inner cannula removed to increase diameter. Breath sounds coarse throughout.\n\nCVS - Sinus rhythm-sinus tachycardia with no witnessed ectopy. HR 85-115bpm, SBP 100-120, MAP 70-90, Tmax 99.4. HCT stable, WCC decreasing. Continues on gentamycin/pipercillin. Peripherally warm/well perfused, minimal edema.\n\nRenal - UO 80-200ml/hr, -ve 450ml in last 24hours, currently -ve 300ml for today. BUN creatinine WNL, K 4.5, Mg 2.3, Ca 7.7 (repleted with 2g Calcium gluconate). KVO fluids.\n\nNeuro - Alert/sleeping, GCS 11 (e4v1m6), MAE, Obeying commands with persausion, answering questions. Indicated pain at scalp wound, given Q4 oxycodone-acetaminophen with good effect. Pupils 3mm/3mm brisk reactive.\n\nGI - TF continue at goal rate 70ml/hr promote with fiber via J-tube. NGT clamped, residuals minimal Q4. Abdomen soft/nontender, +ve bowel sounds. No BM overnight. Blood glucose controlled with ISS/NPH.\n\nSkin - Full bed bath/Teeth brushed. DSD to scalp wound .\n\nAccess - PICC patent, dressing .\n\nSocial - Daughter called/updated\n\nPLAN - Encourage cough/deep breathing\n Maintain trach mask reduced FiO2 as tolerated\n ?Reduce Metoprolol Dose\n Scalp dressing (next due )\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-07 00:00:00.000",
"description": "Report",
"row_id": 1611570,
"text": "respiratory care\npt on 35% cool mist tol well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-07 00:00:00.000",
"description": "Report",
"row_id": 1611571,
"text": "pt has a rt 2 lumen PICC line not a RSC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-07 00:00:00.000",
"description": "Report",
"row_id": 1611572,
"text": "Neuro: pt alert at times. responds to question by nodding head. follows commands. moves rt arm freely. moves left arm and legs on bed to stimuli. PERL.\n\nPain: pt denies pain but appears uncomfortable with ADLs roxicet given 5cc X2 with effect.\n\nCV: SR/ST 90-118.SBP < 110 most of shift held lopressor currently > 110 .lopressor given. RSC 3 lumen patent.\n\nLungs: coarse throughout. suction for thick yellow sputum. Good cough brought up thick green plug x1. FIO@ decreased to 35% SAT still > 97.\n\nGI: ABD soft . BS present. TF @ goal 70cc. tolerated well. fecal bag on brown loose stool small amt.\n\nGu: Foley to gravity. clear yellow urine.\n\nSkin: head laceration DSG changed x2 ; NS to dry dsg . Drainage yellow small amt. OOB to chair for 4 hours today. no pressure areas noted.\n\nA/P continue current plan of care. see care view for data. to go to OR tomoorrow for closure of head laceration . NPO after midnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-08 00:00:00.000",
"description": "Report",
"row_id": 1611573,
"text": "Resp Care\nPt. remains trached with #7 Portex- perc.Inflated with cuff pressure 29cm. Currently on 35% CA. Spo2 96-100%. Pt. tachypneic at times high 30's- low 40's.\nBs: coarse with occ. scattered rhonchi/exp. wheeze. Sxn'd q1-4 for thick yellow, mod. amts.Tx'd with albuterol prn.\nPlan:cont. pulm. toliet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-08 00:00:00.000",
"description": "Report",
"row_id": 1611574,
"text": "NPN 7pm-7am\n\nROS: See carevue for exact data\n\nEvents of noc-Uneventful\n\nN: Pt more responsive. Still with periods of sleepiness to wakefullness. Following commands incons. Pt able to give thumbs up, squeeze hands, stick out tongue. Moving all ext's, more purposeful with . can lift and hold, all other ext's move on bed minimally. All w/draw to painful stim. Pt able to nod yes and no to questions. corneal's, gag/cough. Pupils equal and reactive 3mm. No sz activity. Roxicet needed for pain\n\nResp: Pt remains on trache mask 35%. Tolerating well. Sats 96-98%. LS coarse to clr. Frequent suctioning, trache care. Resp rate still remains elevated 30's. Pt with high resp when intubated. Will monitor closely.\n\nCV: SBP wnl. HR Sr to ST 90-120. Lopressor ATC. NS @KVO. Pulses weakly palpable. venodynnes, lovenox injection.\n\nGI: Pt cont on reglan ATC and cont with loose stool. ?d/c of medication. Will pass on for rounds. Abd soft/distended. Rectal bag on. Positive BS, Jtube . Pt was to be NPO after MN, per HO no need for NPo secondary to Jtube, cont feeds as ordered, and fixed doses of NPH\n\nGU: u/o adeq. yellow clr.\n\nHEM: HCT 28.4 HGB 9.1 Plt 502 RBC 2,91\n\nID: Low grade temps 99's, no spike overnoc. WBC 12.7. Pt cont on anbx\n\nEndo: Pt with high bld sugar at bed 199--> fixed dose and sliding scale, ? need for a.m. fix dose and pm dose. bld sugar this am 135 3 units reg given.\n\nLytes: Calcium being repleted 7.8, Phos 2.6 pt on nphos \n\nSkin: Old ct sites healed. Steris to abd. Staples remain in right hip and left arm . Rest of skin with hematomas. Pt to go to OR today for head laceration cont with W -->D\n\nSoc: husband-very supportive\n\nA: 53 yr old woman s/p MVC with mult injuries. Pt cont on trache mask.\nLow grade temps, still ST but otherwise stable. Large laceration to left side of head.\n\nP: Cont trache mask, plan for OR ? time pt is an add on for today--> fix left head lac. Cont feeds, await plan. Monitor resp status sux prn. Possible transfer to floor if stable after surgery. ?d/c reglan\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-28 00:00:00.000",
"description": "Report",
"row_id": 1611529,
"text": "Resp care\nPt remains on vent. Intubated with 7.5 @ 23, patent and secure. Suctioned mod amt of thick yellow secretions., Rsbi 105. Abg acceptable on current conditions. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-28 00:00:00.000",
"description": "Report",
"row_id": 1611530,
"text": "cv: hr frequently increased above 100. additional doses of lopressor 5 mg iv times 3 .aline dampening. nbp stable 99/50-135/90\n\ngi: us done of gall bladder. no stones visualized. \"sludge\" tube feeds on avernoc at 10 cc/hr. tf off at 0400 in prep for trach and peg today.pos bowel sounds.. hypoactive. no bm\n\ngu: foley draining clear yellow urine adequate amounts.\n\nresp: suctioned frequently for moderate amounts thin and thick white and yellow.resp increased to 40's when pt required suctioning. resp rate decreased to 27-31 after ssuctioning.breath sounds clear upper diminished at bases.ct draining serosanguinous.\n\nlabs q 6 hr blood sugars tx with sliding scale 2units at 2200 bs= bs = 68 no tx. repleting ca and mag this a.m.\n\nintnegumentary: r hip and side of r knee dressings changed for serous fluid. left wrist draining serosanguinous..covered with dsd after cleansing.\n\nid temp to 101.4 dr no cx at this time tylenol 650 mg ng times one.\n\nneuro: tp more alert opening eyes to sounds and stimulation.very little movement of left arm and leg. moves r arm and r leg to stimulation and nailbed pressure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-28 00:00:00.000",
"description": "Report",
"row_id": 1611531,
"text": "resp. care\npt. continues on vent. bedside trach done with #8.0 portex.\nplaced on a/c and 100% o2 during trach and once awake changed\nback to ps 10/5. requires frequent sx'ing for white sputum.\nplan to wean to trach collar when ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-28 00:00:00.000",
"description": "Report",
"row_id": 1611532,
"text": "T/SICU Shift Report 0700-\n53 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - S/P Rollover MVA\n\nPMH - NIl of Note\n\nInjuries - Open book pelvic # with pelvic hematoma\n # L humerus\n Bilateral Frontal Lobe Contusions\n R Temporal Lobe Contusion\n R Temporal Subdural Hemorrhage\n SAH\n Interventricular bleeding\n L Parietal Skull Fracture\n\nOR - - Open Abdomen\n - Closed abdomen\n - ORIF Pelvis\n - ORIF Humerus\n - Trach\n\nReview of Systems:\n\nResp - CPAP/PS PS 10 PEEP 5 FiO2 50%. SpO2 95-99%, RR 20-30bpm, TV 300-400ml. Breath sounds clear-coarse in upper lobes, diminished at the bases. Copious thick/yellow/bloodstained secretion on ETT suction. Percutaneous trach at bedside today, no events, bronchoscopy performed concurrently to clear LLL secretions.\n\nCVS - Sinus rhythm-sinus tachycardia with no witness ectopy. HR 80-110, SBP 85-190 (hyperdynamic with agitation), MAP 50-120, CVP 17-20, Tmax 101.2. PEripherally warm/well perfused with weak palpable pedal pulses. Antibiotics changed to gentamycin, and pipercillin following +ve urine culture. IV metoprolol Q4 (aim HR <100).\n\nRenal - UO 40-180ml/hr, +ve 450ml today. Maintenance fluid 75ml/hr LR. Lytes stable today.\n\nNeuro - Arousable to voice, GCS 10 (e4v1m5), MAE to noxious stimuli, localising to trach/ETT with Right hand, spontaneous movement of right hand. Pupils 3mm/3mm brisk reactive. No evidence of pain, fentanyl increased to 150mcg/hr to suppress cough following trach.\n\nGI - TF held, OG pulled due to patient gagging, needs NG prior to CT scan for abdominal CT with contrast. Abdomen soft/distended, hypoactive bowel sounds. Blood glucose covered by ISS.\n\nSkin - Pressure areas intact. Labia skin tear draining serous fluid. Pin site R leg draining +++ serous fluid, DSD changed. dressing intact. CT dressing intact. Laceration to left wrist redressed. Collar care done.\n\nAccess - Aline dampened, cline patent dressing intact.\n\nSocial - Family updated by RN, will call tonight after CT scan\n\nPLAN - Abdominal CT with contrast\n NGT\n WEan ventilation as able\n Regular suctioning\n Maintain HR >100\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-05 00:00:00.000",
"description": "Report",
"row_id": 1611562,
"text": "NPN 0700-1900\nNEURO: Pt is alert and interactive. Follows commands and nods to yes/no questions. Denies pain.\n\nRESP: Weaned PS to 10 from 13 x several hours however pt placed back on PS 15 d/t tachypnea and increase in work effort. Sat WNL.\n\nCV: HR 80s-100s BP 90s-130s/40s-70s. Lopressor weaned to 50mg PO QID.\n\nHEME: Acceptable H/H. Fe supplement cont. Lovenox/pboots for DVT prophylaxis.\n\nGI: Small amount of bilious fluid via NGT. TF cont. BM x1.\n\nGU: Adequate u/o via foley.\n\nID: Temps 99-100, no changes in abx.\n\nENDO: NPH addedd to RISS regimen. Gluc 140s-160s.\n\nSKIN: See carevue for wounds. No breakdown noted to back/buttocks.\n\nSOCIAL: Family in to visit and appear to be happy about pt's progress. Asking appropriate questions about rehab process.\n\nASSESSMENT: Pt s/p MVA with multiple injuries.\n\nCurrent nsg issues:\nAltered neuro status (though neuro exam is improving).\nVentilatory weaning impairment.\nRisk for infection.\nHyperglicemia.\n\nPLAN: Cont to monitor vs, neuro checks, rest on previous vent settings overnight, cont to wean vent if tolerated and/or appropriate, wound care, encourage mobility.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-05 00:00:00.000",
"description": "Report",
"row_id": 1611563,
"text": "resp care\nremains trached/vented in spontaneous mode. psv weaned from 13 to 10, did well for a few hours then tachypneic. initially tried suctioning without only transient improvement, subsequently increased ps back to 15. mdi's given q4h. small amts white/tinged sputum. c.w slow wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-06 00:00:00.000",
"description": "Report",
"row_id": 1611564,
"text": "Resp Care\nPt remains on vent. No changes made. Suctioned mod amt of thick yellow secretions. Mdis given. Rsbi 136.5. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-06 00:00:00.000",
"description": "Report",
"row_id": 1611565,
"text": "T/SICU Shift Report 1900-0730\n53 Year Old Female NKA FULL CODE Contact Precautions\n\nAdmission - - S/P rollover MVA\n\nPMH - Nil of note\n\nInjuries - Open book pelvic #/pelvic hematoma\n #L humerus\n Frontal lobe contusions\n R temporal lobe contusion\n R temporal lobe subdural hemorrhage\n SAH\n Interventricular hemorrhage\n L Pariental Fracture\n 2xScalp Laceration\n\nOR - - Open Abdomen/Ex-lap\n - Closed Abdomen\n - ORIF Pelvis\n - ORIF Humerus\n - Trach\n - PEG\n PICC\n\nReview of Systems:\n\nResp - PS/CPAP PS 15 PEEP 5 FiO2 40%. SpO2 100%, RR 15-30bpm, TV 350-650ml. Breath sounds coarse to the upper lobes, diminished at the bases. Small thick/yellow secretion on trach suction. Chest tube sites redressed. Trach care done.\n\nCVS - Sinus rhythm-sinus tachycardia with no witnessed ectopy. HR 80-115bpm, SBP 100-130, MAP 75-100, Tmax 99.7. HCT down to 25.5%, Hb down to 8.2, WCC down to 10.3. Continues on pipercillin. Metoprolol 50mg QID. Peripherally warm/well perfused/palpable pedal/radial pulses. + to LUE.\n\nRenal - UO 45-220ml/hr, 24 hour balance +ve 250ml, Currently -ve 150ml. KVO fluid. BUN/Creatinine WNL, K 4.1, Mg 2.3, Ca 7.8 (repleted with 2g Calcium gluconate).\n\nNeuro - Improving Neuro status. Alert/asleep, GCS 11 (e4v1m6), MAE, corneal/gag/cough . Pupils 3mm/3mm brisk reactive. Obeying commands consistently, answering questions. One complaint of pain, indicated wound, premedicated for dressing changes with oxycodone-acetaminophen.\n\nGI - TF continue at goal rate 70ml/hr promote with fiber via J-tube. NGT to suction 100ml bilious output overnight. Abdomen soft/distended, +ve bowel sounds. Large liquid stool overnight, fecal bag in situ. Blood glucose controlled with ISS/NPH.\n\nSkin - Full bed bath/sheet change, teeth brushed. Q8 -dry dressing to scalp wound. Chest tube sites redressed. J-tube site redressed. Pressure areas .\n\nAccess - PICC line patent, dressing .\n\nSocial - Daughter called/updated.\n\nPLAN - Wean PS to 13 as tolerated\n Continue pulmonary hygiene\n ?Wean metoprolol\n Premedicate with oxycodone-acetaminophen for dressing change\n Q8 -dry to scalp (next due 1200)\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-06 00:00:00.000",
"description": "Report",
"row_id": 1611566,
"text": "NPN 0700-1900\nNEURO: Pt is alert, inconsistently interactive. Inconsistently follows commands but is able to MAE and nod to yes/no questions. C/O slight pain to head wound; roxicet prn.\n\nRESP: Pt has audible cuff leak despite high cuff pressures. Weaned to trach mask and tolerated for > 5hrs. Sat WNL. Suctioned for small amts of thick white secretions. Strong productive cough.\n\nCV: HR 100s ST no ectopy noted. BP WNL. Lopressor QID cont.\n\nHEME: Lovenox cont. H/H acceptable.\n\nGI: NGT clamped and residuals checked q4. Small amt of NGT residuals. Abd slightly distended. No BM this shift.\n\nGU: Adequate u/o via foley.\n\nID: Afebrile. No changes in abx.\n\nENDO: NPH increased to 20u q12 and FS now checked q6. Gluc well controlled with RISS.\n\nSKIN: Staples to abd removed and steristrips applied. Granulating tissue noted to head wound. Per Dr. ; may use DSD's if wound has drainage.\n\nSOCIAL: Family in to visit and supportive.\n\nASSESSMENT: Pt s/p MVC with multiple injuries.\n\nCurrent nsg issues:\nAltered neuro status.\nRisk for infection.\nResp status improving.\n\nPLAN: Cont to monitor vs, neuro checks, cont to wean from vent as tol, encourage mobility/PT consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-30 00:00:00.000",
"description": "Report",
"row_id": 1611540,
"text": "NPN 0700-1900\nNEURO: Pt on fentanyl gtt for pain, otherwise does not receive any type of sedation. Pt does not follow commands or attempt to interact. Opens eyes very inconsistently. RUE localizes to suctioning and mouth care, other extremities withdraw to nailbed pressure.\n\nRESP: Attempted to place pt on CPAP; within approx 90min pt became tachypneic with RR as high as 38-39 and sat decreased to 92%. Pt placed back on assist control. LS very coarse. Pt has congested, nonproductive cough. Scant secretions with suctioning even despite ambu/lavage.\n\nCV: HR 100s ST, no ectopy noted. BP WNL.\n\nHEME: Acceptable H/H. Sq heparin/pboots for DVT prophylaxis.\n\nGI: Abd soft distended. TF advanced to goal of 70cc/hr. TPN dc'd after completion of today's infusion. Large loose stool via mushroom cath cont.\n\nGU: Adequate u/o via foley. IVF kvo'd.\n\nID: Tmax 101.2. Down with tylenol and tepid bath. Pt pan cultured. Zosyn cont.\n\nENDO: Gluc 190s-200s despite 20u reg insulin in TPN. Also covered with RISS.\n\nSKIN: Back/buttocks grossly intact. Sutures to lac's on anterior and posterior head dc'd by Dr. . Left JP dc'd by Dr. . See carevue for other wound descriptions.\n\nSOCIAL: Multiple family members in to visit and updated on pt's progress and POC.\n\nASSESSMENT: Pt s/p MVC with multiple injuries.\n\nCurrent nsg issues:\nAlteration in neuro status.\nInfection/fever.\nVentilatory weaning impairment.\nImpaired skin.\nImmobility.\n\nPLAN: Cont to monitor vs, neuro checks, aggressive pulmonary hygiene, skin care, f/u with culture results and monitor fever curve, cont with CPAP trials and vent weaning as tolerated.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-26 00:00:00.000",
"description": "Report",
"row_id": 1611522,
"text": "Respiratory Care:\nPt has been doing OK except for transient desats that responded to a few bag breaths and some suctioning, secretions were unimpressive\nat this point. The NEURO exam has been the problem in that she does not respond as well as we feel she should. This may represent a setback in her overall recovery. SeeCareVue for ABG's and further info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-26 00:00:00.000",
"description": "Report",
"row_id": 1611523,
"text": "Nursing Progress Note.\nPlease refer to CareVue for specifics.\n\nEVENTS TODAY:\n\nCT scan brain.\nCentral line rewired and arterial line resited.\n\nOn exam:\n\nNEURO:\nSlow to wake this morning off propofol. At best, exam was opening eyes to stimuli, not regarding, no blink to threat, PEARL. Imparied cough and gag although resisting oral care and thermometer. Weak withdrawal Rt arm from painful stimuli. Exam did not improve much over several hours until line change, when pt started coughing spontaneously. CT brain attended. Pt remains off propofol at this time. Continues to move eyes and opening lids part way. PEARL, still not regarding. Have noted more spontaneous movement of Rt arm, but pt lifts it off the bed nonpurposfully, then it drops back down promptly.\nC-collar in place. Fentanyl for pain.\n\nRESP:\nRemains orally intubated, tube rotated and well secured. Remain on a/c with occasional resps above set rate. Chest coarse initally but improving. Few secretions initially but found to have large amount of thick tan-bloody x1 occasion. Few otherwise.\nHad some oxygenation problems at change of shift this morning with desaturation requiring increased Fi02 but weaned to 50% (up from 40% overnight).\nChest tubes placed to water today. Repeat cxr attended and reviewed by ICU fellow. Minimal drainage today.\n\nHEMODYNAMICS:\nTachycardia persisting. Improved with metoprolol (dose increased today) but still becomes tachycardic and hypertensive with interventions. Globally warm to hot, pitting edema. Some serous ooze from old skin openings from external fixators. Pulses palpable. CVP climbing.\n\nID:\nFebrile to 102F today. Tylenol given. Central line required and arterial line resited.\n\nENDOCRINE:\nCovered per sliding scale for hyperglycemia.\n\nFLUIDS/LYTES:\nFluids at KVO rate. Phos to be repleted.\n\nGI:\nTHe abd is softly distended and slightly firm but not rigid. Most of it is covered with dry dressings, which were changed less than 12 hrs ago, so not removed for repeat assessment of wound beds. There has not been any oozing onto the dressings. The JP drains have put out minimal hemoserous ooze.\nOGT in place. Recommenced tube feeds at trophic rate but pt to be NPO from midnight pending OR in the am. No audible bowel sounds. Continues to receive metoclopramide and erythromycin.\n\nRENAL:\nGood urine output via foley. Amber colored.\n\nSKIN:\nAssessments per CareVue. The dressings are fresh and were redone overnight. The Lt thumb dressing has a scant amount of serous ooze on it at this time. The Rt thight (? old external fixator site) has oozed a larfge amount of serous ooze. Dry dressing refreshed. There was a scant amount of bloody drainage from a labral tear, and moderate bruising in perineum. Head lacs are stapled and sutured with minimal ooze.\n\nSOCIAL:\nFamily visiting, husband, daughter, and their friend. They have many questions and they have not previously been educated regarding the long trajectory for brain injury rehab. Several questions answered, and also\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-26 00:00:00.000",
"description": "Report",
"row_id": 1611524,
"text": "(Continued)\narranged for them to speak with the TSICU HO. Would suggest requesting social work support tomorrow, and also a meeting with neurosurgery to address their questions regarding the extent of the injury and prognosis. The family are visibly saddenned by the pt's slow progress. Reassurance offered. The husband also requested a priest visit, and this was arranged today.\n\nPLAN:\nContinue neuro checks.\nFollow temp and culture data.\nPressure support trial.\nNPO from midnight.\nOR tomorrow for Lt humerus.\nFamily meeting tomorrow with Neurosurgery.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-31 00:00:00.000",
"description": "Report",
"row_id": 1611541,
"text": "ROS:\n\nNeuro: Eyes open occasionally at random. Does not blink to protect. + corneal, cough, and gag reflexes. Random to purposfull movements of RUE. NO movements of other extremities noted. Resists po cares. Grimicing to nailbed pressure. J collar on at all times. On po dilantin. No seizure activitiy noted. Fentanyl gtt at 75 mcg/hr, appears to be comfortable.\n\nCV: ST 100-126 no ectopy noted. On metoprolol 50 mg po BID. Peripheral pulses palpable in all 4 extremities. Has left subclavain MML w/prox port transduced for CVP=. Generalized edema esp in LE,hips, and abd area. Sub Q heparin and P boots for DVT prophylaxis.\n\nResp: Remains trached and on vent, AC 500x14, peep 5, 40%. Sats 100%. No abgs drawn, no A line. Lungs coarse. Sx thick yellow via Trach. No resp distress noted, = rise and fall of chest. Has left chest tube draining straw colored fluid in small amts.\n\nGI: Pedi tube via left nare, Post pyloric w/TF infusing at goal. Abd firm distended w/active BS x's 4 quads of abd. Liq stools managed w/mushroom cath. H2 blocker for GI prophylaxis.\n\nGU: Foley patent draining clear yellow to amber urine in QS.\n\nSkin: Many skin issues, see carevue flow record for detailed assessment. Large ecchymotic area lumbar spine area, purple.\n\nEndo: FSG covered w/RSSI\n\nID: Tmax 102.5 po. Tylenol via NG. On zosyn and gent.\n\nSocial: Husband phoned in for update.\n\nPlan: Gent levels w/next dose. Pulmonary toileting. Wean vent as able, ? try SIMV mode. Mobilization. Monitor, tx, support, and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-27 00:00:00.000",
"description": "Report",
"row_id": 1611525,
"text": "respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Peep weaned to 5cm and vent mode changed to cpap/ps. Currently on Cpap 5 PS 15 with . ventilation of 10L. Tolerating well. ABG: 7.45/42/164 30 5. Breathsounds are coarse. Please see respiratory care section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-27 00:00:00.000",
"description": "Report",
"row_id": 1611526,
"text": "TSICU NPN:\nNEURO: PERRL 3-4mm and brisk. Opens eyes to stimuli. No following of commands, w/d to painful stimuli to all four extremities. No sz activity. Moving R arm in bed but otherwise very little movement of other extremities. Fentanyl at 120mcg/hr. Propofol off. Weak cough, corneals and gag.\nCV: Tmax 101 and pan cx'd. HR 90s-100s SR/ST, no ectopy noted. BP stable although hypertensive at times with coughing. On lopressor. Repleted with , Na phosphate, Cagluconate and KCL overnight. Generalized 3+ edema.\nRESP: CPAP/PS 15 Peep 5 FiO2 50% with TVs 350- 400s and O2 Sat >95%. No episodes of desaturation. L #2 CT pulled by resident last pm and now with #1 Ct on L to H2O with minimal drainage, no leak or crepitus noted. LS coarse and diminished LLL. Sx'd for thick rust/tan colored secretions in small amts.\nGI/GU: Abd. softly distended with very hypoactive bowel sounds. TF off at midnight for planned repair of L humerus in OR today. Passing flatus but no BM so far. Foley draining amber clear urine >30cc/hr. Q6hr fingersticks with insulin ss as ordered.\nSKIN: Abd. incision with staples/sutures intact, no swelling or drainage noted. Two JP drains draining scant amts of serosang. drg. Lower abd. incision with staples, C/D/I. Lacerations to forhead/head with staples C/D/I. L hand with small abrasion with DSD. R hip with staples C/D/I. Old ex-fix pin sites to R knee draining large amts serous fluid with aquacel dsg applied to lateral site. Tear to labia draining small amts of serous fluid. L foot a-line intact. L SC TLC line inteact.\nOTHER: Husband and daughter into visit last pm. Plan for family mtg today to discuss pt's plan of care and prognosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-27 00:00:00.000",
"description": "Report",
"row_id": 1611527,
"text": "resp. care\npt. remains intubated/vented. most of day spent on cpap/ps\nexcept when post op. tolerating well. sx'd for thick tan\nsecretions. continue to wake...opens eyes. see flowsheet\nfor more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-27 00:00:00.000",
"description": "Report",
"row_id": 1611528,
"text": "T/SICU Shift Report 0700-\n53 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - - S/P Rollover MVA\n\nPMH - Nil of Note\n\nInjuries - Open Book Pelvis#\n #Left Humerus\n Frontal lobe contusions\n R Temporal Lobe Contusions\n R Temporal Lobe Subdural hemorrhage\n SAH\n Interventricular Hemorrhage\n L Parietal Skull Fracture\n\nOR - - Open Abdomen\n - Closed Abdomen\n - ORIF Pelvis\n - ORIF Humerus\n\nReview of Systems:\n\nResp - CPAP/PS PS 10 PEEP 5 FiO2 50%. SpO2 98-100%, RR 14-30bpm, TV 360-500ml, ABG pH 7.44, PaCO2 46, PaO2 164, BE 6. Breath sounds coarse to the upper lobes, diminished at the bases. Thick yellow secretions on ETT suction. CT to H20 50ml serosanguinous output this shift.\n\nCVS - Sinus rhythm-tachycardia with no witnessed ectopy. HR 95-120bpm, SBP 95-185, MAP 60-120, Tmax 101.2. Peripherally warm/well perfused. Started on cefazolin post-operatively, started on levofloxacin for pneumonia.\n\nRenal - UO 40-80ml/hr, +ve 500ml today. Maintenance fluid 75ml/hr LR. K 3.9 (repleted with 20mEq KCl), IOnised Ca 1.05 (repleted with 2g Ca gluconate).\n\nNeuro - Arousable to voice, GCS 10 (e4v1m5), MAE to painful stimuli. Localising to ETT on ETT suction. No evidence of pain, fentanyl decreased to 100mcg/hr. Pupils 3-4mm/3-4mm brisk reactive. Corneal/cough reflex intact, impaired gag reflex.\n\nGI - NPO for USS, restart trophic TF at 10ml/hr promote with fiber. Abdomen soft/distended/hypoactive bowel sounds, no BM since admission.\nBlood glucose stable with ISS.\n\nSkin - Q4 turns. Pressure areas intact. Skin tear to labia. CT site redressed. dressings intact. Hip redressed. Pin sites redressed.\n\nAccess - Aline/cline patent, cline dressing changed.\n\nSocial - Family talked to neurosurgery following review, informed of improved CT scan, and neuro injury the unlikely cause of decreased neuro status. Consented for trach/PEG.\n\nPLAN - Percutaneous Trach/PEG\n Wean ventilation as able\n USS liver\n WEan fentanyl as able\n Maintain HR <100 with PRN metoprolol\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-03 00:00:00.000",
"description": "Report",
"row_id": 1611554,
"text": "NPN 7pm-7am\n\nROS: (See carevue for exacts)\n\nNeuro: Pt with poor neuro exam. Does not follow commands, no tracking with eyes/no eye contact. Moves purposeful, localizing to pain. All other exts move on bed, weak w/drawal reaction to painful stimuli. x1 episode pt very awake, looked over at RN as she entered room, eye contact made, pt incons following commands. Pt able to stick out tongue when asked repetively.Pt was also able to shake her head no when asked if she had pain. No sz activity. Pupils equal and reactive. with restraint.\n\nCV: Hr SR-ST. Up to 110's, usually tachycardia seen more when pt is febrile. BP wnl 90-100's ststolically. Pt on lovenox, venodynnes. positive pulses. IVF at KVO\n\nRESP: Pt fully vented currently, will attempt to turn to CPAP and PSUPP in a.m. Pt appears very comfortable on AC. Settings 500x14 peep 5, 40% LS coarse, sux'd, trache care done. O@ sats 97-100%, RR 20's\n\nGI: Pt cont on TF at goal via daubhoff, post pyloric. ?Peg plcmt. NGT to LIWS draining lg amts of bilious drainage HO aware. Abd softly distended. Pos BS.\n\nGU: u/o adeq\n\nSkin: mult brusing to exts. no breakdown noted. Left occipital head drsg to dry per HO attempting to let wound granulate, ? need muscle flap. Mult surgical sites to ext's with staples .\n\nENDO: Pt cont on insulin drip. Bld sugars q1. Titrate for Bld glucose <120. BLD sugars labile through noc.\n\nHEM: HCT 22.7, PLT 513 HGB 7.5\n\nID: Pt has been cultured, tylenol for temps. WBC 11.1 Pt cont on zosyn and gentamicin. Trough needed before afternoon dose.\n\nLytes: wnl except ca slightly low, will replete\n\nDilantin 7.7\n\nSoc: Husband called for update, very pleasant, appropriate.\n\nA: s/p MVA with mult injuries. Stable, febrile, ventilated\n\nP: ? Peg plcmt, eventually wean to trache collar. eventually rehab, cont with fever workups. Provide emotional support. Monitor and maintain safety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-03 00:00:00.000",
"description": "Report",
"row_id": 1611555,
"text": "NPN: Review of Systems\nNeuro: Pt intermittently alert. Opening eyes to voice. PERRL. (+) corneal reflex. Moving right arm purposefully. Squeezed twice to command. Soft wrist restraint on to prevent dislodgement of tubes. LUE and LEs withdraw to nailbed pressure. Pt has followed commands inconsistently such as opened her mouth when asked while brushing her teeth, squeezing w/ right hand, nodding to some questions. Dilantin as ordered. No seizure activity observed.\n\nResp: Pt has been on CPAP throughout the day. Rate has been primarily in the 20s, but has periodically gone up to the upper 30s, when more alert. BS are coarse, but small amts of secretions suctioned even w/ lavaging.\n\nCV: SR-ST. responds well to lopressor, w/ rate initially in the low 100s and coming down to the 80s. Skin moist. Palpable DP/PT pulses bilaterally. Assessed for PICC line, but per IV Nurse it would not be able to be done at bedside d/t phlebitic veins.\n\nGI: Tubefeeds at goal. large soft bowel movement this morning. rectal bag put on. No stool since. (+) bowel sounds.\n\nEndo: Regular insulin drip being titrated to achieve blood sugar <120. Currently on 3 units per hour.\n\nGU: Foley to gravity. Clear yellow urine.\n\nID: Low grade temp. Awaiting gentamicin trough level before giving dose. Continues on antibiotics.\n\nSkin: Bruising on back, but no open lesions. Head wound assessed by Plastic team. ->dry dressing applied. S/S drainage. Wound base pink. No open lesions. ARM, thigh and abdominal incisions OTA, w/ staples and no drainage.\n\nSocial: Husband, Dtr, friend and priest in to visit. Pt annointed today.\n\nActivity: Per ortho Pt may get OOB nonweightbearing on both LEs. seen by Physical and occupational therapy today.\n\nA: Tolerated CPAP today. Low grade temp persist. Hemodynamics stable. More alert today.\n\nP: Continue to monitor per plan. If Temp increases to 101.5-> pan culture. Possible OR next week for closure of head wound. ? rest overnight on vent. Please send stool for c-diff.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-04 00:00:00.000",
"description": "Report",
"row_id": 1611556,
"text": "Resp Care Note, Pt placed on A/C overnight to rest. Suctioned for mod amts thick pl yellow secretions. MDI'S given. RSBI done on 0 peep 5 ips 117.Not responding to commands. Will cont to wean to cpap/ips this AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-04 00:00:00.000",
"description": "Report",
"row_id": 1611557,
"text": "T/SICU Shift Report 1900-0730\n53Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - S/P Rollover MVC\n\nPMH - Nil of Note\n\nInjuries - Open book pelvis/Pelvic Hematoma\n #L Humerus\n Frontal Lobe contusions\n Temporal Lobe contusion\n Temporal Lobe Subdural hemorrhage\n SAH\n Interventricular hemorrhage\n L Parietal Fracture\n 2xScalp Laceration\n\nOR - - Open abdomen/ex-lap\n 6/31 - Close abdomen\n - Pelvis ORIF\n - Humerus ORIF\n - PEG\n\nReview of Systems:\n\nResp - Rested overnight on AC 14x500 PEEP 5 FiO2 40%. SpO2 100%, TV 450-550, RR 15-35bpm. Breath sounds coarse throughout. Small-moderate secretions on trach suction, strong cough reflex. Tachypenic when suction needed, settles quickly. Will return to CPAP 0600.\n\nCVS - Sinus rhythm-sinus tachycardia with no witnessed ectopy. HR 80-115bpm, SBP 100-115, MAP 70-90, Tmax 100.2. HCT upto 24.2%, Hb upto 8.0, WCC upto 11.6. Peripherally warm/well perfused, palpable pedal pulses. + edema to left hand. Betablocked. Continues on gentamycin, pipercillin.\n\nRenal - UO 40-200ml/hr, 24 hour balance -ve 250ml, currently +ve 250ml this shift. BUN/Creatinine WNL, K 4.4, Mg 2.2, Ca 7.2 (repleted with 2g Calcium Gluconate). Maintenance fluid 90ml/hr NS.\n\nNeuro - Intermittently following commands, tracking with eyes. GCS (e4v1m5-6). MAE, making purposeful movements with . Pupils 4mm/4mm brisk reactive, cough/gag . No evidence of pain. Continues on phenytoin.\n\nGI - NPO since midnight, NG to LCS, Post-pyloric tube clamped. Abdomen soft/distended, no BM overnight, +ve bowel sounds. Blood glucose controlled with insulin infusion.\n\nSkin - Full bed bath, teeth brushed. Scalp laceration redressed with -to-dry. Chest tube sites redressed. Midline incision well-approximated. Pressure areas .\n\nAccess - 2xPIV patent/.\n\nSocial - Husband called overnight, updated with progress, will visit today.\n\nPLAN - CPAP/PS\n ?Wean metoprolol\n Complete 7days of antibiotics\n PEG insertion under IR\n -dry TID (next due 0800)\n PICC insertion under IR\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-04 00:00:00.000",
"description": "Report",
"row_id": 1611558,
"text": "Resp Care\nPt was placed on PSV, tol well. Plan to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-04 00:00:00.000",
"description": "Report",
"row_id": 1611559,
"text": "TSICU Nursing Progress Note\nNeuro - Remains on vent with trach, not sedated. Intermittently follows commands, openes eyes and squeezes right hand, occasionally squeezes left hand, does not follow commands with feet. Withdraws LE's to pain. Moves right hand purposefully. PERRLA. cough and gag. Shook head when asked if having pain.\n\nCV - HR 90-120 sinus rhythm, no ectopy noted. BP by cuff 85-140 systolic. + peripheral pulses, skin warm and dry. PICC placed by IR this afternoon.\n\nResp - Lungs coarse to cleasr throughout. Suctioned for scant to small amounts white to clear secretions. Remains on CPAP, onto CMV for IR. Tolerated procedure well. Sats remain 100%.\n\nGI - ABdomen softly distended. NGT to suction, putting out small amount bilious fluid. Post-pyloric tube with tube feeds promote with fiber at goal 70cc/hr. To IR this afternoon for placement of G/J tube. While in IR post-pyloric tube removed. use J portion of new tube now, wait overnight for G portion. Fecal bag on in am, off due to leakage, moderate amount brown soft stool.\n\nGU - Foley draining clear yellow urine in adequate amounts.\n\nEndo - Off insulin gtt. Restarted sliding scale insulin, scale tightened. Q4H blood sugars. Highest 162 today.\n\nId - Tmax 100.4, tylenol given, with temp down to 99.4 currently. Remains on antibiotics. Placed on contact precautions for MRSA in wound in scalp.\n\nSkin - Surgical sites healing well, no drainage. Scalp lac with to dry dressings TID. Small amount s/s drainage. Posterior skin .\n\nPsych/social - Husband in during day. Coping well, talking with pt, trying to remain upbeat and hopeful. Call from daughter this am.\n\nA - S/P MVC, with head injury and altered mental status. Infection, impaired family coping.\n\nPlan - Continue to monitor per routine. Continue to monitor and treat for pain PRN. to dry dressings to scalp lac, being followed by plastics, with possible surgery next week. Screen for vented rehab. Maintain MRSA precautions. Continue to update pt and family of current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-05 00:00:00.000",
"description": "Report",
"row_id": 1611560,
"text": "Resp Care Note, Pt remains on current bent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions. MDI'S given. Temp 100.More alert today. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-05 00:00:00.000",
"description": "Report",
"row_id": 1611561,
"text": "T/SICU Shift Report 1900-0730\n53 Year Old Female NKA FULL CODE Contact PRecautions\n\nAdmission - S/P rollover MVA\n\nPMH - Nil of Note\n\nInjuries - Open book pelvis with hematoma\n #L Humerus\n Frontal lobe contusions\n R Temporal Lobe Contusion\n R Temporal Lobe Subdural hemorrhage\n SAH\n Interventricular Hemorrhage\n L Parietal Skull Fracture\n\nOR - - Ex-lap/Open Abdomen\n - Close Abdomen\n - Pelvis ORIF\n - Humerus ORIF\n - Trach\n - J-tube\n PICC\n\nREview of Systems:\n\nREsp - PS/CPAP PS 15 PEEP 5 FiO2 40%. SpO2 100%, RR 19-30bpm, TV 350-450. Breath sounds coarse throughout. Small/thick/yellow secretions on trach suction.\n\nCVS - Sinus rhythm to sinus tachycardia with no witnessed ectopy. HR 80-115bpm, SBP 85-125, MAP 60-85, Tmax 99.9. HCT upto 27.8%, Hb upto 9.0, WCC down to 10.5. Peripherally warm/well perfused, with palpable pedal pulses. Continues on pipercillin/gentamycin.\n\nRenal - UO 40-80ml/hr, 24 hour balance +ve 200ml, currently postive 200ml for today. BUN/Creatinine WNL, K 4.5, Mg 2.4, Ca 7.3 (repleted with 2g Calcium gluconate). KVO fluids.\n\nNeuro - Improving neuro status, alert at times, GCS 11 (e4v1m6), cough/gag/corneals , pupils 4mm/4mm brisk reactive. Obeying commands consistently with right hand, answering yes/no questions. No evidence of pain, given regular acetaminophen overnight post J-tube placement.\n\nGI - J-tube approved for recommencement of tube feeds, restarted at goal rate 70ml/hr promote with fiber. NGT to intermittent suction with moderate bilious output. ABdomen soft/distended/nontender, +ve bowel sounds. Medium soft brown bowel movement overnight. Blood glucose controlled with ISS.\n\nSkin - Full bed bath/hair washed, teeth cleaned. PRessure areas , some residual bruising to lower back/buttocks. Midline incision/humerus incision - clips in situ. Q8 to dry dressing to scalp wound. J-tub redressed. CT site redressed.\n\nAccess - IV fluids started via PICC line, patent, dressing .\n\nSocial - Husband in to visit at begining of shift. Daughter called overnight, updated.\n\nPLAN - Wean ventilation tentatively\n ?Wean metoprolol\n Q8 -dry dressing to Scalp (next due 1200)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-26 00:00:00.000",
"description": "Report",
"row_id": 1611520,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported. Minimal changes overnight. BS's coarse, sxing small amts tan secretions. No RSBI this am, no spont. RR. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-26 00:00:00.000",
"description": "Report",
"row_id": 1611521,
"text": "TSICU NPN:\nNEURO: PERL 3mm and brisk. When off propofol, moves all extremities, follows commands intermittently and purposeful with RUE. Propofol at 20mcg/kg/ and fentanyl at 120mcg/hr. No sz activity noted. On dilantin with am level pending. ? absorbing via stomach- high residuals.\nCV: Tmax 101.7. HR 90s-110s SR/ST, no ectopy noted. On lopressor and prn iv lopressor- ? need to increase dose. BP stable. Skin warm and dry with palpable pedal pulses. HCT 23.9. Repleted with Mag sulfate this am.\nRESP: Continues on ACV 500 +8 peep and 40% FiO2 with adequate ABG. O2 Sat >95%. Sx'd for small amts thick tan secretions. L CT x2 to LWS with small amts serosang. drainage, no leaks or crepitus noted. LS coarse and diminished at bases.\nGI/GU: Abd. firm with hypoactive bowel sounds. No BM. Reglan started yesterday for high TF residuals. TF off overnight and will restart this am. Blood glucose wnl this am. Foley draining amber clear urine with decreasing amts- NS 500cc bolus given with some effect- will address with MD.\nSKIN: All dsgs changed. Abd. with staples C/D/I, no redness or drainage noted. Lower abd. transverse incision with small amts of serosang. drainage, no redness or swelling. Old CT site to R chest open with xeroform and dsd applied. L CT dsgs changed with large amts serous drainage on old dsg. R Hip dsg changed with scant drainage. R knee old pin sites with outer site draining large amts serous fluid- aquacel dsg applied and changed x3 overnight. Lacerations to forehead/head OTA with scant drainage. J collar on with collar care done this am. L elbow cast intact with arm elevated on pillow. L hand lac with dsd applied.\nOTHER: Husband called and updated on pt's condition and plan of care. Plan for possible OR tomorrow to fix humerus fx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-30 00:00:00.000",
"description": "Report",
"row_id": 1611537,
"text": "Neuro: Unchanged. Remains unresponsive except to deep pain. Moves only right arm spontaneously. unable to follow commands. Does not open eyes. Fentanyl gtt decreased to 75.\nCV/Resp Nsr no ectopy bp stable suctioned q3h for small amt yellow sputum. o2 sat wnl. vent changed to AC vent due to tachypnea.\ngi/gu tube feeds now at 40cc/hr. no residuals.Infusing well via post pyloric. very loose stool x1 around mushroom cath. Mushroom cath reinserted but not draining at present. good uop via foley.\ninteg dsgs on left hand and right legchanged for small openings draining large amt serous fluid. abdominal dsg changed. Incision clean and dry. sutures intact. No drainage. JPs minimal drainage to bulb sx.\nHead lacs open to air drainage.\nRemains on TPN.\nInsulin SS\nPlan: Continue to monitor Neuro status. Wean fent, gtt. Provide emotional support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-02 00:00:00.000",
"description": "Report",
"row_id": 1611552,
"text": "NPN: \nROS: see carevue for details\n\nNEURO: patient not following commands. weakly purposeful with right upper extremity. left arm & lower extremities move slightly on bed to painful stimuli. patient recieving roxicet for pain every 4-6 hours. perla briskly reactive. opens eyes spontaneously, intermittantly tracks to voice. dilantin dosing cont. rebolused this afternoon as ordered\n\nCV: HR 90-100s, BP stable. tachycardic with stimulation/activity. +pp, lovenox as ordered. HCT low.\n\nRESP: tolerating cpap + PS most of day with less periods of tachypnea. ls coarse, diminished. o2 sat 100% suctioned for small amounts of thick tan secretions\n\nGI: tolerating TF at goal via post-pyloric feeding tube. NGT remains to suction with bilious output. abd softly distended with + BS. large loose BM this morning. reglan, prevacid as ordered\n\nGU: foley catheter changed this morning. adequate urine out > clear yellow.\n\nENDO: insulin drip titrated to maintain BS less than 120. better control today.\n\nID: cont on gent and zosyn as ordered. low grade temps cont. cultures pending.\n\nSKIN: abrasions & incision as charted. lac to back of head with W>D dressings to cont. plastics up to see, will follow\n\nsocial: husband in to visit today, updated by RN, awaiting Dr. update\n\nPLAN: cont. to vent wean if tolerated. follow culture data, lab values. cont. w>d of scalp laceration. monitor & support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-03 00:00:00.000",
"description": "Report",
"row_id": 1611553,
"text": "Resp Care\nPt remains on vent. Trached with 7 portex. Suctioned mod amt of yellow secretions. Mdis given. No changes made. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-30 00:00:00.000",
"description": "Report",
"row_id": 1611538,
"text": "Resp Care\nPt remains on MV and currently in AC mode as noted on Careview. Pt became tachypneic (low grade temp) w/RR in mid 30's, increasing to 40's w/stimulation/freq need for sx, and also w/SpO2 dropping to 90-91% at times. Unable to resolve by increasing PS levels, so pt changed to AC with immediate decrease in RR to 18-20 and decreased wob. Physician . Pt sx'ed frequently for sm amts thick, yellow secretions. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-30 00:00:00.000",
"description": "Report",
"row_id": 1611539,
"text": "Respiratory Care Note\nPt received on AC as noted. Pt placed on PSV 15/5 with VT 360 and RR 34. Pt tachypneic consistently at 40 and pt subsequently placed back on AC with improvement - RR decrease to 22. BS coarse bilaterally - pt requiring frequent suctioning. Pt suctioned for small amts. Pt started on Albuterol MDI. BS clear after suctioning and MDI. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-23 00:00:00.000",
"description": "Report",
"row_id": 1611512,
"text": "T/SICU RN Progress Note\nNeuro: Lightly sedated on fentanyl and propofol, eyes open spontaneously, intermittenly follows commands. Dilantin changed to PO\n\nCV: HR 80-90's SR no ectopy noted. NBP systolic 110-140's. CVP 8-16. P-boots.\n\nResp: Remains orally intubated, no vent changes, suctioned for thick tan secretions, lungs coarse, CTX3 to water seal.\n\nGU/GI: Foley with clear yellow urine. Abd firm, no bowel sounds, trophic tubefeeding to advance, but high residuals. PPI, Bladder pressures 15-18. JP X2 with small amount of serosang drainage.\n\nSkin/Mobility: Remain in c-collar, skeletal traction, skin grossly intact, small area on labia with skin tear drainag serosang drainage.\n\nSocial: Family in updated.\n\nPlan: OR in the the morning for ortho, wean vent as toleraed, cont to montior and support, follow plan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-24 00:00:00.000",
"description": "Report",
"row_id": 1611513,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Currently A/C ventilation w/ PIP/Pplat = 26/22. BS coarse bilaterally, suctioned for small to moderate amounts of thick tan sputum. SpO2 high 90s-100%. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-24 00:00:00.000",
"description": "Report",
"row_id": 1611514,
"text": "Nursing Progress Note\n Pt sedated on Propofol, ^ to 20mcg overnight for comfort w/effect.Fentanyl remains @ 120mcg, pt arouses to voice, looks to speaker, follows commands intermittently.Pain w/movement,repositioning,comfortable atr rest.\n\nCV- MP-SR,no ectopy.bp stable by cuff pressures, no aline. TLC intact RSC, CVP 6-10. Pulses palpable but weak d/t edema, extremities warmer.Boots on lle only d/t skeletal tx rle\n\nResp- no vent changes overnight. on cmv 14,450, 50%, peep8,ls coarse, diminished at bases, sxn small amt bloody/tan. ct x2 on L, x1 onR, all to water , . dge\n\nGI- tf off @ mn, abd firm, but bs+ x4. midline incision well approximated w/ clips, stay sutures- dsd intact. jpx2, scant serosang dge.Bladder pressures trending down, last one 8.\n\nGU- foley in place, u/o qs\n\nID- afebrile off antibx\n\nF/E/N- tf off for or today, ivf @ kvo. K repleted.\n\nSkin- lac forehead d+i, lac l hand rx steri-strips/dsd, lue splint in place, rle skeletal tx in place, pin sites clean. Skin tear labia dg serous dge in mod/lge amts, perineal bruising unchanged\n\nPlan- To OR today for orif l humerus, open book pelvic fx.\n Cont to maintain adequate comfort level\n Optimize nutritional status, ^ tf as tolerated\n Wean pt from vent as tolerated\n Monitor for skin breakdown at pressure points, pin sites, mobilize pt as tolerated\n Continue to provide support/ teaching to pt and family as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-24 00:00:00.000",
"description": "Report",
"row_id": 1611515,
"text": "resp care\nremains intubated/vented in ac mode. s/p O.R for ORIF of pelvis. no vent changes made, acceptable abg. scant yellow secretions. bS cta anteriorly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-24 00:00:00.000",
"description": "Report",
"row_id": 1611516,
"text": "T/SICU Shift Report 0700-\n53 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - Restrained Rollover MVA\n\nPMH - NIl of Note\n\nInjuries - Open book pelvic#\n #L Humerus\n 2xScalp Lacerations\n Frontal lobe contusion\n R temporal lobe contusion\n R temporal subdural hemorrhage\n SAH\n Intraventricular hemorrhage\n L parietal #\n\nOR - - Ex-lap (open abdomen)\n - Abdomen closed\n - ORIF Pelvis\n\nReview of Systems:\n\nResp - Fully ventilated on AC 14x450 PEEP 8 FiO2 50%. SpO2 99-100%, RR 14-15, TV 450-500ml. ABG pH 7.44, PaCO2 40, PaO2 188, BE 3. Breath sounds coarse to upper lobes, diminished at the bases. Thick yellow secretions on ETT suction, strong cough reflex. 3xCT to H2O , small volume of serosanguinous drainage, entrance sites redressed. ETT rotated.\n\nCVS - Sinus rhythm-sinus tachycardia with no witnessed ectopy. HR 90-120bpm, SBP 125-155, MAP 90-110, CVP 2-3, Tmax 99.8. HCT 27% (after 1xPRBC in OR), lactate 1.0. Peripherally warm, weak palpable pedal pulses. EBL 400ml.\n\nRenal - UO 45-120ml/hr, -ve 300ml today. K 3.1 (repleted with 40mEq KCl), Ionised Calcium 1.03 (repleted with 2gCa gluconate).\n\nNeuro - Arousable to stimuli/voice, GCS (e3-4v1m6), MAE, localising to pain/obeying commands intermittently following OR. Fentanyl 120mcg/hr, propofol 20mcg/kg/. Pupils 3mm/3mm brisk reactive.\n\nGI - TF restarted at 10ml/hr (goal rate 70ml) promote with fiber. Abdomen firm, hypoactive bowel sounds, no BM this shift, Bladder pressure 8. Blood glucose stable with ISS.\n\nSkin - Full bed bath post-operatively. wound redressed with DSD. Pelvic incision dry and intact, primary OR dressing. Cervical collar maintained.\n\nAccess - Femoral aline inserted in OR, cline patent.\n\nSocial - Husband in to visit.\n\nPLAN - wean ventilation as able\n ?CTs out\n Q4 neuro checks\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-25 00:00:00.000",
"description": "Report",
"row_id": 1611517,
"text": "TSICU Nursing Progress Note\nNeuro - Remains intubated and sedated on propofol and fentanyl gtts. When lightened MAE's, did not follow commands. Opens eyes to voice and stimuli. Purposeful with RUE. PERRLA, intact cough and gag. Remains in c-collar. No s/s pain with current fentanyl dose.\n\nCV - HR 90-120 sinus rhythm, no ectopy noted. ABP 120-140 systolic. Given one dose 5mg metoprolol for tachy and hypertension, with positive result. Skin warm and dry. + peripheral pulses.\n\nResp - Lungs coarse throughout. Suctioned for small to moderate amounts tan thick secretions. Fio2 weaned to 40%, sats remain 99-100%. No other vent changes made overnight. 3 chest tubes remain, all with minimal drainage to water .\n\nGI - Abdomen firm. + bowel sounds throughout. Receiving tube feeds 40cc/hr currently goal 70, minimal residuals thus far. no BM overnight.\n\nGU - Foley draining clear yellow urine ~60cc/hr.\n\nEndo - No insulin needed per RISS.\n\nId - Temperature climbing over night. Tmax 100.6. Not currently on antibiotics.\n\nSkin - Lac x2 to head, with scant s/s drainage from posterior. Small lac to L hand, scant s/s drainage. Abdomen with dressing in place, scant s/s drainage in inferior region. Small pin size hole in L groin with moderate amount serous drainage. Small surgical site at R hip from pelvic fixation, no drainage. Pin sites at R knee, with small amount s/s drainage. Bruising noted in perineal area. Posterior skin intact.\n\nPsych/social - Husband called once overnight for update.\n\nA - s/p MVC, multiple head bleeds. Impaired mental status. Acute pain. Multiple injuries.\n\nPlan - COntinue to monitor per routine. Increase tube feeds as tolerated to goal of 70cc/hr promote with fiber. Start bowel regimen. ? start PO metoprolol for persistent low grade tachycardia. Wean vent as tolerated. Return to OR wed, or thurs for fixation of L humerous. Continue to monitor for pain. COntinue to update pt and family of current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-25 00:00:00.000",
"description": "Report",
"row_id": 1611518,
"text": "Respiratory Care:\nPt seemed to be progressing well ,however after removal of chest tube her PaCO2 inc. to 51 from 36 before removal could be from lung contusion ?? ICP removed.. No real movement, but on Propofol..See CareVue .\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-25 00:00:00.000",
"description": "Report",
"row_id": 1611519,
"text": "T/SICU Shift Report 0700-\n53 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - Rollover MVA\n\nPMH - Nil of Note\n\nInjuries - Open book pelvis with retroperitoneal hematoma\n #L humerus\n L pariental skull fracture\n Bilateral frontal lobe contusions\n R Temporal lobe contusions\n R temporal lobe subdural hemorrhage\n SAH\n Interventricular hemorrhage\n\nOR - - Ex-lap (open abdomen)\n - Closed abdomen\n - ORIF pelvis\n\nReview of Systems:\n\nResp - Fully ventilated on CMV 14x450 PEEP 8 FiO2 40%. SpO2 98-100%, RR 14-25, TV 425-500ml. ABG pH 7.43, PaCO2 51, PaO2 147, BE 8. Breath sounds coarse to upper lobes, diminished at the bases. Small-moderate thick/yellow secretions on ETT suction. Right CT removed. Left CT placed to suction due to small L pneumothorax.\n\nCVS - Sinus tachycardia with no witnessed ectopy. HR 95-125bpm, SBP 120-145, MAP 85-105, CVP 7-16, Tmax 102.3 (pancultured). Lactate 1.2. Peripherally warm, weak/palpable pedal pulses. Started on metoprolol (AIM HR<100).\n\nRenal - UO 25-120ml/hr, currently in balance. K 4.3 (after 20mEq KCl), Ca 1.12 (after 2g Ca Gluconate).\n\nNeuro - GCS 11 (e4v1m6), MAE to noxious stimuli, intermittently obeying commands off propofol with plenty of stimulation. No fixing and following. Pupils 3-4mm/3-4mm brisk reactive. No evidence of pain. Fentanyl 120mcg/hr, propofol 20mcg/kg/.\n\nGI - TF stopped due to residual>200, started on metoclopramide. Abdomen firm/hypoactive bowel sounds/no BM. Blood glucose stable on ISS.\n\nSkin - Pressure areas intact. Small skin tear to labia. midline incision DSD intact. CT dressing dry and intact. Previous pin sites oozing +++.\n\nAccess - Aline/cline patent, dressing intact.\n\nSocial - Husband/daughter in to visit, updated with condition.\n\nPLAN - Increase TV on ventilation\n regular pulmonary hygiene\n Monitor temp\n Restart TF\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-19 00:00:00.000",
"description": "Report",
"row_id": 1611496,
"text": "Resp Care\nAt beginning of shift, pt was being sutured for lacs on head. Pt desating after dr. asked for peep to go from 5 to 10 ( Rt not present for change). I went into room, as peep was returned to 5. Sats were in the 80s. Proceeded to suction large amt of thick bloody secretions. Noted resistance as in advancing and aswell high pips on vent. Placed a oral airway in mouth, with slight decreasement in pips. Pt continued to desat to 55%. Bagging started with ambu. Noticed resistance in bagging and ett patent. Placed peep valve and increase peep to 20 cm h20, to hold sats between 83-87%. Bagged to or. Set vent up on heated circuited and awaiting pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-19 00:00:00.000",
"description": "Report",
"row_id": 1611494,
"text": "Social Work\n\nSW met with pt's husband, , outside the . has already spoken to Dr. mult times for updates on pt's condition. Appears to be coping well at this time. Accompanied by a friend for support. Pt and husband reside in , RI, and is awaiting his daughter, , and her husband, from RI. Pt also has an adult son, , who lives in , but has not been notified of pt's accident yet. SW provided support for husband. Provided visitation details, lodging list, and other orienting info. Husband may commute back and forth from RI or get a hotel in the area. SW provided contact info and will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-19 00:00:00.000",
"description": "Report",
"row_id": 1611495,
"text": "nursing progress/admit note\n\npt 58 yo female involved in rollover mva, pt belted backseat passenger. sustained open book pelvic fx, left humerus fx, left 6th rib fx. fluid resuscitated in ED, given 4u prbc for falling hct, bilat chest tubes placed, to CT for head, neck scans. per trauma team CT shows frontal contusion, SDH, SAH. pt fairly stable in transferred to TSICU. upon arrival bp dropping, pt requiring massive fluid and blood resuscitation. initial abg showing metabolic acidosis, additional fluid requirement evident. pt responded well to blood products, bp improving drastically w/ prbc. levophed introduced for very short while, eventually being stopped. ortho team in to place skeletal traction to right leg to stabilize pelvic fx's, series of xrays completed. ekg obtained, cxr completed as well. full set labs sent, hct dropped from 31-13 despite all products. at , pt w/ sudden drop in o2 sats, unable to ventilate due to abdomen becoming more and more distended, belly extremely firm, taut. o2 sats as low as 45 w/ proper waveform on monitor. entire icu and trauma teams in room, Dr. , Dr. in, decision made to take pt to OR for exploration. Pt transferred at w/ 2 rapid infusion pumps in tow.\nfull report given to oncoming RN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-08 00:00:00.000",
"description": "Report",
"row_id": 1611575,
"text": "Nursing Progress Note.\nPlease see CareVue for specifics.\n\nUneventful day. OR cancelled until tomorrow.\n\nNEURO:\nRestful, opening eyes to voice. PEARL. Not regarding examiner. Trying to mouth words. Making appropriate facial expressions. Obeying intermittantly (thumbs up, show two fingers) waxing and , is more asleep now. Obeys with rt arm only. Other limbs have minimal reflexive movements only. Shakes head to deny pain.\n\nRESP:\nStill tolerating trache collar. Coughing well. Suctioning after turns but has few secretions only. Chest rhonchorous.\nPt is consistently tachypneic with rate 30s-40s, in no distress.\n\nHEMODYNAMICALLY:\nSR-ST. Tolerating new metoprolol regime. Measuring BP via cuff on Lt lower arm due to humerous fracure on Lt, and PICC on Rt. Warm, slightly diaphoretic in face only. PICC site satisfactory. Pboots on.\n\nENDOCRINE:\nReceiving sliding scale insulin plus fixed dose of NPH. Covered earlier today but not tonight.\n\nGI:\nAbd soft, apart from pelvic area over symphysis pubis suture line which is firm, but unchanged per colleagues. Tolerating tube feeds. Soft stool today.\n\nID:\nAntibiotics as charted. Nursed in contact precautions.\n\nRENAL:\nSatisfactory urine output via foley.\n\nSKIN:\nSkin . Suture lines have staples in place. to dry to scalp attended.\n\nSOCIAL:\nFamily present for afternoon. Updated. They requested to speak with case manager regarding transfer to . Email sent to case manager.\n\nPLAN:\nOR tomorrow for scalp.\nTransfer out to floor.\nWatch neuro exam.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-09 00:00:00.000",
"description": "Report",
"row_id": 1611576,
"text": "Resp Care\nPt. remains trached with #7 Portex- Perc/ cuff inflated for a pressure of 29cm.\nBs: scattered rhonchi at times. Sxn'd x2 for thick yellow. Mdis given as ordered.\nPlan: cont/ protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-06-09 00:00:00.000",
"description": "Report",
"row_id": 1611577,
"text": "npn 7pm-7am\n\nno significant events overnight\n\nneuro- pt opens eye slightly to voice, moves right arm to command at times. did not show 2 fingers or give tumbs up. nods to answer questions r/t pain, but does not answer any other question. pt does not move left side or right LE. PERL. Oxycodone given X1 for ? pain.\n\nCV- SR-ST.98-120 no ectopy. b/p wnl 110's- 130's. tol 25 lopressor Q6 hrs. + peripheral pulses. skin warm and dry. right PICC wnl. blue port slow to flush. cont on lovenox and p-boots for prophalaxis.\n\nResp- lung sounds clear to coarse. sx mod amt thick white/yellow frothy sputum form trach. pt remains on trach mask 35%. sats 97-100%. strong productive cough. pt remains tachypnic high 20-40's.\n\nGI- and soft. + BS. tol tube feed promote with fiber at goal of 70/hr via peg. no stool this shift. on ranitidine.\n\nGU- brisk u/o clear yellow. lytes wnl, except ca 7.8 to be replaced. IVF at KVO.\n\nSkin- abd and right hip staples clean and dry. head lac to dry dsg . trach site wnl. no excess drainage.\n\nID- remains on zosyn and gent. afebrile. wbc down.\n\nendo- fixed dose and s/s coverage.\n\nsocial- daughter called and was updated on condition.\n\nplan- pt is an add on for OR today to repair head lac. ? possible revision of trach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-20 00:00:00.000",
"description": "Report",
"row_id": 1611497,
"text": "Resp Care\nshift note: 1900-0700\npt returned from OR for ex-lap, belly open. see carevue for settings. Noting notable suctioned form ett. Titrated fio2 based abgs. last abg WNL. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-20 00:00:00.000",
"description": "Report",
"row_id": 1611498,
"text": "T/SICU Shift Report 1900-0730\n58 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission S/P High speed restrained MVC\n\nPMH - Nil of note\n\nInjuries - Parietal Skull Fracture\n SAH with midline shift\n SDH\n Frontal lobe contusion\n R temporal lobe contusion\n Intraventricular hemorrhage\n Open book pelvic fracture\n Pelvic hematoma\n Left comminuted humerus fracture\n 2x Scalp lacerations\n\nShift Events - Massive fluid resuscitation\n Developed pulmonary edema/compartment syndrome of \n Acute desaturation to 50s, upto 80 with ambu bag\n Transferred emergently to OR - open abdomen\n ICP bolt placed\n PA line placed\n\nReview of Systems:\n\nResp - Fully ventilated on AC 16x400 PEEP 12 FiO2 60%. RR 16-20bpm, TV 350-450ml, SpO2 96-100%. ABG pH 7.31, PaO2 120, PaCO2 47, BE -2. Breath sounds coarse to upper lobes diminished at the bases, pulmonary edema resolving, small bloody secretions on ETT suction. ETT retaped 21cm at teeth. 3xCT to 20cm suction, combined output 600ml serosanguinous fluid.\n\nCVS - Sinus tachycardia with occasional PVCs. HR 100-125bpm, SBP 120-150, MAP 80-110, CVP 7-20, PAPm 23-38, Wedge , CO 3.6-8.1, CI 3.4-4.9, SvO2 69-84, CPP 58-88 (aim >60), Tmax 37.1 (from 34.2). 0100 labs HCT down to 32%, Hb down to 11.6, WCC down to 3.9, platelets up to 116 (after platelets), COAGs now WNL. 8xPRBC, 6xFFP, 1xplatelets, 2xCyro, 1xfactor VII. Gentamycin/cefazolin/metronidazole IVABs. Petechiae to lower extremities, initially cool/pale, weak palpable pulses.\n\nRenal - UO 300-650ml/hr, 24hour balance +15500ml, currently -ve 1800ml today. 0100 labs BUn/creatinine WNL, K 4.2 (after repletion with 40mEq KCl), Mg 2.3 (after repletion with 4gMgSO4), Ionised Ca 1.13 (after repletion with 8g Ca gluconate).\n\nNeuro - Arousable to stimuli, GCS 8 (e2v1m5), pupils 3mm/3mm brisk reactive. Midazolam infusion stopped due to poor neuro exam, fentanyl continues at 100mcg/hr. Localising to ETT following stimulation. ICP 21-40, 3x25gm mannitol given to treat ICP >25. ICP bolt transducer changed.\n\nGI - OG to LCS 50ml bilious output. Open abdomen, absent bowel sounds. Blood glucose controlled with insulin infusion, currently off (aim 90-120).\n\nSkin - Full bed bath overnight. Abdominal dressing reinforced. Laceration to forehead/occipital sutured by trauma surgery. Pressure areas intact. Skeletal traction in situ 30lb pressure, repeat x-rays taken.\n\nAccess - Triple lumen femoral line, PA line inserted, right radial aline.\n\nSocial - Husband, daughter, son in to visit, all updated by Dr . Husband has returned home, will visit this afternoon and stay overnight.\n\nPLAN - Wean ventilat as able (aim CO2 35)\n Serial labs\n ICP <25 - ?mannitol\n CPP >60\n ?further imaging\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-20 00:00:00.000",
"description": "Report",
"row_id": 1611499,
"text": "NPN 0700-1900\nNEURO: Pt initially without sedation to obtain accurate neuro exam (fentanyl gtt remained infusing). Pt became increasingly agitated and restless throughout shift. Attempted propofol gtt, however pt became hypotensive. Versed gtt attempted, however it was noted that overnight neuro exam was difficult to obtain d/t versed gtt. While in XRAY/CT, versed gtt was essentially ineffective; pt agitated, restless and hypertensive with elevated ICP. Propofol gtt attempted again with success, however pt requires low doses d/t tendency for hypotension. ICP 10s-20's; no mannitol required this shift. Post CT, values noted to be 0-1 and did not increase when pt was awake or stimulated. ?accuracy...neuro to evaluate. At best, pt opens eyes to voice and intermittenly follows commands. Pt localizes to ETT with RUE and withdraws all extremities to nailbed pressure.\n\nRESP: Vent changes made this shift to keep pCO approx 30-35. Oxygenation/Sats WNL. LS coarse with occasional I/E wheezing. Scant secretions with suctioning.\n\nCV: Swan dc'd and changed to TLCL. HR 90s-100s. Hypotension resolved with IVF bolus.\n\nHEME: PM Hct 29. No anticoagulants ordered at this time. Pboots on.\n\nGI: Abd remains open. OGT replaced by Dr. d/t improper position noted on xray. Scant output via OGT. No BM this shift.\n\nGU: U/O 100-400cc/hr. IVF kvo'd. Lytes repleted.\n\nID: Afebrile this shift. Kefzol/flagyl dc'd. Gent cont.\n\nENDO: Insulin gtt off this shift and gluc WNL.\n\nSKIN: Overall skin moist d/t abd dsg draining s/s fluid. Moderate drainage from lacs to anterior/posterior skull. Back/buttocks with no breakdown noted.\n\nSOCIAL: Family in to visit this shift and updated on POC. Spoke with anesthesia for consent to close abd.\n\nASSESSMENT: Pt s/p MVC with multiple injuries.\n\nCurrent nsg issues:\nAlteration in neurological functioning.\nImpaired gas exchange.\nIneffective airway clearance.\nFluid volume overload/electrolyte imbalance.\nAcute Pain.\nBP alteration.\nRisk for infection.\n\nPLAN: Cont to monitor vs, neuro checks, sedation/analgesia, pulmonary hygiene, cont mechanical ventilation as needed, monitor lytes, cont to keep pt euvolemic if tolerated, anticipate OR tomorrow for closure of abd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-20 00:00:00.000",
"description": "Report",
"row_id": 1611500,
"text": "Respiratory Care\nPt with vent increases to keep paco2 >35 last abg 742/33/163/22/-1/100. Pt traveled to x-ray and Cat-Scan without incident. Plan to continue support as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-21 00:00:00.000",
"description": "Report",
"row_id": 1611501,
"text": "Resp Care\nPt remains on vent. Suctioned nothing out of ett. Good oxygenation in abgs, decreased peep and fio2. On icp protocol and hyperventilated. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-21 00:00:00.000",
"description": "Report",
"row_id": 1611502,
"text": "T/SICU Shift Report 1900-0730\n53 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - - S/P Highspeed Restrained Rollover MVA\n\nPMH - Nil of Note\n\nInjuries - Pareital Skull Fracture\n Frontal Lobe contusion\n R Temporal Lobe contusion\n R Temporal Subdural hemorrhage\n SAH with midline shift\n Intraventricular bleeding\n L comminuted humerus fracture\n Open book pelvic fracture\n Retroperitoneal hematoma\n\nOR - - Exlap, abdoben left open\n ICP bolt inserted\n\nReview of Systems:\n\nResp - Fully ventilated CMV 20x400 PEEP 8 FiO2 50%. SpO2 99-100%, RR 20, TV 400-500ml. ABG pH 7.46, PaCO2 33 (aim <35), PaO2 169, BE 1. Breath sounds coarse to upperlobes, diminished at the bases. Small bloody/thick secretions on ETT suction. 3xCT on 20cm suction, minimal serosanguinous output overnight, no crepitus.\n\nCVS - Sinus rhythm with no witness ectopy. HR 90-115, MAP 65-90, CVP 4-10, CPP 45-70, Tmax 98.9. 0200 Labs HCT down to 26.2%, Hb down to 9.8, WCC upto 12.0. Started on norepinehrine to maintain CPP > 60, currently at 0.1mcg/kg/min. Peripherally warm, weak palpable pedal pulses bilaterally. Continues on gentamycin.\n\nRenal - UO 30-280ml/hr, previous 24hour -ve 3500ml, currently -ve 300ml today. 0200 labs BUN/creatinine WNL, K 4.0, Mg 2.3, Ionised Ca 1.16, Na 143. Fluids KVO'd.\n\nNeuro - Sedated with 10mcg/kg/min Propofol, 125mcg/hr Fentanyl. Arousable to voice without sedation, GCS 11 (e4v1m6), obeying commands, localising to ETT, MAE. Pupils 3mm/3mm brisk reactive. Corneals/cough intact, gag reflex impaired. ICP 18-30, aiming for ICP <25. No mannitol required this shift.\n\nGI - OGT to LCS (50ml bilious drainage overnight), abdomen open, absent bowel sounds, no BM since admission. Blood suger controlled with insulin infusion (aim 90-120).\n\nSkin - Full bed bath overnight. Pressure areas intact. Abdominal dressing reinforced, small-moderate serosanguinous drainage, 2xJP (no drainage). MD informed that occipital scalp laceration continues to ooze moderate volumes of sanguinous fluid. Skeletal traction maintained at 30lb.\n\nAccess - Lines patent, dressing intact.\n\nSocial - Husband stayed in waiting room overnight, updated over the phone by this RN.\n\nPLAN - Wean ventilation as able (Maintain CO <35)\n Wean norepinephrine as able (Maintain CPP >60)\n Maintain blood glucose 90-120\n Return to OR for closure of abdomen\n Return to OR next week for repair of pelvis\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-21 00:00:00.000",
"description": "Report",
"row_id": 1611503,
"text": "T/SICU RN Progress Note\nEvents of day: To OR for abd washout and closure. Head CT, ICP bolt removed, PEEP decreased to 5.\n\nCurrent ROS:\n\nNeuro: Lightly sedated on propofol and fentanyl drips, when off, MAE's slightly on bed to command, nodds yes/no to questions. Remains on dilantin.\n\nCV: HR 80's SR no ectopy noted. ABP systolic 110-130's, CVP 5-8, P-boots.\n\nResp: Remains intubated, lungs coarse suctioned for scant secretions. CT X3 to wall sx with s/s drainage, dressings changed no crepitus noted. ABG's and vent changes as per carevue\n\nGU/GI: Abd closed, under dressing, JPX2 with sero/sang drainage. Abd firm, absent bowel sounds, PPI, NPO, Bladder pressures 15-18. Foley with clear yellow urine.\n\nSkin/Mobility: Skin as per carevue, RLE in 30lbs skeletal tx, + pulses, bedrest, logroll discontinues, remains in c-collar.\n\nID: Afebrile, abx ancef started Q8hrs, gentamicin discontinued.\n\nSocial: Family in upated, support given.\n\nPlan: Wean vent as tolerated, skin care, monitor neuro status, pain control, plan OR on Monday for ortho injuries. Cont to montior and support patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-21 00:00:00.000",
"description": "Report",
"row_id": 1611504,
"text": "Respiratory care\npt to OR for abd. closure, pt also traveled to cat-scan for head ct without incident. Abg this shift 745/33/184/24/0/100 weaned peep to 5cm. Plan to wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-22 00:00:00.000",
"description": "Report",
"row_id": 1611505,
"text": "TSICU Nursing Progress Note\nNeuro - Remains intubated and sedated on propofol and fentanyl gtts. When lightened MAE's intermittently to command. Purposeful with right arm, reaching for ETT, withdraws all other extremities, only very slight movement of left arm. PERRLA 3mm brisk, intact corneals, impaired gag and intact cough. Fentanyl gtt titrated for pain control. Remains in c-collar.\n\nCV - HR 80-90 NSR, no ectopy noted. ABP 100-130 systolic. + peripheral pulses, extremities cool to touch. Crit down to 22 this am. Lytes repleated PRN.\n\nResp - Lungs coarse throughout, diminished at bases. Attempted CPAP this am around 0400, however pt apneic despite being off propofol. Pt returned to CMV with sats only 91%, when had been 97% most of shift. Suctioned for scant amount blood tinged secretions with no improvement in sat. Increased PEEP from 5 to 8, and recruitment manuever performed by RT, with some improvement in sats...94-95% range. Blood gases drawn as well, see carevue. Currently on CMV 14 x 450 x 8 x 50%, with sats 95-96%. 3 chest tubes to wall suction, all with s/s drainage in small amounts, pos. fluctuation, no leak or crepitus.\n\nGI - Abdomen firm, incision remains covered with primary OR dressing. Bladder pressures obtained over night, most recent 11. Small amount s/s drainage from abd. 2 JP's in abd as well, with small amount s/s drainage. Absent bowel sounds. No BM. OGT to wall suction with small amount bilious drainage.\n\nGU - Foley draining clear yellow urine in adequate amounts.\n\nEndo - No insulin needed for RISS.\n\nId - afebrile, continues on cefazolin.\n\nSkin - Lacs to head, sutured no drainage. Old bolt site no drainage. Small lac to left hand with steri-strips, no drainage over night. Left humerous remains in splint. Right leg remains in 30lbs traction. Bruising noted in perineal area. Posterior remains intact, unable to position on a side with proper pelvic allignment.\n\nPsych/social - Husband and son in at beginning of shift. Husband called overnight once. Concerned appropriate. Husband went home for first time since admission.\n\nA - Impaired mental status. Impaired skin integrity. Risk for infection. Impaired oxygenation.\n\nPlan - Continue to monitor per routine. Monitor oxygenation and attempt CPAP again if pt tolerates. Continue to monitor neuro status. Continue to monitor for s/s bleeding. Continue to monitor and treat for pain. Maintain skeletal traction. Planned OR on monday for ortho injuries. Continue to update pt and family of current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-05-22 00:00:00.000",
"description": "Report",
"row_id": 1611506,
"text": "Resp Care\nPt remains on vent. Suctioned mod amt blood-tinged secretions. Pt off icp protocol, decreased rr after abgs. After decreasing fio2 to 40% and doing rsbi. Pt desated to 89-91%. Returned to 50%, abg sent, repositoned probe. Peformed recruitment manuever, increased peep. Sats improved. Abgs improved. Will conitnue to monitor.\n"
},
{
"category": "ECG",
"chartdate": "2145-05-25 00:00:00.000",
"description": "Report",
"row_id": 200655,
"text": "Sinus rhythm. Short P-R interval. Low precordial lead voltage. Non-specific\nST-T wave flattening. Compared to the previous tracing of no diagnostic\ninterim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-05-23 00:00:00.000",
"description": "Report",
"row_id": 200656,
"text": "Sinus rhythm\nExtensive T wave changes are nonspecific\nLow QRS voltages\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 917977,
"text": " 5:20 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval pac position, eval for ptx\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, new pac\n REASON FOR THIS EXAMINATION:\n please eval pac position, eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Peripheral access catheter placement.\n\n COMPARISON: .\n\n CHEST: AP supine portable view. The new left subclavian Swan-Ganz catheter\n terminates in the right interlobar pulmonary artery. The new nasogastric tube\n terminates in the distal esophagus. The endotracheal tube remains in good\n position. There are two left chest tubes, one of which is new. A preexisting\n right chest tube remains in place. A left lateral sixth rib fracture is again\n noted. A small left pleural effusion is probably present. No pneumothorax is\n identified in supine position. Increased opacity within the left lung may\n represent worsening contusion or developing pneumonia. Nasogastric tube and\n Swan-Ganz catheter malposition were discussed with Dr. at 10:10\n a.m. on .\n\n IMPRESSION:\n 1. Nasogastric tube and Swan-Ganz catheter malposition.\n 2. Worsening left pulmonary contusion or developing superimposed pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 918024,
"text": " 11:47 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: please reimage pin\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traction pin\n REASON FOR THIS EXAMINATION:\n please reimage pin\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right femur, two views. .\n\n HISTORY: Patient with lower leg traction. Imaging of the hardware.\n\n FINDINGS: There is a pin seen through the distal femoral metaphysis with a\n slight bend within the pin. There is no sign for hardware fracture. The\n adjacent bony structures are within normal limits. Fractures of the right\n sacrum and the right superior and inferior pubic rami are seen in the\n periphery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 918025,
"text": " 11:47 AM\n PELVIS (AP ONLY); -76 BY SAME PHYSICIAN # \n Reason: reassess pelvis\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with open pelvic fx s/p traction\n\n REASON FOR THIS EXAMINATION:\n reassess pelvis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old woman with open pelvic fracture status post traction.\n\n FINDINGS: The left-sided femoral catheter has been removed. There is again\n seen a fracture of the right and left superior and inferior pubic rami as well\n as of the right sacral ala. These fracture fragments are unchanged in\n position and alignment. No interval change in the position of the fracture\n fragments since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 918066,
"text": " 3:15 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: cvl and OGT placement? pneumothorax?\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, new cvl and OGT.\n\n REASON FOR THIS EXAMINATION:\n cvl and OGT placement? pneumothorax?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST, .\n\n COMPARISON: 6:00 a.m.\n\n INDICATION: Central line and orogastric tube placement.\n\n There has been removal of a Swan-Ganz catheter and placement of a left\n subclavian vascular catheter, terminating in the superior vena cava. A\n nasogastric tube has been advanced and now coils in the stomach. Bilateral\n chest tubes remain in place, with no pneumothorax. Air space opacities in the\n left mid and lower lung zone are slightly improved in the interval. Heart\n size remains normal and mediastinal contours are stable.\n\n IMPRESSION: Standard positioning of central catheter with no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919496,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with likely R SCV pulled out partially\n REASON FOR THIS EXAMINATION:\n eval line\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:12 A.M, .\n\n HISTORY: Right central venous line partially withdrawn.\n\n IMPRESSION: AP chest compared to through 10:\n\n The tip of a nasogastric drainage tube projects over the upper stomach, while\n a feeding tube passes beyond the mid stomach and out of view. Tracheostomy\n tube in standard placement. No radiopaque central venous catheter is seen.\n Mild pulmonary edema has worsened slightly. Heart size is normal. There is\n no appreciable pleural effusion or indication of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918595,
"text": " 5:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX< effusion\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT\n\n REASON FOR THIS EXAMINATION:\n eval for PTX< effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Evaluate for pneumothorax.\n\n Bilateral chest tubes remain in place. There is a new small left apical\n pneumothorax with a probable additional small anterior medial component\n adjacent to the left heart border. Various lines and tubes are unchanged in\n position. Cardiac and mediastinal contours are stable. Previously reported\n interstitial edema has resolved, and there is continued improvement in left\n lower lobe opacity possibly due to resolving contusion. Left rib fractures\n are again demonstrated.\n\n IMPRESSION: New small left apical pneumothorax with chest tubes in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918819,
"text": " 9:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for PTX status post chest tube pull\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT s/p CT removal\n REASON FOR THIS EXAMINATION:\n Eval for PTX status post chest tube pull\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after MVC with\n discontinuation of one of the left chest tubes.\n\n Portable AP chest radiograph compared to , done earlier at 14:27\n p.m. The current film does not include the very apices of the lungs.\n\n The lower left chest tube has been removed in the interval. The tip of the\n remaining left chest tube projects over the lung apex. There is no visible\n pneumothorax on the current x-ray within the limitations of this study. The\n ET tube tip, the left subclavian line tip, and the direction of the NG tube\n are in standard positions. The tip of the NG tube is below the lower field of\n view.\n\n The heart size is normal. Mediastinum has normal contour, and width.\n The left lower lobe opacity has improved in the interval\n consistent with resolving lung contusion. There is a 3.5- cm distance between\n the left hemidiaphragm and the gastric bubble, which could be due to\n subpulmonic effusion.\n\n IMPRESSION:\n 1. No evidence of definite pneumothorax howevre since lung apices are not\n included in the film. Repeat chest x- ray, including the lung apices would be\n worthwhile.\n 2. Improving of the left lower lobe consolidation, most probably representing\n clearance of the pulmonary contusion.\n 3. Standard position of tubes and lines.\n 4. Left subpulmonic effusion cannot be excluded. If clinically suggested,\n further evaluation with left decubitus is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 918029,
"text": " 12:22 PM\n CT T-SPINE W/O CONTRAST Clip # \n Reason: fractures/dislocations?\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old s/p MVC w/ SDH/SAH.\n REASON FOR THIS EXAMINATION:\n fractures/dislocations?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT THORACIC SPINE.\n\n HISTORY: Motor vehicle crash.\n\n Contiguous axial images were obtained from the top of T2 to mid T11. No\n contrast was administered. No prior thoracic spine imaging studies are\n available for comparison.\n\n FINDINGS: There is no evidence of fractures within the portion of the\n thoracic spine included in this examination. Alignment of the spine appears\n normal over this region. There is bilateral posterior atelectasis. There are\n bilateral chest tubes. The patient is intubated and a nasogastric tube is in\n place.\n\n CONCLUSION: No evidence of fracture or dislocation from the T1-T2 interspace\n to mid T11.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-27 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 918955,
"text": " 8:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: EVAL FOR BILIARY SOURCE. ELEVATED LFT'S\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with elevated LFTs, ventilator dependent, fever, pancreatitis\n REASON FOR THIS EXAMINATION:\n evaluate for biliary source\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with elevated LFTs, fever, and pancreatitis.\n\n COMPARISON: None.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture without\n evidence of focal mass. There is no intra- or extra-hepatic biliary ductal\n dilatation. Echogenic layering material in the gallbladder body is\n consistent with sludge or small stones. There is no evidence of gallbladder\n wall edema or pericholecystic fluid to indicate acute cholecystitis. The\n common bile duct is not dilated measuring 5 mm. The main portal vein is\n patent with appropriate hepatopetal flow. There is no perihepatic ascites.\n Limited views of the right kidney demonstrate no hydronephrosis or renal\n calculi. The pancreas is not visualized secondary to overlying bowel gas.\n\n IMPRESSION: Echogenic material within the gallbladder lumen consistent with\n sludge or small stones. No evidence of acute cholecystitis or biliary ductal\n dilatation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-21 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 918241,
"text": " 8:08 PM\n PELVIS (AP ONLY) Clip # \n Reason: PORTABLE please - eval. s/p traction re-applied\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traction pin s/p resetting.\n\n REASON FOR THIS EXAMINATION:\n PORTABLE please - eval. s/p traction re-applied\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old female with traction pin status post resetting.\n\n COMPARISON: .\n\n FINDINGS: Again seen is a fracture of the right and left superior and\n inferior pubic rami as well as of the right sacral ala. Fracture fragments\n are unchanged in position and alignment compared to the prior study. Skin\n staples project over the midline of the abdomen. Bilateral surgical pelvic\n drains remain unchanged in position.\n\n IMPRESSION: No interval change in the position of the fracture fragments\n since the prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918692,
"text": " 7:27 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval pna, effusion, edema, ptx\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT now c hypoxia\n REASON FOR THIS EXAMINATION:\n eval pna, effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:48 A.M. .\n\n HISTORY: Motor vehicle accident. Chest tubes. Hypoxia.\n\n IMPRESSION: AP chest compared to through :\n\n Consolidation in the right lower lobe which worsened between and 5 has\n improved. This could be due to asymmetric edema or aspiration. Moderate\n degree of consolidation has been present in the left lower lobe since .\n Two left pleural tubes are unchanged in position. There is mild degree of\n left pleural thickening adjacent to lateral rib fractures, but no appreciable\n pleural effusion or indication of pneumothorax. The heart is normal size and\n mediastinum is midline. Tip of the left subclavian line projects over the\n SVC, ET tube is in standard placement and nasogastric tube ends at or beyond\n the pylorus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-31 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 919356,
"text": " 9:41 AM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: new CVL at right subclavian\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman multisystem trauma,\n REASON FOR THIS EXAMINATION:\n new CVL at right subclavian\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: .\n\n INDICATION: Line placement.\n\n There is a new right subclavian vascular catheter terminating in the superior\n vena cava, with no pneumothorax. Preexisting line and tubes are unchanged in\n position. Cardiac and mediastinal contours are stable. There are persistent\n bilateral infrahilar lower lobe opacities, which are probably not\n substantially changed allowing for positional differences. Left-sided rib\n fractures are again demonstrated.\n\n IMPRESSION: New right subclavian vascular catheter in standard position with\n no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 918763,
"text": " 2:07 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate position of central line and +/- pneumothorax\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT now c hypoxia\n\n REASON FOR THIS EXAMINATION:\n Evaluate position of central line and +/- pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle trauma. Evaluate central line placement.\n\n COMPARISON: at 7:48 a.m.\n\n CHEST: AP upright portable view. The left subclavian venous catheter\n terminates in the lower SVC, unchanged. There is no pneumothorax. The\n endotracheal and nasogastric tubes remain in unchanged, satisfactory\n positions. Two left-sided chest tubes remain in place. No new central venous\n catheter is identified.\n\n The consolidation in the left mid and lower lung zones appears more extensive\n and dense compared to 7 hours earlier, suggestive of aspiration or hemorrhage.\n Right basilar consolidation is unchanged or minimally improved. There is no\n pulmonary edema. Heart size remains normal. A left lateral rib fracture is\n again noted.\n\n IMPRESSION:\n 1. Satisfactory left subclavian central line position. No new central line\n identified.\n\n 2. Rapid worsening of left mid and lower lung zone consolidation, suggestive\n of aspiration or hemorrhage.\n\n 3. Unchanged or minimally improved right basilar consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-27 00:00:00.000",
"description": "L HUMERUS (AP & LAT) LEFT",
"row_id": 918882,
"text": " 11:55 AM\n HUMERUS (AP & LAT) LEFT Clip # \n Reason: ORIF HUMERUS\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture.\n\n Two radiographs of the left humerus again demonstrate a mid humeral diaphyseal\n fracture. The fracture has been reduced with lateral fixation plate and\n screws, new when compared to . Fracture line remains visible.\n Overlying soft tissue defect is noted. Limited assessment of the elbow joint\n is grossly unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918301,
"text": " 2:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CT to water seal x 3 hours, pls eval for interval change\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT\n REASON FOR THIS EXAMINATION:\n CT to water seal x 3 hours, pls eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Chest tube to waterseal.\n\n Bilateral chest tubes remain in place with no evidence of pneumothorax. Other\n lines and tubes are unchanged in position. Cardiac and mediastinal contours\n are stable. There is improving consolidation in the left mid and lower lung\n regions. Minimal hazy opacities are present in the perihilar regions as well\n as subtle peripheral interstitial opacities in the right lower lobe, likely\n due to interstitial edema from mild fluid overload. Left-sided rib fracture\n is again demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 917978,
"text": " 5:20 AM\n PELVIS (AP ONLY) Clip # \n Reason: eval alignment\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with open pelvic fx s/p traction\n\n REASON FOR THIS EXAMINATION:\n eval alignment\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP pelvis .\n\n HISTORY: 56-year-old woman with open pelvic fracture status post traction.\n\n FINDINGS: Comparison is made to the prior study performed on .\n\n The patient has fracture seen of the right sacrum. There are also fractures\n of the right superior and inferior pubic rami and of the left inferior pubic\n rami. A left femoral catheter is identified. The proximal femurs are intact.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919093,
"text": " 4:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval trach position\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT s/p CT removal\n\n REASON FOR THIS EXAMINATION:\n eval trach position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate trach position.\n\n Comparison is made to .\n\n PORTABLE AP RADIOGRAPH OF THE CHEST: The tracheostomy tube appears in\n satisfactory position. An NG tube is seen traversing the stomach and out of\n view. There is a left subclavian vein central venous catheter in unchanged\n position with the tip in the distal SVC. A left-sided chest tube projects\n with the tip over the left apex. The heart size is normal. Mediastinum has\n normal contour and width. There is worsening of the patchy opacity in the\n right mid lung which may represent evolving consolidation or pleural effusion.\n The left lower lobe opacity is also slightly increased in density. There is a\n nondisplaced left-sided rib fracture. No pneumothorax is seen.\n\n IMPRESSION:\n 1. Tracheostomy tube in satisfactory position.\n\n 2. Increased patchy opacity in the right mid lung and left lower lung which\n may represent evolving pneumonia.\n\n Dr. has been notified of the findings at 5:50 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-02 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 919704,
"text": " 10:26 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: FEVER, IN ICU EVAL FOR DVT\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with fever in ICU\n REASON FOR THIS EXAMINATION:\n eval DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with fever in the Intensive Care Unit.\n Evaluate for DVT.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND WITH DOPPLER EXAMINATION: Grayscale,\n color flow, and Doppler ultrasound of bilateral common femoral, superficial\n femoral, and popliteal veins were performed. Normal flow, augmentation,\n compressibility and waveforms are demonstrated. No intraluminal thrombus is\n seen.\n\n IMPRESSION: Negative bilateral lower extremity DVT study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 917920,
"text": " 4:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line/tube position\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with mvc\n REASON FOR THIS EXAMINATION:\n eval line/tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC. Eval line/tube position.\n\n PORTABLE AP CHEST RADIOGRAPH: The endotracheal tube is located approximately\n 4.7 cm above the carina. The left subclavian central venous catheter is\n projecting with the tip over the cavoatrial junction. A right-sided chest\n tube is seen with the tip projecting over the spine. A left-sided chest tube\n is seen with the tip projecting over the left upper lung. The cardiac\n silhouette is normal in size. There is slight mediastinal shift to the left,\n and there is a diffuse opacity in the left lung, which most likley represents\n atelectatic volume loss. Of note, there is a fracture of the left sixth rib\n laterally with only minimal displacement of the fracture fragments. No\n definite pneumothorax is seen, however, the left hemidiaphragm outline is very\n prominent and an anterior- posterior pneumothorax cannot be excluded.\n\n IMPRESSION:\n 1. Fracture of the left sixth rib.\n 2. Prominence of the outline of the left hemidiaphragm which may represent a\n pneumothorax.\n 3. Mild leftward mediastinal shift due to volume loss in the left lung.\n 4. Possible small right-sided pleural effusion.\n These findings have communicated to Dr. at 5:35 p.m. on .\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-31 00:00:00.000",
"description": "P C-SPINE TRAUMA W/FLEX & EXT 5 VIEWS PORT",
"row_id": 919392,
"text": " 11:54 AM\n C-SPINE TRAUMA W/FLEX & EXT 5 VIEWS PORT Clip # \n Reason: eval fx, subluxtn\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with s/p MVC and pelvic fx neg Csp CT but intubated and\n sedated\n REASON FOR THIS EXAMINATION:\n eval fx, subluxtn\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture.\n\n Radiographs of the cervical spine demonstrate C1-C7. There is no listhesis in\n flexion or extension views. A nasogastric tube is partially visualized. A\n tracheostomy is present. A right-sided central venous catheter is partially\n imaged. The visualized lung apices are unremarkable. No fracture. Surgical\n staples project over the occiput. Vertebral body height and intervertebral\n body disc space heights are maintained. Mild multilevel degenerative endplate\n change is present.\n\n IMPRESSION:\n\n No listhesis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-31 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 919393,
"text": " 11:54 AM\n CHEST (PA & LAT) Clip # \n Reason: CAN DO CXR AND C-SPINE FILMS AT THE SAME TIME. Eval. for PTX\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman multisystem trauma,\n\n REASON FOR THIS EXAMINATION:\n CAN DO CXR AND C-SPINE FILMS AT THE SAME TIME. Eval. for PTX s/p CT removal.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM \n\n HISTORY: Multisystem trauma.\n\n IMPRESSION: PA and lateral chest compared to 9:52 a.m. today and \n through 9:\n\n Very small left apical pneumothorax is slightly larger compared to 9:52 a.m.\n since removal of left pleural tube. Atelectasis in the posterior basal\n segment of the left lower lobe is stable. Right lung is clear. There is no\n pleural effusion. Pleural thickening still present along the left lateral rib\n fractures. Heart is normal size and mediastinum is midline. Nasogastric\n feeding tube passes into the stomach and out of view. Tracheostomy tube and\n right subclavian line are in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 917915,
"text": " 4:02 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with MVC, head injury\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VK WED 5:35 PM\n - No cervical spine fx.\n - ? subtle fx extending through the left mastoid air cells, with small amount\n of air in deep soft tissues of superior neck.\n - right 1st rib fx. ? contusion rt lung apex\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old in motor vehicle accident with severe intracranial\n trauma and hemorrhage. Assess for spinal fracture.\n\n TECHNIQUE: MDCT images of the cervical spine without IV contrast. Coronal\n and sagittal reformatted images were obtained.\n\n No prior studies.\n\n FINDINGS: In the sagittal projection, the C1 through upper portion of T2\n vertebral bodies are visualized. There is normal vertebral body height and\n alignment with preservation of disc space height. No cervical spine fracture\n is seen. Minor degenerative changes are seen at C5-6 with endplate sclerosis\n and subchondral cyst formation. The spinal canal is normal in caliber.\n Prevertebral soft tissues are normal.\n\n In the deep soft tissues of the left superior neck, a small amount of air is\n seen and likely related to adjacent fracture extending through the mastoid.\n There is a fracture of the right first rib. Upper lung fields demonstrate\n lucency at the left lung apex concerning for apical pneumothorax.\n Consolidation is seen at the right lung apex, which may represent aspiration\n or contusion. The patient is intubated. An OG tube is seen malpositioned,\n curling in the posterior oropharynx.\n\n IMPRESSION:\n 1. No cervical spine fracture or malalignment.\n 2. Fracture of the first right rib. Possible pulmonary contusion.\n Malpositioned orogastric tube.\n\n Findings were communicated to Dr. at the time of dictation, and\n were conveyed to the ED dashboard at the completion of the examination.\n\n DFDgf\n (Over)\n\n 4:02 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 918217,
"text": " 3:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVAL CONTUSION\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old motor vehicle accident with known intraparenchymal\n hemorrhages, assess for interval change.\n\n TECHNIQUE: MDCT images of the brain without IV contrast. Comparison made to\n one day earlier.\n\n There has been a slight increase in the extent of edema surrounding the right\n frontal hemorrhagic contusion. The extent of hemorrhage is unchanged. Other\n areas of intracranial hemorrhage including subarachnoid hemorrhage are stable.\n There is a slight increase in mass effect in the right frontal lobe due to\n increasing edema, but no significant change in the extent of midline shift.\n There is no hydrocephalus. No new areas of hemorrhage are identified. There\n have been no other changes.\n\n IMPRESSION:\n\n Evolving right frontal contusion with slight increase in surrounding edema and\n mass effect, but no significant change in the extent of midline shift. No new\n hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918627,
"text": " 12:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please assess for pneumothorax s/p removal of right-sided ch\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT\n\n REASON FOR THIS EXAMINATION:\n Please assess for pneumothorax s/p removal of right-sided chest tube.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: at 5:44 a.m.\n\n INDICATION: Removal of right chest tube.\n\n There has been removal of a right-sided chest tube, with no evidence of\n pneumothorax. Previously reported left pneumothorax is visible laterally but\n not at the apex. There is otherwise no change from the recent radiograph of\n earlier the same date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-11 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 920948,
"text": " 1:21 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Edema\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with fever in ICU\n\n REASON FOR THIS EXAMINATION:\n Edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever. Edema.\n\n COMPARISON: .\n\n -scale and Doppler son of the right and left common femoral,\n superficial femoral, and popliteal veins were performed. Normal flow,\n augmentation, compressibility, and waveforms are demonstrated. No\n intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of DVT in the right or left lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-28 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 919110,
"text": " 10:52 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Eval. for pancreatitis\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with elevated /lip and fevers\n REASON FOR THIS EXAMINATION:\n Eval. for pancreatitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 53-year-old female with elevated amylase and lipase with fever and concern for\n pancreatitis.\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen were\n obtained without IV contrast followed by images of the abdomen and pelvis\n after 130 mL Optiray IV contrast. Coronal and sagittal reformatted images\n were also obtained.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is consolidation of the\n posterior lower lobes. There is a minimal right pleural effusion. The liver,\n gallbladder, pancreas, spleen, adrenal glands, and kidneys are unremarkable.\n There is no peripancreatic inflammatory stranding or fluid collection. The\n pancreatic duct is not dilated, and there is no evidence of calcification. The\n visualized portion of the common bile duct is normal caliber. There is no\n intrahepatic biliary ductal dilatation. There is free passage of oral\n contrast through to the rectum. There is no evidence of obstruction. There is\n no bowel wall thickening, adjacent inflammatory stranding or mural gas\n identified. There is a small amount of free intra- abdominal fluid tracking\n along the pericolic gutters but no free intraperitoneal gas.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the\n decompressed urinary bladder. The uterus, adnexa, and pelvic loops of bowel\n are unremarkable. There is trace free pelvic fluid.\n\n BONE WINDOWS: There are multiple pelvic fractures including comminuted\n fractures of the superior and inferior pubic rami as well as the anterior\n column of the left acetabulum. A fixation plate and cortical screws fixates\n the pubic symphysis. A comminuted fracture of the right sacral ala is fixated\n by large cortical screws, which traverse the right ilium and sacrum. There is\n no evidence of spondylolisthesis. No suspicious lytic or sclerotic osseous\n lesions are identified.\n\n IMPRESSION:\n 1. Unremarkable pancreas without CT evidence of acute pancreatitis.\n 2. Consolidation of the posterior bilateral lower lobes may simply represent\n atelectasis, but is concerning for pneumonia.\n 3. Status post ORIF of multiple pelvic fractures.\n\n\n (Over)\n\n 10:52 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: Eval. for pancreatitis\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 917909,
"text": " 3:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ich, mass effect\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with MVC, known skull fx, humeral fx, open pelvic fx\n REASON FOR THIS EXAMINATION:\n eval ich, mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDgf WED 4:16 PM\n severe head injury - contusions, especially right frontal lobe, rt. subdural\n hematoma, subarachnoid blood\n rt. lateral vent narrowed and mild shift of midline structures to left,\n however, the sulci and suprasellar cistern are narrowed and this is concerning\n for early edema - close follow-up advised\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old in motor vehicle accident with known skull fracture\n and multiple other fractures, assess for intracranial hemorrhage.\n\n TECHNIQUE: MDCT images of the brain without IV contrast. No prior studies.\n\n FINDINGS: Numerous intraparenchymal contusions are seen in the right frontal\n lobe, superior left frontal lobe, right temporal lobe, and along the region of\n the right petrous apex. There is a right subdural hematoma extending along\n the convexity of the frontal and parietal lobes and extending inferiorly along\n the anterior temporal lobe probably into the middle cranial fossa. Subdural\n hematoma is also seen extending along the posterior aspect of the falx and\n over the tentorium. There is a mild degree of subarachnoid hemorrhage, best\n seen in the interpeduncular fossa and within the interfolial spaces of the\n cerebellum. Blood is also seen within the Sylvian fissures and in the right\n temporal of the lateral ventricle.\n Mass effect from the hemorrhages and injury produces compression of the body\n of the right lateral ventricle and mild shift of midline structures towards\n the left. Additionally, cerebral sulci and the suprasellar space appear\n somewhat narrowed.\n\n There is a fracture of the left parietal bone, which appears to extend\n inferiorly into the lambdoid suture on the left, where there is sutural\n diastasis. Small amount of fluid is seen within the left mastoid air cells and\n a small amount of air in the deep soft tissues of the upper left neck inferior\n to the mastoid air cells. Findings are related to the inferior aspect of the\n fracture extending through the mastoid air cells. High-density fluid is seen\n in the sphenoid sinus consistent with hemorrhage. There appears to be a\n somewhat irregular fracture through the clivus. There is a large scalp\n laceration with a significant hematoma and subcutaneous air seen overlying the\n left parietal fracture. Soft tissue laceration and skin staples are also seen\n overlying the right frontal bone, though no frontal bone fracture is seen.\n\n There is minimal mucosal thickening within the ethmoid air cells. The patient\n is intubated, and an OG tube is also seen curling within the posterior\n oropharynx.\n (Over)\n\n 3:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval ich, mass effect\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n Multiple cerebral contusions. Subdural hemorrhage extending along the\n convexity of the right frontoparietal region and probably extending into the\n middle cranial fossa. Subarachnoid hemorrhage and intraventricular hemorrhage.\n Narrowing of the suprasellar space is concerning for early cerebral edema.\n Continued close followup is recommended.\n Fractures through the left parietal bone extending into lambdoid suture\n causing diastasis. There is also a fracture of the clivus. Findings were\n communicated to the ED immediately via the ED dashboard.\n\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 919666,
"text": " 3:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with R frontal contusion\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old female with right frontal contusion. Evaluate for\n interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is interal decrease in attenuation involving a number of\n parenchymal hemorrhages consistent with interval absorption of the high-\n density elements of the blood. No new areas of hemorrhage are identified.\n There is no short interval change in the extent of brain edema within a large\n right frontal hemorrhagic contusion. There is persistent mass effect in the\n right frontal lobe due to edema but no significant change in the extent of\n leftward subfalcine herniation. There is no evidence of hydrocephalus. The\n basal cisterns are not effaced. Surrounding soft tissue and osseous\n structures are stable. Again noted is opacification of the sphenoid sinuses\n with aerosolized secretions.\n\n IMPRESSION: Evolving right frontal contusion with no short interval change in\n surrounding edema and mass effect. No new areas of hemorrhage are identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-19 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 917905,
"text": " 3:32 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: assess chest and plvis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman s/p mvc\n REASON FOR THIS EXAMINATION:\n assess chest and plvis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVA. Trauma series.\n\n AP supine chest radiograph obtained on trauma board. There is an undisplaced\n fracture of the sixth lateral left rib. No other fractures identified\n although assessment suboptimal and right lateral thorax not fully imaged.\n Small left predominantly apical pneumothorax. Heart and mediastinum are\n normal with no vascular congestion or focal consolidations. I doubt the\n presence of effusion although layering small pleural fluid not entirely\n exclude on the left. Tip of ET tube normally positioned. Small rectangular\n opaque artifacts overlie right hemithorax.\n\n AP FILM OF THE PELVIS OBTAINED ON TRAUMA BOARD. There are fractures of both\n inferior and superior pubic rami of the right fractures extending into the\n pubic symphysis. The right hemipelvis is proximally displaced with poorly\n assessed involvement of the right SI joint and associated fractures, right\n sacrum. I cannot exclude several transverse process fractures of lower\n vertebral bodies. Hip joints and proximal femurs intact.\n\n IMPRESSION: Small left PTX and associated rib fracture. Multiple fractures\n pelvis and superior displacement right hemipelvis from shearing injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-03 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 919837,
"text": " 9:16 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: please reassess pelvis\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with s/p orif pelvis\n REASON FOR THIS EXAMINATION:\n please reassess pelvis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF of the pelvis.\n\n AP PELVIS: Comparison with . There is fixation of the pubic\n rami with a malleable plate across the pubic symphysis. Bilateral inferior\n pubic rami fractures are visualized. There are skin staples. A screw is seen\n traversing the right SI joint and right sacral fracture. There is no evidence\n of hardware complication. There is stable alignment. Note is made of a\n feeding tube terminating in the region of the distal duodenum.\n\n IMPRESSION: No evidence of hardware complication following ORIF of the right\n sacrum and pubic symphysis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-19 00:00:00.000",
"description": "O ABD (SINGLE VIEW ONLY) IN O.R.",
"row_id": 917948,
"text": " 9:03 PM\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \n Reason: LOST NEDDLE\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Lost needle.\n\n A SINGLE VIEW OF THE ABDOMEN, INTRAOPERATIVELY: Two drains are seen overlying\n the abdomen. There is a left femoral venous catheter. In the superior\n portion of the image, the distal end of a nasogastric tube is seen. No\n metallic foreign body is seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919232,
"text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow ? RML infiltrate\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman multisystem trauma, G- in sputum\n REASON FOR THIS EXAMINATION:\n follow ? RML infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 05:55\n\n INDICATION: Positive sputum culture.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior study all lines and tubes remain in place.\n Previously visualized patchy features in the right lower lung field and\n laterally in the right mid lung field are much improved. There is no evidence\n of new airspace disease and no pneumothorax. Left subsegmental basilar\n atelectasis is noted.\n\n All lines and tubes remain in place.\n\n IMPRESSION:\n Improving airspace disease in the right hemithorax - no new consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-04 00:00:00.000",
"description": "PELVIS (AP, INLET & OUTLET)",
"row_id": 920077,
"text": " 7:04 PM\n PELVIS (AP, INLET & OUTLET) Clip # \n Reason: Eval. s/p ORIF\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with pelvic fx.\n REASON FOR THIS EXAMINATION:\n Eval. s/p ORIF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with pelvic fracture.\n\n THREE VIEWS OF THE PELVIS: There is fixation of the pubic rami with a\n malleable plate across the pubic symphysis. Bilateral inferior pubic rami\n fractures are visualized. There are skin staples. Screws are seen\n transversing the SI joints for fixation of right sacral ala fracture. There\n is a feeding tube unchanged compared to the prior study. No evidence of\n hardware complication is noted.\n\n IMPRESSION: Overall unchanged appearance of the pelvis with right sacral ala\n and bilateral pubic rami fractures, status post fixation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 918030,
"text": " 12:22 PM\n CT L-SPINE W/O CONTRAST Clip # \n Reason: fractures?\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old s/p MVC w/ SDH/SAH.\n REASON FOR THIS EXAMINATION:\n fractures?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT LUMBAR SPINE WITHOUT CONTRAST .\n\n HISTORY: Motor vehicle crash.\n\n Contiguous axial images were obtained from lower T11 through the upper sacrum.\n No contrast was administered. Comparison to pelvis radiographs performed on\n and .\n\n FINDINGS: There is a comminuted sagittally oriented fracture through the\n right sacral ala. This is substantially displaced with inferior rotation of\n the right side of the sacrum with respect to the ala. The ala appears to\n continue to articulate at the sacroiliac joint. CT imaging is limited for\n intraspinal soft tissue resolution. The possibility of a disc protrusion or\n hematoma cannot be excluded.\n\n There is extensive retroperitoneal stranding of tissue suggesting\n retroperitoneal hemorrhage.\n\n There is extensive intraperitoneal fluid. This may represent blood, fluid\n from a laparoscopy, or both.\n\n These findings were discussed with Dr. at 2:00 p.m. on .\n\n CONCLUSION:\n\n Comminuted, displaced, sagittally oriented fracture through the right sacral\n ala.\n\n CT is not adequate for evaluating soft tissue encroachment on the spinal\n canal. If this is a clinical concern, a MR examination may be helpful.\n\n Evidence of retroperitoneal hemorrhage.\n\n Intraperitoneal fluid which may represent hemorrhage, fluid from surgery, or\n both.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 918032,
"text": " 12:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change?\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old s/p MVC w/ SDH/SAH.\n REASON FOR THIS EXAMINATION:\n interval change?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n HISTORY: Status post motor vehicle crash with intracranial hemorrhage. Has\n there been interval change ?\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of .\n\n FINDINGS: There is no evidence of new hemorrhage since the prior examination.\n Again noted are multiple intraparenchymal hematomas in a distribution\n suggestive of diffuse axonal injury. There is also a large right frontal\n hemorrhagic contusion. There are small amounts of subarachnoid hemorrhage\n diffusely in the supra- and infratentorial compartments, and in the\n interpeduncular cistern. There is a small amount of air in the occipital \n of the left lateral ventricle. There is increased density along the tentorium\n indicating a subdural hematoma in this location. There is a small amount of\n hemorrhage in the anterior pole of the right temporal lobe. There is right\n hemispheric mass effect with mild right to left midline shift. There has been\n an increase in the edema surrounding the right frontal contusion. However,\n the small right convexity subdural hematoma, noted on the prior study, is no\n longer demonstrated.\n\n CONCLUSION: Increased edema surrounding the right frontal hemorrhagic\n contusion. No evidence of new hemorrhage.\n\n Multiple intraparenchymal hematomas along with subarachnoid, intraventricular,\n and subdural hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-23 00:00:00.000",
"description": "LP HUMERUS (AP & LAT) LEFT PORT",
"row_id": 918370,
"text": " 11:09 AM\n HUMERUS (AP & LAT) LEFT PORT Clip # \n Reason: assess humerus\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s.p mvc with humerus fx\n\n REASON FOR THIS EXAMINATION:\n assess humerus\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE LEFT HUMEROUS RADIOGRAPH, .\n\n INDICATION: Humerus fracture.\n\n No prior humerus radiographs are available for comparison.\n\n There is a oblique fracture through the mid shaft of the left humerus with\n slightly greater than one shaft with lateral displacement of the distal\n fracture fragment with respect to the proximal fracture fragment. There is\n also overriding of the fracture fragments of approximately 2.5 cm. A plaster\n casting device obscures fine bone detail.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-24 00:00:00.000",
"description": "R LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT",
"row_id": 918462,
"text": " 7:59 AM\n PELVIS & SACRO-ILIAC; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHTClip # \n Reason: PELVIC FX WITH ORIF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pelvic fracture, ORIF.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Eight spot views obtained. Fluoro time not recorded on\n the electronic requisition. Views demonstrate steps related to ORIF of the\n right SI joint and pubic symphysis. Right inferior pubic ramus fracture\n noted. Skin staples, surgical drains noted. Further evaluation on routine\n radiographs is recommended for full assessment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 918783,
"text": " 3:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P MVA ALTERED NEURO EXAM EVAL FOR INTERVAL CHANGE.\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with altered neuro. exam.\n REASON FOR THIS EXAMINATION:\n Eval. for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN.\n\n HISTORY: Altered neurological examination. Evaluate for interval change.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: head CT scan, which was interpreted by\n doctors and , revealing \"evolving right frontal contusion\n with slight increase in surrounding edema and mass effect, but no significant\n change in the extent of midline shift.\"\n\n FINDINGS: A number of the hemorrhages show slightly less density, consistent\n with interval partial resorption of the high-density elements of the blood.\n Otherwise, the scan appears stable, with no new hemorrhages or perceptible\n alteration in the extent of brain edema, particularly in relation to the large\n right frontal hemorrhagic contusion. No new extracranial pathology is\n discerned, either, with redemonstration of air fluid levels within the\n sphenoid sinus, likely related to intubation.\n\n CONCLUSION: Relatively little change in scan appearance, as noted in above\n report.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-29 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 919177,
"text": " 1:59 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: please place post pyloric tube\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with pelvic fx and high residuals c OG\n REASON FOR THIS EXAMINATION:\n please place post pyloric tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with pelvic fracture and high residuals with\n orogastric tube. Please place post-pyloric tube.\n\n -INTESTINAL TUBE PLACEMENT:\n\n Under fluoroscopic guidance, an 8 French - feeding tube was\n advanced into the left naris through the stomach and into the third segment of\n the duodenum. Placement was confirmed by 10 cc of Conray contrast. The\n patient tolerated the procedure well with no immediate post-procedural\n complications.\n\n IMPRESSION: Successful placement of post-pyloric tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-19 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 917927,
"text": " 6:02 PM\n PELVIS (AP ONLY) PORT; FEMUR (AP & LAT) IN O.R. PORT RIGHT Clip # \n Reason: eval fx, hardware\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with open pelvic fx s/p traction\n REASON FOR THIS EXAMINATION:\n eval fx, hardware\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Open pelvic fracture, status retraction. Evaluate fracture,\n hardware.\n\n PORTABLE VIEW OF PELVIS AND RIGHT FEMUR. There is a fracture through os\n sacrum on the right. There is a fracture through the pubic bone and ischium\n on the right near the pubic symphysis. There is a translucent line through\n the os ischium on the left, which may be due to overlay of soft tissue fold,\n but a fracture in this location cannot be excluded.\n\n There is an incomplete view of the right femur without including the right the\n major trochanter or the femoral head or neck. An external fixation device is\n seen in the distal aspect of the femur. No fractures are seen.\n\n IMPRESSION:\n\n 1. Fracture through the right os sacrum\n\n 2. Fracture through the right os pubis and ischium.\n\n 3. Lucent line through the left os ischium, which may represent overlay of\n soft tissue fold, but a fracture in this location cannot be excluded.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-04 00:00:00.000",
"description": "PERC PLCMT GASTROMY TUBE",
"row_id": 919969,
"text": " 7:23 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please assess for percutaneous G-J placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n Contrast: OPTIRAY Amt: 25\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF C1892 INT/SHTH,EP,FXD CURVE/ AWY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with recent decompressive laparotomy, closure, head injury\n REASON FOR THIS EXAMINATION:\n please assess for percutaneous G-J placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA, high residuals with orogastric tube, need for\n nutrition.\n\n RADIOLOGISTS: Drs. and , the Attending Radiologist, present\n and supervising the entire procedure.\n\n PROCEDURE/FINDINGS: After the risks and benefits of the procedure were\n discussed with the patient's family, written informed consent was obtained. A\n preprocedure timeout was performed to confirm patient identity and the\n procedure to be performed.\n\n Utilizing an indwelling NG tube, the stomach was insufflated with air under\n fluoroscopic guidance. A suitable spot for percutaneous gastrojejunostomy\n tube placement was then chosen. Under local anesthesia with 1% lidocaine,\n gastropexy was performed using three T fasteners. Gastric puncture was then\n performed using an 18-gauge needle advanced into the stomach under\n fluoroscopic guidance. An 0.035 wire was then advanced into the\n stomach and the wire was then introduced across the pylorus into the duodenum\n and then into the proximal jejunum. The wire was exchanged for an\n Amplatz wire. The patient's indwelling NJ tube was then removed. The\n percutaneous tract was then sequentially dilated and a peel- away introducer\n sheath placed. A 14- French gastrostomy tube was then advanced into\n the proximal jejunum and the peel- away sheath removed. The retention pigtail\n loop was formed and positioned in the proximal duodenum. The position of the\n tube was confirmed and documented with injection of contrast. The catheter was\n then secured using a flexitrack device.\n\n The patient tolerated the procedure well without immediate complications.\n\n MEDICATION: Moderate sedation was provided by administering divided doses of\n fentanyl (100 mcg total) throughout the total intra-service time of 1 hour and\n 20 minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n\n (Over)\n\n 7:23 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please assess for percutaneous G-J placement\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n Contrast: OPTIRAY Amt: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Successful placement of percutaneous gastrojejunostomy\n tube with the tip in the proximal jejunum.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-23 00:00:00.000",
"description": "RP FEMUR (AP & LAT) RIGHT PORT",
"row_id": 918369,
"text": " 11:09 AM\n FEMUR (AP & LAT) RIGHT PORT; PELVIS (AP ONLY) PORT Clip # \n Reason: assess pin\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with traction pin\n\n REASON FOR THIS EXAMINATION:\n assess pin\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE PELVIS AND FEMUR \n\n INDICATION: Traction.\n\n Radiographs of the right femur demonstrate a traction device in place. Images\n of the pelvis demonstrate fractures of the inferior and superior pubic rami\n with associated free fracture fragment related to the right-sided fractures.\n Overall, allowing for projectional differences, there has not been a change in\n alignment of the fracture fragments compared to portable pelvis radiograph of\n . Surgical clips and drains are again demonstrated within the\n abdomen and pelvis. Additional fractures involving the right sacrum are also\n without change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-06-04 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 920068,
"text": " 5:25 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with need for IV access\n REASON FOR THIS EXAMINATION:\n Please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVA, need for long-term IV access.\n\n PROCEDURE/FINDINGS: The procedure was performed by doctors and\n , the attending radiologist, who was present and supervising throughout\n the procedure. As no suitable superficial veins were identified, ultrasound\n of the right upper extremity was performed, which demonstrated the right\n brachial vein to be patent and compressible. The area was prepped and draped\n in the usual sterile fashion. Local anesthesia was achieved with subcutaneous\n injection of approximately 3 cc of 1% lidocaine. Under real-time ultrasound\n guidance, the right brachial vein was accessed using a 21-gauge micropuncture\n needle. Hard copy pre- and post-puncture images with ultrasound were\n obtained. A 0.018 guidewire was then advanced through the needle and into the\n SVC under fluoroscopic guidance. The needle was then exchanged for the\n introducer sheath. Based upon markers on the guidewire, the dual lumen PICC\n was then trimmed to a length of 40 cm. The PICC was then advanced over the\n wire through the sheath under fluoroscopic guidance. The wire and peel-away\n sheath were then removed. The line was then aspirated, flushed, capped, and\n then heplocked. The line was secured with a statlock device and a sterile\n transparent dressing applied. A final limited chest radiograph confirmed\n placement of the tip of the catheter to be in the lower SVC at the cavoatrial\n junction. There were no complications. The line is ready for use.\n\n IMPRESSION: Successful placement of a 40-cm long dual lumen PICC via the\n right brachial vein with the tip terminating at the cavoatrial junction using\n fluoroscopic and ultrasound guidance. The line is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 918674,
"text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna, effusion, edema, ptx\n Admitting Diagnosis: STATUS POST MOTOR VEHICLE ACCIDENT WITH INJURIES;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p mvc, bilat CT now c fever\n REASON FOR THIS EXAMINATION:\n eval pna, effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:14 A.M., .\n\n HISTORY: Motor vehicle accident, fever.\n\n IMPRESSION: AP chest compared to through :\n\n Substantial increase in heterogeneous opacification in the right lower lobe\n could represent asymmetric edema or worsening pneumonia. Subsequent\n radiograph on available at time of this dictation shows subsequent\n improvement. Left lower lobe consolidation is probably atelectasis. No\n pneumothorax or pleural effusion. Stable pleural thickening adjacent to left\n lateral rib fractures. Cardiomediastinal silhouette unremarkable. ET tube\n and left subclavian line in standard placements. Nasogastric tube passes\n beyond the distal stomach and out of view. Two left pleural tubes are\n unchanged in their positions.\n\n\n"
}
] |
70,016 | 130,064 | 63M initially presented to OSH with R temporal/occipital headache. At OSH, CTH showed 5 x 2.5cm right occipital bleed. He also was noted to go into aflutter with RVR and was started on diltiazem gtt. Upon txfer to , he was noted to have a left facial droop with good motor strength throughout. Repeat head CT showed that the hemorrhage had grown to 4 x 2.3cm with edema but no midline shift. He was admitted to stroke Neurology/ Neuro-ICU. On he had Aflutter with RVR and he received a Amio , Aline was placed, and he received Metoprolol 5mg IV x 2. Metoprolol PO was started. A TTE showed an EF >75% and impaired relaxation. On he was tachycardiac, cardiac enzymes were sent but negative. Digoxin was started and Metoprolol was increased. A CTA was performed which showed an underlying AVM. On he continued to have Aflutter with RVR and Cardiology was consulted. The patient was given Lasix, Ibutilide, Verapamil, Lopressor, and Digoxin. He was made NPO at midnight for possible TEE and cardioversion. On he underwent a TEE which showed no clot and then underwent cardioversion into normal sinus rhythm. He remained stable and on he underwent a Angiogram for embolization of the AVM. Post-embolization, he was transferred to Neurosurgery and remained in the Neuro-ICU for observation. Post-embolization, his SBP was kept below 110, this was acheived with Labetolol IV PRN, no drip was required. On he remained stable and visual fields appeared improved, his SBP was liberalized to 160. He was written for SDU transfer but no beds were available and he was kept in the ICU. On , he was transferred to the floor on telemetry. Early morning patient was noted to have aflutter with RVR and cardiology was consulted. He received Lopressor and a Heparin drip was started for the PTT goal of 60-90. Once therapeutic, a head CT was done which was stable. He remained stable with the plan for Cardioversion/ablation on . He underwent this procedure and was cleared without issue. he was maintained on heparin drip overnight and was cleared for d/c home by cardiology with daily coumadin dosing and follow up with his pcp. He will see us in the office in 4 weeks with CT. He agrees with this plan | Unchanged size of the right occipital intraparenchymal hemorrhage, and surrounding edema, and minimal mass effect on the adjacent occipital of the right lateral ventricle. Suboptimal imagequality - patient unable to cooperate.Conclusions:The left atrium is normal in size. PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA.BP (mm Hg): 103/60HR (bpm): 70Status: InpatientDate/Time: at 12:09Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Symmetric LVH. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Essentially unchanged large right occipital lobe intraparenchymal hemorrhage, with mild mass effect in the adjacent parenchyma but no gross midline shift. On the T2-weighted images on series 7 image 11 slightly prominent vascular flow void is identified at the medial aspect of the hematoma. No MR. LV inflow patternc/w impaired relaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The mitral valve appears structurally normal withtrivial mitral regurgitation. Normal PA systolicpressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Mild compression of the occipital of the right lateral ventricle is unchanged. Right occipital intraparenchymal hemorrhage with mild surrounding edema. Right occipital intraparenchymal hemorrhage with mild surrounding edema. Right occipital intraparenchymal hemorrhage with mild surrounding edema. FINAL REPORT INDICATION: New right occipital intraparenchymal hemorrhage with edema and mass effect. Suboptimal image quality as the patient wasdifficult to position. There is symmetric left ventricularhypertrophy. Right-sided occipital and posterior temporal intraparenchymal hemorrhage with mild surrounding edema. Compared to the previoustracing of atrial flutter is now present.TRACING #1 Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) 1. Noglycopyrrolate was administered. There is mild surrounding edema seen and is minimal mass effect on the occipital of the right lateral ventricle. IMPRESSION: Although slightly prominent right posterior cerebral artery is noted, no definite enlargement or tortuosity of this vascular structure is seen. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: There is no significant interval change in size of right occipital intraparenchymal hemorrhage with surrounding edema. No significant short-interval changes of the large right occipital intraparenhcymal hemorrhage, measuring now 4.0 x 2.3 cm, with peri-hemorrhagic edema and mass effect. FINDINGS: There is no significant change in the size of the right occipital intraparenchymal hemorrhage and surrounding edema. There is mild mass effect on the adjacent atrium of the right lateral ventricle. (Over) 11:11 AM CAROT/CEREB Clip # Reason: R/O AVM Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE Contrast: OPTIRAY Amt: 160ML OPTI240; 53ML OPTI320 FINAL REPORT (Cont) Right posterior cerebral artery arteriogram shows that the calcarine branch supplies the AVM nidus measuring about 1 cm. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Similar size of right occipital intraparenchymal hemorrhage and surrounding edema with a similar mass effect on occipital of right lateral ventricle. Left pleural effusion. The findings are suggestive of an arteriovenous malformation with small dense area could be representing compressed nidus or venous aneurysm. There is partial opacification of the right sphenoid sinus, with moderate ethmoidal opacification. There is persistent small peri-hemorrhagic edema and mass effect on adjacent parenchyma. FINDINGS: There is an area of acute hemorrhage identified in the right occipital and posterior temporal region with mild surrounding edema. Evidence of embolization of likely AVM in right occipital lobe. AVM, etiology of bleed. AVM, etiology of bleed. AVM, etiology of bleed. AVM, etiology of bleed. AVM, etiology of bleed. COMPARISON: CT head, . The wandering baseline, which is marring interpretation of ST segmentsfor myocardial ischemia, is new. The slight diminished visualization of the left middle cerebral artery on projection images appears artifactual. IMPRESSION: underwent angiography which revealed a right occipital pial AVM fed primarily by the right posterior cerebral artery and draining superficially. PATIENT/TEST INFORMATION:Indication: Atrial flutter.Height: (in) 70Weight (lb): 242BSA (m2): 2.27 m2BP (mm Hg): 125/88HR (bpm): 142Status: InpatientDate/Time: at 11:00Test: Portable TEE (Unsuccessful Placement) (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:GENERAL COMMENTS: A TEE was performed in the location listed above. INTERVENTIONAL PROCEDURE PERFORMED: Embolization of right occipital AVM with Onyx 18. MRA OF THE HEAD: The head MRA demonstrates slightly prominent right posterior cerebral artery compared to the left but otherwise no evidence of significantly enlarged arterial structure identified. hemorrhagic transformation of infarct vs. mass vs. hemorrhagic transformation of infarct vs. mass vs. 11:11 AM CAROT/CEREB Clip # Reason: R/O AVM Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE Contrast: OPTIRAY Amt: 160ML OPTI240; 53ML OPTI320 ********************************* CPT Codes ******************************** * EMBO TRANSCRANIAL SEL CATH 3RD ORDER * * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER * * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER * * TRANSCATH EMBO THERAPY F/U TRANS CATH THERAPY * * CAROTID/CERVICAL BILAT -59 DISTINCT PROCEDURAL SERVICE * * CAROTID/CEREBRAL BILAT -59 DISTINCT PROCEDURAL SERVICE * * EXT CAROTID BILAT -59 DISTINCT PROCEDURAL SERVICE * * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE * * SEL EA ADD'L -59 DISTINCT PROCEDURAL SERVICE * * SEL EA ADD'L -59 DISTINCT PROCEDURAL SERVICE * * SEL EA ADD'L -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** FINAL REPORT DATE OF SERVICE: . | 20 | [
{
"category": "Radiology",
"chartdate": "2139-04-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1179975,
"text": " 9:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please rule out progression of intracranial hemorrhage on he\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with R parietal AVM and now with A-flutter on heparin\n REASON FOR THIS EXAMINATION:\n Please rule out progression of intracranial hemorrhage on heparin\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 9:50 AM\n No significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old man with parietal AVM and now with A-flutter heparin.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: CT head, .\n\n FINDINGS: There is no significant interval change in size of right occipital\n intraparenchymal hemorrhage with surrounding edema. There is similar\n positioning of coils adjacent to the area of hemorrhage. There is no new\n acute hemorrhage in the interval. There is a similar mass effect on the\n occipital of the right lateral ventricle. There is a similar appearance\n of the configuration and size of ventricles compared to last CT. There is no\n evidence of interval hydrocephalus. There is no significant shift of midline\n structures. There is mucosal thickening in the paranasal sinuses.\n\n IMPRESSION:\n No significant interval change.\n Similar size of right occipital intraparenchymal hemorrhage and surrounding\n edema with a similar mass effect on occipital of right lateral ventricle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-03-28 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1178849,
"text": " 4:52 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? AVM, etiology of bleed.\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with IPH\n REASON FOR THIS EXAMINATION:\n ? AVM, etiology of bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 12:27 PM\n PFI:\n 1. Right occipital intraparenchymal hemorrhage with mild surrounding edema.\n 2. Findings on CT angiography of the head suggest a most likely an\n arteriovenous malformation in the region of hemorrhage within tortuous\n arterial structures supplying the region with a 5-mm density could represent\n compressed nidus or venous aneurysm. Draining vein is also visualized. No\n other vascular abnormalities. The findings were discussed with Dr. \n at the time of interpretation of this study on at 11:30\n a.m.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with intraparenchymal hemorrhage for further\n evaluation.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this, using departmental protocol CT angiography of the head was\n acquired.\n\n FINDINGS:\n\n CT HEAD: There is an intraparenchymal hemorrhage in the right occipital lobe\n identified as on the previous examinations measuring approximately 4.1 x 2.1\n cm. There is mild surrounding edema seen and is minimal mass effect on the\n occipital of the right lateral ventricle. There is no midline shift.\n\n CT ANGIOGRAPHY HEAD:\n\n CT angiography of the head demonstrates enlargement and tortuosity of the\n right posterior cerebral artery hemispheric branch. There is a small\n approximately 5-mm area of density identified in the region of hemorrhage with\n draining vein arising from this region. The findings are suggestive of an\n arteriovenous malformation with small dense area could be representing\n compressed nidus or venous aneurysm.\n\n The other arteries of the anterior circulation as well as the posterior\n circulation are well maintained.\n\n IMPRESSION:\n (Over)\n\n 4:52 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? AVM, etiology of bleed.\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Right occipital intraparenchymal hemorrhage with mild surrounding edema.\n 2. Findings on CT angiography of the head suggest a most likely an\n arteriovenous malformation in the region of hemorrhage within tortuous\n arterial structures supplying the region with a 5-mm density could represent\n compressed nidus or venous aneurysm. Draining vein is also visualized. No\n other vascular abnormalities. The findings were discussed with Dr. \n at the time of interpretation of this study on at 11:30\n a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1179448,
"text": " 4:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate the position of the CVL\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M with new R occipital IPH with edema and mass effect suggestive of AVM,\n persistent aflutter.\n REASON FOR THIS EXAMINATION:\n evaluate the position of the CVL\n ______________________________________________________________________________\n WET READ: WED 11:43 PM\n L subclavian CVL terminates at the confluence of the brachiocephalic veins.\n No PTX. Improved aeration of the right lung.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Left subclavian catheter tip is at the confluence of the brachiocephalic\n veins. There is no pneumothorax. Compared to prior study performed , , there has been markedly improved pulmonary edema, now mild, decrease\n in bilateral pleural effusions, now small, larger on the right side and\n improved bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1179539,
"text": " 10:14 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess change\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63M with new R occipital IPH with edema and mass effect suggestive of AVM,\n persistent aflutter.\n REASON FOR THIS EXAMINATION:\n assess change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:06 PM\n No significant change in size of the right occipital intraparenchymal\n hemorrhage, surrounding edema, or minimal compression of the occipital of\n the right lateral ventricle. No new intracranial bleed. Evidence of\n embolization of likely AVM in right occipital lobe.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New right occipital intraparenchymal hemorrhage with edema and\n mass effect. Suggestive of an AVM. Assess change.\n\n TECHNIQUE: Sequential axial images were obtained through the head without\n administration of intravenous contrast.\n\n COMPARISON: CTA from .\n\n FINDINGS: There is no significant change in the size of the right occipital\n intraparenchymal hemorrhage and surrounding edema. Interval placement of\n coils adjacent to the area of hemorrhage is noted. Mild compression of the\n occipital of the right lateral ventricle is unchanged. There is no\n evidence of transtentorial or uncal herniation. Enlargement of the ventricles\n and sulci are likely related to age-related involutional changes. Moderate\n mucosal thickening is seen in the sphenoid and ethmoidal air cells\n bilaterally. The frontal sinuses are well-aerated. Opacification of several\n mastoid air cells bilaterally is seen. The bony calvarium appears intact.\n\n IMPRESSION:\n\n 1. Unchanged size of the right occipital intraparenchymal hemorrhage, and\n surrounding edema, and minimal mass effect on the adjacent occipital of\n the right lateral ventricle.\n\n 2. Extensive paranasal mucosal thickening and opacification of mastoid air\n cells bilaterally could represent an ongoing inflammatory process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-03-26 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1178526,
"text": " 8:53 PM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST\n Reason: R IPH. ? hemorrhagic transformation of infarct vs. mass vs.\n Contrast: MAGNEVIST Amt: 21\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with HA and L field cut x1 day\n REASON FOR THIS EXAMINATION:\n R IPH. ? hemorrhagic transformation of infarct vs. mass vs. amyloid\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc FRI 6:22 AM\n No evidence of mass or amyloid angiopathy. Abnormally coursing vessel to the\n region of hemorrhage suggestive of a vascular malformation as the etiology.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain and MRA head and neck.\n\n CLINICAL INFORMATION: Patient with headache and left field cut with\n intracranial hemorrhage on CT, for further evaluation.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired before gadolinium. T1 axial and\n MP-RAGE sagittal images acquired following gadolinium.\n\n FINDINGS: There is an area of acute hemorrhage identified in the right\n occipital and posterior temporal region with mild surrounding edema. The\n hemorrhage measures approximately 4.5 x 2.5 cm in size. There is mild mass\n effect on the adjacent atrium of the right lateral ventricle. On the\n T2-weighted images on series 7 image 11 slightly prominent vascular flow void\n is identified at the medial aspect of the hematoma. This area demonstrates\n enhancement on post-gadolinium images. There is no evidence of a large\n draining vein identified.\n\n There are no other areas of chronic microhemorrhages seen. There is no\n midline shift, mass effect or hydrocephalus. Following gadolinium, there is\n no evidence of intrinsic enhancement seen within the region of hematoma or in\n other parts of the brain.\n\n IMPRESSION:\n 1. Right-sided occipital and posterior temporal intraparenchymal hemorrhage\n with mild surrounding edema.\n 2. Slightly prominent arterial structure medial and deep to the hematoma\n could be secondary to stasis or could also be due to a slightly prominent\n arterial supply of an arteriovenous malformation. CT angiography or\n conventional angiography can help for further assessment.\n 3. Alternatively the hematoma can be caused by a cavernous malformation. No\n other foci of microhemorrhages are seen.\n\n MRA NECK:\n\n Gadolinium-enhanced MRA of the neck was obtained and demonstrates no evidence\n (Over)\n\n 8:53 PM\n MR HEAD W & W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W&W/O CONTRAST\n Reason: R IPH. ? hemorrhagic transformation of infarct vs. mass vs.\n Contrast: MAGNEVIST Amt: 21\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of vascular stenosis, occlusion in the carotid or vertebral arteries.\n\n IMPRESSION: Normal MRA of the neck.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates slightly prominent right posterior cerebral artery\n compared to the left but otherwise no evidence of significantly enlarged\n arterial structure identified. No vascular occlusion seen or an aneurysm\n greater than 3 mm in size identified.\n\n IMPRESSION: Although slightly prominent right posterior cerebral artery is\n noted, no definite enlargement or tortuosity of this vascular structure is\n seen. No other abnormalities are seen on MRA of the head. The slight\n diminished visualization of the left middle cerebral artery on projection\n images appears artifactual.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-03-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1178498,
"text": " 5:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for evolution of ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with right occipital ICH\n REASON FOR THIS EXAMINATION:\n eval for evolution of ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:02 PM\n 1. No significant short-interval changes of the large right occipital\n intraparenhcymal hemorrhage, measuring now 4.0 x 2.3 cm, with peri-hemorrhagic\n edema and mass effect.\n 2. No midline shift. No intraventricular hemorrhagic extension. No new foci\n of hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old man, with right occipital intraparenchymal hemorrhage.\n Assess for evolution.\n\n COMPARISON: Outside hospital study on at 12:58 hours.\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: Again noted is a large intraparenchymal hemorrhagic area in the\n right occipital lobe, currently measuring 4.0 x 2.3 cm (image 2:14), compared\n to 4.4 x 2.1 cm in the study five hours ago, essentially unchanged allowing\n for the difference of technique and angulation. There is persistent small\n peri-hemorrhagic edema and mass effect on adjacent parenchyma. No midline\n shift, intraventricular hemorrhagic extension, or new foci of hemorrhage.\n There is good preservation of -white matter differentiation. The basal\n cisterns remain patent.\n\n There is partial opacification of the right sphenoid sinus, with moderate\n ethmoidal opacification. The visualized maxillary sinuses and mastoid air\n cells are clear. There is no acute fracture.\n\n IMPRESSION:\n 1. Essentially unchanged large right occipital lobe intraparenchymal\n hemorrhage, with mild mass effect in the adjacent parenchyma but no gross\n midline shift. Differential diagnosis consideration for acute\n intraparenchymal hemorrhage includes hypertension, underlying brain lesion,\n AVM, or amyloid angiopathy.\n\n 2. No intraventricular hemorrhagic extension. No new foci of hemorrhage. No\n developing hydrocephalus.\n (Over)\n\n 5:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for evolution of ICH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1178499,
"text": " 5:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with R IPH\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 1732 HOURS\n\n HISTORY: Right intracranial hemorrhage.\n\n COMPARISON: None.\n\n FINDINGS: No focal consolidation is noted. There is mild aortic tortuosity.\n The cardiac silhouette is within normal limits for size. No effusion or\n pneumothorax is seen.\n\n IMPRESSION: No acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-03-29 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1178964,
"text": " 3:08 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pneumonia\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with fever in ICU\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 63-year-old male with fever and possible pneumonia.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is prominence of pulmonary vascular markings as well as increased\n opacities at the lung bases. Findings are suggestive of an element of fluid\n overload. There is a left retrocardiac opacity that may be due to atelectasis\n or developing infiltrate. The cardiac silhouette is upper limits of normal.\n There are bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-01 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1179393,
"text": " 11:11 AM\n CAROT/CEREB Clip # \n Reason: R/O AVM\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 160ML OPTI240; 53ML OPTI320\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * TRANSCATH EMBO THERAPY F/U TRANS CATH THERAPY *\n * CAROTID/CERVICAL BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * CAROTID/CEREBRAL BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * EXT CAROTID BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * SEL EA ADD'L -59 DISTINCT PROCEDURAL SERVICE *\n * SEL EA ADD'L -59 DISTINCT PROCEDURAL SERVICE *\n * SEL EA ADD'L -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PREOPERATIVE DIAGNOSIS: Right occipital lobe arteriovenous malformation\n rupture with hematoma.\n\n REASON FOR PROCEDURE: Delineate characteristics of AVM and embolization of\n AVM.\n\n ATTENDING PHYSICIAN: .\n\n ASSISTANT: .\n\n ANESTHESIA: General.\n\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, right external\n carotid artery arteriogram, right internal carotid artery arteriogram, left\n common carotid artery arteriogram, left internal carotid artery arteriogram,\n left external carotid artery arteriogram, left vertebral artery arteriogram,\n basilar artery arteriogram, left posterior cerebral artery arteriogram, right\n posterior cerebral artery arteriogram, right common femoral artery arteriogram\n and Angio-Seal closure of right common femoral artery puncture site.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Embolization of right occipital AVM with\n Onyx 18.\n\n DETAILS OF PROCEDURE: The patient was brought to the angiography suite.\n Following this anesthesia was induced in the supine position. Both groins\n were prepped and draped in a sterile fashion. Access was gained to the right\n common femoral artery using a Seldinger technique and a 6 French vascular\n sheath was placed in the right common femoral artery. Now using 2\n catheter, the above-mentioned vessels were catheterized and AP, lateral\n (Over)\n\n 11:11 AM\n CAROT/CEREB Clip # \n Reason: R/O AVM\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 160ML OPTI240; 53ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n filming was done. The multiple vessels listed above were catheterized.\n Eventually the left vertebral artery was catheterized and this revealed an\n occipital AVM, which was primarily fed by a branch of the right calcarine\n artery. At this point, to get distal access a DAC 038 138 cm catheter was\n passed triaxially over an SL-10 microcatheter and Synchro wire, which was\n placed in the basilar artery and AP, lateral filming done. This again\n confirmed the location of the AVM. We now proceeded to catheterize the left\n posterior cerebral artery with a microcatheter and a microcatheter injection\n was done. Following this, the right posterior cerebral artery was also\n catheterized with a Marathon microcatheter and a Mirage wire. Under\n roadmapping guidance the Marathon catheter was taken right up to the nidus and\n Onyx 18 was injected to obliterate the nidus. Following this, the Marathon\n was removed and a run in the left vertebral artery arteriogram showed that the\n AVM was completely obliterated. I now performed a right common femoral artery\n arteriogram and 6 French Angio-Seal was used for closure of the right common\n femoral artery puncture site.\n\n FINDINGS: Left common carotid artery arteriogram shows no evidence of\n stenosis.\n\n Left internal carotid artery arteriogram: Anterior and middle cerebral\n arteries are seen well. There is no supply to the AVM.\n\n Left external carotid artery arteriogram shows no supply to the AVM. No\n dural AV fistula.\n\n Right common carotid artery arteriogram shows no evidence of stenosis at the\n bifurcation.\n\n Right internal carotid artgeriogram The anterior and middle cerebral arteries\n fill well. There is no supply to the arteriovenous malformation.\n Right external carotid artery arteriogram shows no evidence of dural AV\n fistula or dural supply to the AVM.\n\n Left vertebral artery arteriogram shows that the right posterior cerebral\n artery supplies the AVM through an enlarged calcarine branch. The venous\n drainage is superficial through a single cortical draining vein into the\n superior sagittal sinus. The nidus itself measures about a centimeter in\n size.\n\n Basilar artery arteriogram confirms right posterior cerebral artery supplying\n the AVM.\n Left posterior cerebral artery arteriogram does not show any evidence of AVM.\n\n\n (Over)\n\n 11:11 AM\n CAROT/CEREB Clip # \n Reason: R/O AVM\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 160ML OPTI240; 53ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Right posterior cerebral artery arteriogram shows that the calcarine branch\n supplies the AVM nidus measuring about 1 cm. There is a venous aneurysm and\n there are areas of constriction in the draining vein.\n\n Left vertebral artery arteriogram status post embolization shows no evidence\n of AVM with the nidus completely obliterated by Onyx.\n\n Right common femoral artery arteriogram shows widely patent right common\n femoral artery.\n\n IMPRESSION: underwent angiography which revealed a right\n occipital pial AVM fed primarily by the right posterior cerebral artery and\n draining superficially. The nidus measured 1 cm and was completely obliterated\n by intraarterial injection of Onyx. There were no complications of the\n procedure.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2139-03-28 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1178850,
"text": ", C. NMED SICU-B 4:52 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? AVM, etiology of bleed.\n Admitting Diagnosis: INTRACEREBRAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with IPH\n REASON FOR THIS EXAMINATION:\n ? AVM, etiology of bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Right occipital intraparenchymal hemorrhage with mild surrounding edema.\n 2. Findings on CT angiography of the head suggest a most likely an\n arteriovenous malformation in the region of hemorrhage within tortuous\n arterial structures supplying the region with a 5-mm density could represent\n compressed nidus or venous aneurysm. Draining vein is also visualized. No\n other vascular abnormalities. The findings were discussed with Dr. \n at the time of interpretation of this study on at 11:30\n a.m.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2139-03-30 00:00:00.000",
"description": "Report",
"row_id": 92461,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial flutter.\nHeight: (in) 70\nWeight (lb): 242\nBSA (m2): 2.27 m2\nBP (mm Hg): 125/88\nHR (bpm): 142\nStatus: Inpatient\nDate/Time: at 11:00\nTest: Portable TEE (Unsuccessful Placement) (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). No\nglycopyrrolate was administered. Unsuccessful esophageal intubation.\n\nConclusions:\nThe TEE probe could not be passed into the esophagus due to resistance and\ninability to cooperate.\nDue to borderline baseline oxygen saturation, additional sedation was not\nconsidered safe.\nIf a TEE is desired, involvement of anesthesia for controlled deep sedation is\nsuggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2139-03-27 00:00:00.000",
"description": "Report",
"row_id": 92462,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nBP (mm Hg): 103/60\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 12:09\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Hyperdynamic LVEF >75%.\nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal PA systolic\npressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - poor subcostal views. Suboptimal image\nquality - poor suprasternal views. Suboptimal image quality as the patient was\ndifficult to position. Suboptimal image quality - ventilator. Suboptimal image\nquality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is normal in size. There is symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Left ventricular\nsystolic function is hyperdynamic (EF>75%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. The tricuspid valve leaflets are mildly\nthickened. The estimated pulmonary artery systolic pressure is normal. There\nis no pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2139-03-30 00:00:00.000",
"description": "Report",
"row_id": 92406,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial flutter.\nHeight: (in) 70\nWeight (lb): 242\nBSA (m2): 2.27 m2\nBP (mm Hg): 110/74\nHR (bpm): 132\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nDr. was notified by telephone.\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was under general anesthesia\nthroughout the procedure. Cardiology fellow involved with the patient's care\nwas notified by telephone. Left pleural effusion. Bilateral pleural effusions.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect by 2D or color flow Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). The ascending, transverse\nand descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no pericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of intracardiac thrombus seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-07 00:00:00.000",
"description": "Report",
"row_id": 257675,
"text": "Sinus rhythm. Prolonged Q-T interval. Compared to the previous tracing the\nrhythm has changed. The Q-T interval is now prolonged, likely related to\ncardioversion, possibly chemical.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-06 00:00:00.000",
"description": "Report",
"row_id": 257676,
"text": "Atrial flutter with rapid ventricular response. Compared to the previous\ntracing of atrial flutter is now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-03 00:00:00.000",
"description": "Report",
"row_id": 257677,
"text": "Atrial fibrillation with rapid ventricular response. Wandering baseline\nmarring interpretation of ST segments for possible myocardial ischemia.\nCompared to the previous tracing of atrial flutter with variable block\nhas been replaced by atrial fibrillation with a rapid ventricular response\nrate. The wandering baseline, which is marring interpretation of ST segments\nfor myocardial ischemia, is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-03-29 00:00:00.000",
"description": "Report",
"row_id": 257678,
"text": "Atrial flutter with variable block. Otherwise, no other diagnostic\nabnormalities. Compared to the previous tracing A-V block is now variable.\nThe other findings are similar.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-03-27 00:00:00.000",
"description": "Report",
"row_id": 257679,
"text": "Atrial flutter with 2:1 conduction. No other diagnostic abnormalities.\nCompared to the previous tracing of A-V block in atrial flutter\nis more consistently 2:1 and thus ventricular rate is faster.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2139-03-27 00:00:00.000",
"description": "Report",
"row_id": 257680,
"text": "Atrial flutter with rapid ventricular response and variable atrio-ventricular\nblock. Left axis deviation. Inferior and lateral ST-T wave changes raising\nconsideration of possible ischemia, likely rate-related. Clinical correlation\nis suggested. Compared to the previous tracing of the ventricular\nresponse rate has decreased and variable atrio-ventricular block is now seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-03-26 00:00:00.000",
"description": "Report",
"row_id": 257681,
"text": "Atrial flutter with rapid ventricular response rate and 2:1 atrio-ventricular\nblock. Left axis deviation. Diffuse ST segment changes in the inferolateral\nleads raising consideration of possible ischemia, likely rate-related.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
46,305 | 152,478 | The patient was taken to the operating room for splenectomy. Please see the operative note for complete details. She tolerated the procedure well and was taken extubated in stable condition to the ICU for post-operative monitoring. Post operatively she had mild tachycardia with soft pressrue in the low 90s. Due to continued transfusion requirements, she was reoperated for concern of post op bleeding. Intraabdominal bloood and clot was found around the area for friability of the diaphragm from her radiation, but no active bleeding site was found.She was maintained on fluid and given extra volume with PRBC and FFP and platelets for her nedical coagulopathy as well. Her hematocrit and INR responded appropriately. Her UOP dropped to 5cc/hour for one hour but she responded to the fluid and her UOP picked up. She never required pressors and her creatinine stabilized to her baseline. After adequate rescucitation she was transferred out of the ICU to the floor, where she was monitored. She did well on the floor and advanced her diet and urinated on her own. We spoke with her PCP and her hematologist to discuss pre-splenectomy vaccinations- she had received pneumovax. We gave the patient the hemophilus and neisseria vaccinations. The patient was evaluated by physical therapy to ensure her safety. | Retrocardiac opacity persists, with obscuration of the left hemidiaphragm. Septated areas with internal echogenicity within the perihepatic region and left lower quadrant consistent with hematoma. Probable ectopic atrial tachycardia with leftward P wave axis and shortcomputed P-R interval. Bibasilar atelectasis and left pleural effusion. There is a left retrocardiac opacity and a left-sided pleural effusion. There is bibasilar atelectasis and possibly layering left pleural effusion. CHEST, AP: Nasogastric tube has been removed. There is a diffuse hazy parenchymal density in the left-sided mid lung field in perihilar location suggestive of a pneumonic parenchymal infiltrate. Patent intrahepatic vasculature. There is a persistent moderate-to-large layering left pleural effusion. Presence of left pleural effusion and basal areas of atelectasis persist. Splenectomy changes, with left pulmonary opacities, effusion, and edema. FINDINGS: The right IJ central line has been removed. Unchanged mild interstitial edema and central vascular congestion. In peri-hepatic location and within the left lower quadrant, there are septations and increased echogenicity which may reflect hematoma. DUPLEX: The main portal vein is patent with normal hepatopetal flow. The hepatic artery is patent with sharp systolic upstroke and forward flow within diastole. FINDINGS: AP single view of the chest has been obtained with patient in semi-erect position. Poor anterior R wave progression, cannot exclude prioranterolateral myocardial infarction. The right, middle, and left hepatic veins are patent with normal waveforms. Non-specificST-T wave abnormalities. It is noted that the patient is moderately tilted towards the right, which accounts for some asymmetric presentation of the mediastinal structures. A right internal jugular approach wide caliber sheath has been placed and the tip advanced so to overlie the superior mediastinal structures, terminating approximately 1 cm above the carina. Again seen is a right internal jugular catheter with tip in the mid SVC. (Over) 1:05 PM DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: evaluate flow through portal system and mesenteric vasculatu Admitting Diagnosis: SPLENOMEGALY/SDA FINAL REPORT (Cont) Evaluation of the mesenteric vasculature is limited due to overlying midline dressing. Retrocardiac opacification persists. There is a right IJ line with the distal lead tip in the mid SVC. The gallbladder is distended with sludge present. Hazy opacity at the left base may reflect partial lower lobe atelectasis in the setting of effusion, although pneumonia cannot be entirely excluded. Recommend CT if evaluation of the distal mesenteric vessels is required. Sclerotic bones. Possible superimposed pulmonary edema. Previous splenectomy noted. Bones are diffusely sclerotic. COMPARISONS: AP chest radiograph from . Anterior R waveprogression is worse, most likely due to differences in precordial electrodeplacement. Hazy opacity in the left upper lung zone likely represents infectious process. The stomach appears to be somewhat displaced towards the midline, which could be related to positioning, but also raises the possibility of a post-operative hematoma given that the patient is status post recent splenectomy. New moderate-to-large volume ascites. Size of the cardiac silhouette is unchanged. Evaluation of the mesenteric vessels is limited due to overlying bandaging. Again seen is opacity involving the left upper lung zone which is most likely infectious in nature. Changes of splenectomy, with midline abdominal staples. There is likely a trace amount of free intraperitoneal air, which would be an expected finding for this post-operative patient. Compared to the previous tracingof , the rate is minimally less tachycardic. Sludge present within the gallbladder. FINDINGS: There is a feeding tube whose distal tip and sideport are below the gastroesophageal junction. There is new moderate-to-large volume ascites. There is likely an element of pulmonary vascular congestion as well. FINDINGS: As compared to the previous radiograph, the parenchymal opacities in both the left and the right hemithorax have slightly improved. The right and left portal veins are patent with normal direction of flow. Cardiomediastinal silhouette is unchanged. Patchy opacities in the right lung may also represent superimposed pulmonary edema. Check position. Probable accelerated junctional rhythm with retrograde P waves. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. A portable supine film of the abdomen dated at 7:56 is submitted. The visualized portions of the pancreas are normal. This is compatible with the superior portion of the SVC. The pancreatic body and tail were not well visualized. enlarging abdomen on clinical exam REASON FOR THIS EXAMINATION: e/f ileus or free air FINAL REPORT PORTABLE ABDOMEN PLAIN FILM, 4/28/2102 AT 7:56 CLINICAL INDICATION: 72-year-old status post splenectomy complicated by a post-op bleed and enlarging abdomen on exam, question ileus or free air. COMPARISON: . COMPARISON: . No cholelithiasis. Since the patient apparently has undergone recent abdominal surgery, the possibility of an aspiration pneumonia must be considered. FINDINGS: The liver is normal in echogenicity and echotexture. There are multiple cables and lines overlying the chest apparently external. The proximal SMA and SMV (5cm) are visualized and are patent. The distal mesenteric vessels could not be evaluated on US. No definite pneumothoraces are seen. IMPRESSION: There is scattered air within non-distended loops of bowel with no evidence of obstruction at this time. The proximal (5cm) SMA and SMV are patent. No gallbladder wall edema. No gallbladder wall edema. There are low lung volumes due to poor inspiratory effort. 3. 3. 2. 2. 2. 3:02 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: SPLENOMEGALY/SDA MEDICAL CONDITION: 72 year old woman s/p splenectomy s/p aggressive resuscitation, decreased SaO2 REASON FOR THIS EXAMINATION: interval change FINAL REPORT STUDY: AP chest . | 9 | [
{
"category": "Radiology",
"chartdate": "2157-04-18 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 1237961,
"text": " 1:05 PM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: evaluate flow through portal system and mesenteric vasculatu\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with h/o myelofibrosis s/p splenectomy, high risk for\n thrombotic complications post-op\n REASON FOR THIS EXAMINATION:\n evaluate flow through portal system and mesenteric vasculature for signs of\n thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND DUPLEX ABDOMEN AND PELVIS DATED \n\n COMPARISON: Comparison is made to previous ultrasound dated .\n\n FINDINGS: The liver is normal in echogenicity and echotexture. No focal\n liver lesions are identified. There is no intra- or extra-hepatic duct\n dilation. Previous splenectomy noted. The gallbladder is distended with\n sludge present. No gallbladder wall edema. The common duct measures 4 mm.\n The pancreatic body and tail were not well visualized. The visualized\n portions of the pancreas are normal.\n\n There is new moderate-to-large volume ascites. In peri-hepatic location and\n within the left lower quadrant, there are septations and increased\n echogenicity which may reflect hematoma.\n\n DUPLEX: The main portal vein is patent with normal hepatopetal flow. Peak\n velocity is 20 cm/sec within the main portal vein. The right and left portal\n veins are patent with normal direction of flow. The right, middle, and left\n hepatic veins are patent with normal waveforms. The hepatic artery is patent\n with sharp systolic upstroke and forward flow within diastole. Evaluation of\n the mesenteric vasculature is limited due to overlying midline dressing. The\n proximal SMA and SMV (5cm) are visualized and are patent. The distal\n mesenteric vessels could not be evaluated on US.\n\n IMPRESSION:\n 1. New moderate-to-large volume ascites. Septated areas with internal\n echogenicity within the perihepatic region and left lower quadrant consistent\n with hematoma.\n 2. Patent intrahepatic vasculature. Evaluation of the mesenteric vessels is\n limited due to overlying bandaging. The proximal (5cm) SMA and SMV are\n patent. Recommend CT if evaluation of the distal mesenteric vessels is\n required.\n 3. Sludge present within the gallbladder. No cholelithiasis. No gallbladder\n wall edema.\n\n Findings were discussed by phone with Dr. by Dr. \n at 14:00 on .\n (Over)\n\n 1:05 PM\n DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US (SINGLE ORGAN)Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: evaluate flow through portal system and mesenteric vasculatu\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1237983,
"text": " 3:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for pulmonary edema vs infiltrate\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with increased respiratory distress and O2 requirement,\n myeldysplastic disease s/p splenectomy\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema vs infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with increased respiratory distress and O2\n requirement with myelodysplastic disease and splenectomy, evaluate for\n pulmonary edema versus parenchymal disease.\n\n COMPARISONS: AP chest radiograph from .\n\n FINDINGS: The right IJ central line has been removed. Again seen is opacity\n involving the left upper lung zone which is most likely infectious in nature.\n Retrocardiac opacification persists. Patchy opacities in the right lung may\n also represent superimposed pulmonary edema. Cardiomediastinal silhouette is\n unchanged. There is bibasilar atelectasis and possibly layering left pleural\n effusion.\n\n IMPRESSION:\n 1. Hazy opacity in the left upper lung zone likely represents infectious\n process.\n 2. Possible superimposed pulmonary edema.\n 3. Bibasilar atelectasis and left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1238042,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for continued pulmonary edema\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with likely pulmonary edema\n REASON FOR THIS EXAMINATION:\n evaluate for continued pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pulmonary edema, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the parenchymal opacities\n in both the left and the right hemithorax have slightly improved. Size of the\n cardiac silhouette is unchanged. Presence of left pleural effusion and basal\n areas of atelectasis persist. Also persistent are the diffusely increased\n bone density, given the underlying generalized disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-04-16 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1237725,
"text": " 8:06 AM\n PORTABLE ABDOMEN Clip # \n Reason: e/f ileus or free air\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p splenectomy c/b post-op bleed. enlarging abdomen on\n clinical exam\n REASON FOR THIS EXAMINATION:\n e/f ileus or free air\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN PLAIN FILM, 4/28/2102 AT 7:56\n\n CLINICAL INDICATION: 72-year-old status post splenectomy complicated by a\n post-op bleed and enlarging abdomen on exam, question ileus or free air.\n\n A portable supine film of the abdomen dated at 7:56 is submitted.\n There are no comparison studies.\n\n IMPRESSION:\n\n There is scattered air within non-distended loops of bowel with no evidence of\n obstruction at this time. The stomach appears to be somewhat displaced\n towards the midline, which could be related to positioning, but also raises\n the possibility of a post-operative hematoma given that the patient is status\n post recent splenectomy. There is likely a trace amount of free\n intraperitoneal air, which would be an expected finding for this\n post-operative patient. Hazy opacity at the left base may reflect partial\n lower lobe atelectasis in the setting of effusion, although pneumonia cannot\n be entirely excluded. Clinical correlation would be advised at this time and\n followup imaging should be based on the clinical assessment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1237795,
"text": " 3:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p splenectomy s/p aggressive resuscitation, decreased SaO2\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 72-year-old woman status post splenectomy and aggressive\n resuscitation.\n\n FINDINGS: There is a feeding tube whose distal tip and sideport are below the\n gastroesophageal junction. There is a right IJ line with the distal lead tip\n in the mid SVC. There is a left retrocardiac opacity and a left-sided pleural\n effusion. There are low lung volumes due to poor inspiratory effort. No\n definite pneumothoraces are seen. There is likely an element of pulmonary\n vascular congestion as well.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2157-04-18 00:00:00.000",
"description": "Report",
"row_id": 247359,
"text": "Probable ectopic atrial tachycardia with leftward P wave axis and short\ncomputed P-R interval. Poor anterior R wave progression, cannot exclude prior\nanterolateral myocardial infarction. Compared to the previous tracing\nof , the rate is minimally less tachycardic. Anterior R wave\nprogression is worse, most likely due to differences in precordial electrode\nplacement.\n\n"
},
{
"category": "ECG",
"chartdate": "2157-04-15 00:00:00.000",
"description": "Report",
"row_id": 247360,
"text": "Probable accelerated junctional rhythm with retrograde P waves. Non-specific\nST-T wave abnormalities. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-04-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1237503,
"text": " 4:44 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new CVL R IJ\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with new R IJ\n REASON FOR THIS EXAMINATION:\n new CVL R IJ\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: CHEST AP PORTABLE SINGLE VIEW\n\n INDICATION: 72-year-old female patient with new right internal jugular\n central venous line. Check position. Contact , phone .\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-erect position. It is noted that the patient is moderately tilted\n towards the right, which accounts for some asymmetric presentation of the\n mediastinal structures. A right internal jugular approach wide caliber sheath\n has been placed and the tip advanced so to overlie the superior mediastinal\n structures, terminating approximately 1 cm above the carina. This is\n compatible with the superior portion of the SVC. No pneumothorax is seen.\n There is a diffuse hazy parenchymal density in the left-sided mid lung field\n in perihilar location suggestive of a pneumonic parenchymal infiltrate. Since\n the patient apparently has undergone recent abdominal surgery, the possibility\n of an aspiration pneumonia must be considered. Unfortunately, there exist no\n preoperative chest examination available for comparison. There are multiple\n cables and lines overlying the chest apparently external.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2157-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1237898,
"text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SPLENOMEGALY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman s/p splenectomy\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with myelofibrosis post-splenectomy.\n\n COMPARISON: .\n\n CHEST, AP: Nasogastric tube has been removed. Again seen is a right internal\n jugular catheter with tip in the mid SVC. Changes of splenectomy, with\n midline abdominal staples. Retrocardiac opacity persists, with obscuration of\n the left hemidiaphragm. There is a persistent moderate-to-large layering left\n pleural effusion. Unchanged mild interstitial edema and central vascular\n congestion. Bones are diffusely sclerotic.\n\n IMPRESSION:\n 1. Splenectomy changes, with left pulmonary opacities, effusion, and edema.\n 2. Sclerotic bones.\n\n"
}
] |
83,393 | 144,741 | 65F admitted for an elecive stent assisted recoiling of the L ICA aneurysm and coiling of the R ICA aneurysm. The procedure was successful and the patient was admitted to the ICU post-angio. She was continued on ASA and Plavix. She was monitored overnight in the ICU. On she remained stable. She was tolerating PO intake and ambulated steadily. She was discharged home on ASA and Plavix. | Stent-assisted coiling of left carotid ophthalmic artery aneurysm. FINDINGS: Left internal carotid artery arteriogram demonstrates residual filling of the aneurysm. PREOPERATIVE DIAGNOSIS: Left carotid ophthalmic aneurysm. We now placed a Neuron MAX in the right internal carotid artery and with some difficulty the right carotid ophthalmic aneurysm was catheterized with an SL-10 microcatheter. PROCEDURES PERFORMED: Left internal carotid artery arteriogram, right internal carotid artery arteriogram, right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site. Following this, the aneurysm was obliterated and the internal carotid artery was patent. Following this, the aneurysm was catheterized with an SL-10 microcatheter and an exchange length wire was placed in the left middle cerebral artery. Following this, the right internal carotid artery was catheterized and AP and lateral filming done. Post-right carotid ophthalmic artery aneurysm. Coiling of right carotid ophthalmic artery aneurysm. IMPRESSION: underwent cerebral angiography and coiling of bilateral carotid ophthalmic artery aneurysms. Left internal carotid artery arteriogram status post stent coil shows that the internal carotid artery is patent and the stent is in position. We now catheterized the left internal carotid artery and AP and lateral filming was done. This revealed that there was a 6-mm x 4-mm aneurysm of the right carotid ophthalmic segment pointing superiorly. We now completed coiling of the aneurysm. Therefore, using the exchange length wire, an XT 27 microcatheter was placed in the distal internal carotid artery and a Neuroform 4.5 x 20 mm stent (Over) 9:35 AM CAROT/CEREB Clip # Reason: cerebral angiogram- stent assisted coiling Admitting Diagnosis: BRAIN ANEURYSM/SDA Contrast: OPTIRAY Amt: OPT320=135,OPT240=170 FINAL REPORT (Cont) was deployed. Right internal carotid artery arteriogram status post coil embolization shows that the aneurysm is now completely obliterated. Right internal carotid artery arteriogram status post coil embolization shows that there is some residual flow into the right carotid ophthalmic aneurysm; however, the dye is stagnant and hopefully will thrombose once anticoagulation is withdrawn. Right internal carotid artery arteriogram demonstrated a 6 x 4-mm aneurysm of the supraclinoid carotid. Following this, the II catheter in the left internal carotid artery was exchanged out for a Neuron MAX catheter. Access was gained to the right common femoral artery using a Seldinger technique and an 8 French vascular sheath was placed in the right common femoral artery. The left sided aneurysm still had contrast filling at the end of the procedure. 9:35 AM CAROT/CEREB Clip # Reason: cerebral angiogram- stent assisted coiling Admitting Diagnosis: BRAIN ANEURYSM/SDA Contrast: OPTIRAY Amt: OPT320=135,OPT240=170 ********************************* CPT Codes ******************************** * EMBO TRANSCRANIAL SEL CATH 3RD ORDER * * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER * * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT * * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY * * F/U TRANS CATH THERAPY * **************************************************************************** MEDICAL CONDITION: 65 year old woman with presents for elective stent assisted coling REASON FOR THIS EXAMINATION: cerebral angiogram- stent assisted coiling FINAL REPORT DATE OF SERVICE: . A Neuroform stent was used on the right side. ATTENDING PHYSICIAN: , .D. DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite. Following this, the aneurysm was coiled starting with 4-mm 360 UltraSoft Target coils and finishing with 2-mm UltraSoft coils. Following this, the aneurysm was coiled with Target coils starting with a 5 x 15 mm coil. At some point, it appeared that it would be difficult to seal the neck of the aneurysm without a stent. ANESTHESIA: General. However the dye was stagnant and it is expected to thrombose once anticoagulation is withdrawn. Anesthesia was induced in the supine position. ASSISTANT: , M.D., and , nurse practitioner, and , M.D. | 1 | [
{
"category": "Radiology",
"chartdate": "2198-09-21 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1255030,
"text": " 9:35 AM\n CAROT/CEREB Clip # \n Reason: cerebral angiogram- stent assisted coiling\n Admitting Diagnosis: BRAIN ANEURYSM/SDA\n Contrast: OPTIRAY Amt: OPT320=135,OPT240=170\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old woman with presents for elective stent assisted coling\n REASON FOR THIS EXAMINATION:\n cerebral angiogram- stent assisted coiling\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PREOPERATIVE DIAGNOSIS: Left carotid ophthalmic aneurysm. Post-right carotid\n ophthalmic artery aneurysm.\n\n ATTENDING PHYSICIAN: , .D.\n\n ASSISTANT: , M.D., and , nurse practitioner, and\n , M.D.\n\n PROCEDURES PERFORMED: Left internal carotid artery arteriogram, right\n internal carotid artery arteriogram, right common femoral artery arteriogram\n and Angio-Seal closure of right common femoral artery puncture site.\n\n INTERVENTIONAL PROCEDURE PERFORMED:\n 1. Stent-assisted coiling of left carotid ophthalmic artery aneurysm.\n 2. Coiling of right carotid ophthalmic artery aneurysm.\n\n ANESTHESIA: General.\n\n DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.\n Anesthesia was induced in the supine position. Following this, both groins\n were prepped and draped in a sterile fashion. Access was gained to the right\n common femoral artery using a Seldinger technique and an 8 French vascular\n sheath was placed in the right common femoral artery. We now catheterized the\n left internal carotid artery and AP and lateral filming was done. Following\n this, the II catheter in the left internal carotid artery was\n exchanged out for a Neuron MAX catheter. Following this, the aneurysm was\n catheterized with an SL-10 microcatheter and an exchange length wire was\n placed in the left middle cerebral artery. Following this, the aneurysm was\n coiled with Target coils starting with a 5 x 15 mm coil. At some point, it\n appeared that it would be difficult to seal the neck of the aneurysm without a\n stent. Therefore, using the exchange length wire, an XT 27 microcatheter was\n placed in the distal internal carotid artery and a Neuroform 4.5 x 20 mm stent\n (Over)\n\n 9:35 AM\n CAROT/CEREB Clip # \n Reason: cerebral angiogram- stent assisted coiling\n Admitting Diagnosis: BRAIN ANEURYSM/SDA\n Contrast: OPTIRAY Amt: OPT320=135,OPT240=170\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n was deployed. We now completed coiling of the aneurysm. Following this, the\n aneurysm was obliterated and the internal carotid artery was patent. On the\n lateral view, it appeared that there was some compromise of the caliber of the\n vessel. Following this, the right internal carotid artery was catheterized\n and AP and lateral filming done. This revealed that there was a 6-mm x 4-mm\n aneurysm of the right carotid ophthalmic segment pointing superiorly. We now\n placed a Neuron MAX in the right internal carotid artery and with some\n difficulty the right carotid ophthalmic aneurysm was catheterized with an\n SL-10 microcatheter. Following this, the aneurysm was coiled starting with\n 4-mm 360 UltraSoft Target coils and finishing with 2-mm UltraSoft coils.\n Though complete obliteration was not obtained, the dye was stagnant at the end\n of the procedure. We did not place a stent and completely obliterate the\n aneurysm as I felt that it was risky to place bilateral carotid stents.\n\n FINDINGS: Left internal carotid artery arteriogram demonstrates residual\n filling of the aneurysm. Left internal carotid artery arteriogram status post\n stent coil shows that the internal carotid artery is patent and the stent is\n in position. The aneurysm itself does not fill.\n\n Right internal carotid artery arteriogram demonstrated a 6 x 4-mm aneurysm of\n the supraclinoid carotid.\n\n Right internal carotid artery arteriogram status post coil embolization shows\n that the aneurysm is now completely obliterated.\n\n Right internal carotid artery arteriogram status post coil embolization shows\n that there is some residual flow into the right carotid ophthalmic aneurysm;\n however, the dye is stagnant and hopefully will thrombose once anticoagulation\n is withdrawn.\n\n IMPRESSION: underwent cerebral angiography and coiling of bilateral\n carotid ophthalmic artery aneurysms. A Neuroform stent was used on the right\n side. The left sided aneurysm still had contrast filling at the end of the\n procedure. However the dye was stagnant and it is expected to thrombose once\n anticoagulation is withdrawn.\n\n"
}
] |
15,343 | 167,018 | 49M with HTN and CAD s/p MI in with PCI of LAD and RCA, and CHF with LVEF 41% presents today at wife's insistence with 3 week history of intermittent shortness of breath and vague substernal chest pain. . # CHEST PAIN: History of progressive, worsening chest pain and shortness of breath in a patient with significant CAD and past MI highly concerning for unstable angina. Patient had a recent stress MIBI () that did not showed stable wall motion abnormalities with one small area of reversible ischemia that was also stable from prior. MI was ruled out with negative enzymes x3. EKG was unchanged from prior. PAtient was continued on ASA, Plavix, Statin, BB, . He had no furher episodes of chest pain and therefore was not started on heparin gtt. On HD 3 he went to the cath lab and had 2 DES to his RCA. His groin site was monitored and he had no evidence of hematoma, AV fistual and DP pulses were 2+. He was d/c'd th efollowing morning. . # Chronic Systolic Heart Failure: Patient with history of CHF following MI in . Last measured LVEF was 41%. No evidence of acute exaccerbation on exam. Patient appeared euvolemic, with normal JVP. He was continued on BB, . . # HTN: Continued on outpatient regimen of Carvedilol and Lisinopril. . | Patient appears euvolemic, with normal JVP. Patient appears euvolemic, with normal JVP. Patient appears euvolemic, with normal JVP. Patient appears euvolemic, with normal JVP. Patient appears euvolemic, with normal JVP. Dopamine gtt weaned off. Normal ascending aortadiameter. Checked overnite, and hematoma being reabsorbed, softer. CARDIAC CATH (): 1. CARDIAC CATH (): 1. Hypotension resolved. Hypotension resolved. Hypotension resolved. CARDIAC CATH 1. CARDIAC CATH 1. ABDOMEN: +BS, Soft, NTND. ABDOMEN: +BS, Soft, NTND. ABDOMEN: +BS, Soft, NTND. ABDOMEN: +BS, Soft, NTND. ABDOMEN: +BS, Soft, NTND. Coronary artery disease.Height: (in) 72Weight (lb): 210BSA (m2): 2.18 m2BP (mm Hg): 104/58HR (bpm): 73Status: InpatientDate/Time: at 12:05Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal aortic arch diameter.AORTIC VALVE: No AS.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No lower extremity edema. No lower extremity edema. No lower extremity edema. No lower extremity edema. No lower extremity edema. Am EKG. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: midanteroseptal - akinetic; anterior apex - akinetic; septal apex- akinetic;inferior apex - akinetic; lateral apex - akinetic; apex - dyskinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Excellent distal pulses bilaterally, warm lower extremity, no bruit ascultated over the cath sight. Excellent distal pulses bilaterally, warm lower extremity, no bruit ascultated over the cath sight. Excellent distal pulses bilaterally, warm lower extremity, no bruit ascultated over the cath sight. Excellent distal pulses bilaterally, warm lower extremity, no bruit ascultated over the cath sight. Excellent distal pulses bilaterally, warm lower extremity, no bruit ascultated over the cath sight. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. FINAL DIAGNOSIS: 1. FINAL DIAGNOSIS: 1. CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. CARDIAC: RRR, normal S1, S2. He is currently hemodynamically stable and asymptomatic, on low dose dopamine (2mcg/kg/min) with SBP 90-100 and HR 110-120 (sinus tach). Mild-moderateregional LV systolic dysfunction. There is no pericardial effusion.Compared with the prior study (images reviewed) of , LV systolicfunction appears similar although current images are technically suboptimalfor comparison. Q waves in V1-V3 stable from prior. Q waves in V1-V3 stable from prior. CONCLUSION: Normal examination. R fem angio site soft and non tender. R fem angio site soft and non tender. R fem angio site soft and non tender. Restart po diovan. Restart po diovan. Restart po diovan. Non-specific anterior repolarizationabnormalities. Sm amt of sanginous ooze noted. Sm amt of sanginous ooze noted. Sm amt of sanginous ooze noted. The mitral valve appearsstructurally normal with trivial mitral regurgitation. There is a moderate, mild fixed anteroseptal and inferoseptal defect. There is a moderate, mild fixed anteroseptal and inferoseptal defect. Anteroseptal myocardial infarction, age undetermined.Non-specific repolarizatin abnormalities. Weaned dopa to off. I would add the following remarks: Medical Decision Making Stable with no pressor requirement overnight. Anterior myocardial infarction, age undetermined.Non-specific repolarization abnormalities. Foley dcd. ACCESS: PIV's PROPHYLAXIS: -DVT ppx with SC heparin. ACCESS: PIV's PROPHYLAXIS: -DVT ppx with SC heparin. ACCESS: PIV's PROPHYLAXIS: -DVT ppx with SC heparin. ACCESS: PIV's PROPHYLAXIS: -DVT ppx with SC heparin. ACCESS: PIV's PROPHYLAXIS: -DVT ppx with SC heparin. Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. ------ Protected Section Addendum Entered By: , MD on: 10:52 ------ , M.D. + flatus, no bm. + flatus, no bm. + flatus, no bm. Prior anteroseptal myocardial infarction, age undetermined.Anterior repolarization abnormalities are non-specific. One vessel coronary artery disease. One vessel coronary artery disease. One vessel coronary artery disease. One vessel coronary artery disease. Sclera anicteric. Sclera anicteric. Sclera anicteric. Sclera anicteric. Sclera anicteric. # Hyperlipidemia - continue atorvastatin 80 . # Hyperlipidemia - continue atorvastatin 80 . # Hyperlipidemia - continue atorvastatin 80 . Abd aorta not enlarged by palpation. Abd aorta not enlarged by palpation. Abd aorta not enlarged by palpation. Abd aorta not enlarged by palpation. Abd aorta not enlarged by palpation. Started back on coreg. Action: Pt nauseous at beginning of shift, recd zofran w/ good results. Gated images reveals akinesis of the apex, hypokinesis of the distal anterior wall, and mild hypokinesis of the septum. Gated images reveals akinesis of the apex, hypokinesis of the distal anterior wall, and mild hypokinesis of the septum. HEENT: NCAT. HEENT: NCAT. HEENT: NCAT. HEENT: NCAT. HEENT: NCAT. No abdominial bruits. No abdominial bruits. No abdominial bruits. No abdominial bruits. No abdominial bruits. Selective coronary arteriography of this right dominant system revealed one vessel coronary artery disease. Selective coronary arteriography of this right dominant system revealed one vessel coronary artery disease. Compared to the previous tracingof there is no significant difference.TRACING #1 This AM patient without complaints. This AM patient without complaints. This AM patient without complaints. No c/o chest pain. No c/o chest pain. No TTP over costochondral articulations. No TTP over costochondral articulations. No TTP over costochondral articulations. No TTP over costochondral articulations. No TTP over costochondral articulations. Compared to the previous tracing of there is nosignificant difference.TRACING #1 | 17 | [
{
"category": "Echo",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Report",
"row_id": 67936,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease.\nHeight: (in) 72\nWeight (lb): 210\nBSA (m2): 2.18 m2\nBP (mm Hg): 104/58\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 12:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Mild-moderate\nregional LV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\nanteroseptal - akinetic; anterior apex - akinetic; septal apex- akinetic;\ninferior apex - akinetic; lateral apex - akinetic; apex - dyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is 0-5\nmmHg. There is severe symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild to moderate regional left\nventricular systolic dysfunction with mid to apical anteroseptal akinesis and\napical akinesis/dyskinesis. Right ventricular chamber size and free wall\nmotion are normal. There is no aortic valve stenosis. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The tricuspid valve\nleaflets are mildly thickened. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , LV systolic\nfunction appears similar although current images are technically suboptimal\nfor comparison.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 381606,
"text": "49 year-old man presented on to cardiology floor service for\n intermittent dyspnea/CP. Stable over weekend and taken to cardiac cath\n on - s/p 2 overlapping DES to distal RCA c/b hypotension,\n bradycardia when sheath exchanged. The patient developed a vagal\n episode with decrease in SBP to 75 mmHg and HR to 40s bpm, requiring 2\n mg of IV Atropine, IV fluid, and Dopamine in escalating doses up to 20\n mcg/kg/min with good response. Admitted to CCU for observation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Stable vitals. No c/o chest pain. Hypotension resolved. Dopamine gtt\n off since last night. Received low dose coreg last night. + flatus, no\n bm.\n Action:\n Received increase dose of coreg this am. Lytes repleted. R fem angio\n site soft and non tender. Sm amt of sanginous ooze noted. IVF hep\n locked. Ate 100% of breakfast this am. Foley dc\nd. Repeat echo obtained\n this am to compare to echo post-MI from .\n Response:\n SBP 90-110 this am. No ectopy. No change in angio drainage- transparent\n dsg remains intact.\n Plan:\n Transfer to 3. Restart po diovan. Pt due to void 1630-1830.\n Increase act as tol. Cardiology to determine whether pt will be\n discharged to home later today.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 96.2 kg\n Daily weight:\n 97.3 kg\n Allergies/Reactions:\n Morphine\n Nausea/Vomiting\n Precautions: No Additional Precautions\n CV-PMH: CAD, Hypertension\n Additional history: Dyslipidemia, s/p MI in s/p DES to LAD and RCA\n in , CPK peak of 3500 with ejection fraction of 41%\n Surgery / Procedure and date: cath stents from ' open, new\n distal RCA dz, DES placed.\n c/b vagal episode w/ sbp 60, required 3 amps atropine and started on\n dopamine. tx to CCU on 5 mcg/dopa. pain free.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:65\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,089 mL\n 24h total out:\n 1,445 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 06:15 AM\n Potassium:\n 3.7 mEq/L\n 06:15 AM\n Chloride:\n 102 mEq/L\n 06:15 AM\n CO2:\n 25 mEq/L\n 06:15 AM\n BUN:\n 21 mg/dL\n 06:15 AM\n Creatinine:\n 1.0 mg/dL\n 06:15 AM\n Glucose:\n 104 mg/dL\n 06:15 AM\n Hematocrit:\n 37.4 %\n 06:15 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 20g piv R arm , 20g piv L arm .\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: pt wearing yellow ring on L ring finger.\n Transferred from: ccu 718\n Transferred to: 3\n Date & time of Transfer: 1200\n"
},
{
"category": "Physician ",
"chartdate": "2145-08-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 381480,
"text": "Chief Complaint:\n HPI:\n Patient admitted from: Cardiac catherization lab\n History obtained from Medical records\n Allergies:\n Morphine\n Nausea/Vomiting\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 11:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 110 (92 - 115) bpm\n BP: 102/52(64) {93/52(29) - 104/69(73)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 72 Inch\n Total In:\n 367 mL\n PO:\n TF:\n IVF:\n 367 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -573 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 381482,
"text": "Chief Complaint:\n Hypotension/bradycardia during cardiac catheterization\n HPI:\n Please see admission note for full H/P. Briefly, 49 year-old man\n with HTN, Dyslipidemia and CAD s/p MI in s/p DES to LAD and RCA in\n , CPK peak of 3500 with ejection fraction of 41% presented on \n to cardiology floor service for intermittent dyspnea/CP. Stable over\n weekend and taken to cardiac cath on s/p 2 overlapping DES to\n distal RCA c/b hypotension, bradycardia. When sheath exchanged the\n patient developed a vagal episode with decrease in SBP to 75 mmHg and\n HR to 49 bpm, requiring 2 mg of IV Atropine, IV fluid, and Dopamine in\n escalating doses up to 20 mcg/kg/min with good response.\n .\n Admitted to CCU for observation, weaning off dopamine. Patient also on\n integrillin gtt post cath. On arrival to CCU, patient was asymptomatic,\n denying chest pain, shortness of breath, dizziness, or headache.\n Patient admitted from: Cardiac catherization lab\n History obtained from Medical records\n Allergies:\n Morphine\n Nausea/Vomiting\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 2 mcg/Kg/min\n Other ICU medications:\n Home medications:\n ATORVASTATIN - 80 mg DAILY\n CARVEDILOL - 6.25 mg \n CLOPIDOGREL - 75 mg DAILY\n DIOVAN - 80 mg DAILY\n NITROGLYCERIN - 0.3 mg SL prn\n ASPIRIN - 325MG DAILY\n ECHINACEA prn\n Medications on transfer:\n -Integrillin gtt\n -Lisinopril 10 mg PO DAILY\n -Aspirin 325 mg PO DAILY\n -Ranitidine 150 mg PO DAILY\n -Atorvastatin 80 mg PO DAILY\n -Carvedilol 6.25 mg PO BID\n - Dopamine gtt at 5\n -Atropine Sulfate at bedside 0.5 mg IV X1:PRN symptomatic bradycardia &\n hypotension repeat up to 2 mg total (including Atropine during\n procedure)\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n Anterior MI \n CHF since MI with initial EF 25%. Recent stress MIBI with LVEF 41%.\n -PERCUTANEOUS CORONARY INTERVENTIONS: Anterior MI s/p cypher\n stent to the LAD and elective cypher stent to the RCA the following\n week.\n 3. OTHER PAST MEDICAL HISTORY:\n s/p Remote tonsillectomy\n s/p Arthroscopic knee surgery (left)\n s/p Appendectomy\n s/p remote left ankle fracture\n Father with CAD, died from an MI age 70. Many (>10) cousins and\n extended family members with CAD and sudden cardiac death. He has\n cousins with arrhythmias.\n -Tobacco history: Past - 10 pack-year.\n -ETOH: Rare\n -Illicit drugs: None\n Review of systems:\n Otherwise negative\n Flowsheet Data as of 11:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 110 (92 - 115) bpm\n BP: 102/52(64) {93/52(29) - 104/69(73)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 72 Inch\n Total In:\n 367 mL\n PO:\n TF:\n IVF:\n 367 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -573 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n VS: T: 97.8 HR: 93 BP: 104/62 RR: 18 02sat: 97% RA\n GENERAL: Mildly overweight caucasian male in NAD. Oriented x3. Mood,\n affect appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n CHEST: No chest wall deformities, scoliosis or kyphosis. No TTP over\n costochondral articulations. Resp were unlabored, no accessory muscle\n use. CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged\n by palpation. No abdominial bruits.\n EXTREMITIES: Right groin with clean dry dressing sp catheterization.\n Excellent distal pulses bilaterally, warm lower extremity, no bruit\n ascultated over the cath sight. No lower extremity edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES: 2+ DP bilaterally\n Labs / Radiology\n EKG ( comparison): Post intervention sinus tachycardia at\n 102. Normal Axis. No hypertropy. Q waves in V1-V3 stable from prior.\n Poor R wave progression in lateral leads. TWI in V1- V2.\n .\n STRESS MIBI (): Resting and stress perfusion images reveal a\n severe fixed apical defect. There is a moderate, partially reversible\n defect of the distal anterior wall. There is a moderate, mild fixed\n anteroseptal and inferoseptal defect. Gated images reveals akinesis of\n the apex, hypokinesis of the distal anterior wall, and mild hypokinesis\n of the septum. The calculated left ventricular ejection fraction is\n 41%.\n .\n CARDIAC CATH ():\n 1. Selective coronary arteriography of this right dominant system\n revealed one vessel coronary artery disease. The LMCA had no flow\n liminations. The previously placed Cypher DES in the mid LAD had 20%\n residual stenosis thought to be caused by stent recoil and\n underexpansion. The LCX had mild luminal irregularities.\n The RCA had a 70% proximal lesion and mild luminal irregularities\n distally.\n 2. Successful POBA of the mid LAD stent with a 3.5 balloon and direct\n stenting of the proximal RCA with a 3.5x18mm Cypher to\n 4.0 (see PTCA comments).\n 3. Left femoral arteriotomy site was successfully closed with a 6F\n angioseal closure device.\n FINAL DIAGNOSIS:\n 1. One vessel coronary artery disease.\n 2. PCI of the LAD and RCA.\n 3. Angioseal placement.\n .\n CARDIAC CATH \n 1. One vessel coronary artery disease.\n 2. Sucecssful direct stenting of the distal RCA with two overlapping\n DES.\n 3. Vagal event following sheath exchange requiring IV fluids, Atropine\n and Dopamine.\n 4. Successful closure of the RCFA with a 6 French Angioseal.\n Assessment and Plan\n 49M with HTN and CAD s/p MI in with PCI of LAD and RCA, and CHF\n with LVEF 41% s/p cardiac cath and 2 overlapping DES to RCA c/b\n bradycardia/hypotension likely from vagal response admitted to CCU for\n observation and weaning off dopamine.\n .\n # TRANSIENT HYPOTENSION/BRADYCARDIA: Likely vagal response during\n sheath exchange during cardiac cath. By admission to floor, patient\n asymptomatic, on dopamine 5, HR in 90s.\n - monitor closely in CCU, monitor on telemetry\n - titrate down dopamine as tolerated\n - atropine at bedside for bradycardia\n - hold beta blocker, ACEi for now, but if HR remains stable, can\n restart slowly\n .\n # CORONARIES: Presented with UA/NSTEMI and now s/p 2 overlapping DES to\n distal RCA in cath lab today.\n - Fu final cath report\n - integrillin gtt for 18 hours\n - continue ASA, Plavix, Statin\n - hold beta blocker, ACEi for now, but if HR remains stable, can\n restart in AM (prior to cath was on Carvedilol 6.25 mg PO BID,\n Lisinopril 10)\n - trend post procedures CKs until peak\n .\n # PUMP: Patient with history of CHF following MI in . Last measured\n LVEF was 41%. No evidence of pump failure on exam. Patient appears\n euvolemic, with normal JVP.\n - Continue blood pressure management with BB, ACE-i\n - Consider TTE to assess LV function\n .\n # HTN: Hold BP meds overnight, restart in AM\n .\n # Hyperlipidemia\n - continue atorvastatin 80\n .\n FEN: Cardiac/Heart-healthy diet post procedure.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin.\n -Bowel regimen with colace, senna\n CODE: FULL CODE, ICU consent signed\n COMM: (wife) , \n DISPO: CCU for now, if stable and off pressors, can call back out to\n 3 service\n ICU Care\n Nutrition: Cardiac/Heart-healthy diet post procedure.\n Glycemic Control:\n Lines:\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Sc heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: (wife) , \n Code status: FULL CODE, ICU consent signed\n Disposition: CCU for now, if stable and off pressors, can call back out\n to 3 service\n"
},
{
"category": "Physician ",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 381483,
"text": "Chief Complaint:\n Hypotension/bradycardia during cardiac catheterization\n HPI:\n Please see admission note for full H/P. Briefly, 49 year-old man\n with HTN, Dyslipidemia and CAD s/p MI in s/p DES to LAD and RCA in\n , CPK peak of 3500 with ejection fraction of 41% presented on \n to cardiology floor service for intermittent dyspnea/CP. Stable over\n weekend and taken to cardiac cath on s/p 2 overlapping DES to\n distal RCA c/b hypotension, bradycardia. When sheath exchanged the\n patient developed a vagal episode with decrease in SBP to 75 mmHg and\n HR to 49 bpm, requiring 2 mg of IV Atropine, IV fluid, and Dopamine in\n escalating doses up to 20 mcg/kg/min with good response.\n .\n Admitted to CCU for observation, weaning off dopamine. Patient also on\n integrillin gtt post cath. On arrival to CCU, patient was asymptomatic,\n denying chest pain, shortness of breath, dizziness, or headache.\n Patient admitted from: Cardiac catherization lab\n History obtained from Medical records\n Allergies:\n Morphine\n Nausea/Vomiting\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Dopamine - 2 mcg/Kg/min\n Other ICU medications:\n Home medications:\n ATORVASTATIN - 80 mg DAILY\n CARVEDILOL - 6.25 mg \n CLOPIDOGREL - 75 mg DAILY\n DIOVAN - 80 mg DAILY\n NITROGLYCERIN - 0.3 mg SL prn\n ASPIRIN - 325MG DAILY\n ECHINACEA prn\n Medications on transfer:\n -Integrillin gtt\n -Lisinopril 10 mg PO DAILY\n -Aspirin 325 mg PO DAILY\n -Ranitidine 150 mg PO DAILY\n -Atorvastatin 80 mg PO DAILY\n -Carvedilol 6.25 mg PO BID\n - Dopamine gtt at 5\n -Atropine Sulfate at bedside 0.5 mg IV X1:PRN symptomatic bradycardia &\n hypotension repeat up to 2 mg total (including Atropine during\n procedure)\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension\n 2. CARDIAC HISTORY:\n Anterior MI \n CHF since MI with initial EF 25%. Recent stress with LVEF 41%.\n -PERCUTANEOUS CORONARY INTERVENTIONS: Anterior MI s/p cypher\n stent to the LAD and elective cypher stent to the RCA the following\n week.\n 3. OTHER PAST MEDICAL HISTORY:\n s/p Remote tonsillectomy\n s/p Arthroscopic knee surgery (left)\n s/p Appendectomy\n s/p remote left ankle fracture\n Father with CAD, died from an MI age 70. Many (>10) cousins and\n extended family members with CAD and sudden cardiac death. He has\n cousins with arrhythmias.\n -Tobacco history: Past - 10 pack-year.\n -ETOH: Rare\n -Illicit drugs: None\n Review of systems:\n Otherwise negative\n Flowsheet Data as of 11:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 110 (92 - 115) bpm\n BP: 102/52(64) {93/52(29) - 104/69(73)} mmHg\n RR: 25 (11 - 26) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 72 Inch\n Total In:\n 367 mL\n PO:\n TF:\n IVF:\n 367 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 940 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -573 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n VS: T: 97.8 HR: 93 BP: 104/62 RR: 18 02sat: 97% RA\n GENERAL: Mildly overweight caucasian male in NAD. Oriented x3. Mood,\n affect appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Supple with JVP of 6 cm.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n CHEST: No chest wall deformities, scoliosis or kyphosis. No TTP over\n costochondral articulations. Resp were unlabored, no accessory muscle\n use. CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged\n by palpation. No abdominial bruits.\n EXTREMITIES: Right groin with clean dry dressing sp catheterization.\n Excellent distal pulses bilaterally, warm lower extremity, no bruit\n ascultated over the cath sight. No lower extremity edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES: 2+ DP bilaterally\n Labs / Radiology\n EKG ( comparison): Post intervention sinus tachycardia at\n 102. Normal Axis. No hypertropy. Q waves in V1-V3 stable from prior.\n Poor R wave progression in lateral leads. TWI in V1- V2.\n .\n STRESS (): Resting and stress perfusion images reveal a\n severe fixed apical defect. There is a moderate, partially reversible\n defect of the distal anterior wall. There is a moderate, mild fixed\n anteroseptal and inferoseptal defect. Gated images reveals akinesis of\n the apex, hypokinesis of the distal anterior wall, and mild hypokinesis\n of the septum. The calculated left ventricular ejection fraction is\n 41%.\n .\n CARDIAC CATH ():\n 1. Selective coronary arteriography of this right dominant system\n revealed one vessel coronary artery disease. The LMCA had no flow\n liminations. The previously placed Cypher DES in the mid LAD had 20%\n residual stenosis thought to be caused by stent recoil and\n underexpansion. The LCX had mild luminal irregularities.\n The RCA had a 70% proximal lesion and mild luminal irregularities\n distally.\n 2. Successful POBA of the mid LAD stent with a 3.5 balloon and direct\n stenting of the proximal RCA with a 3.5x18mm Cypher to\n 4.0 (see PTCA comments).\n 3. Left femoral arteriotomy site was successfully closed with a 6F\n angioseal closure device.\n FINAL DIAGNOSIS:\n 1. One vessel coronary artery disease.\n 2. PCI of the LAD and RCA.\n 3. Angioseal placement.\n .\n CARDIAC CATH \n 1. One vessel coronary artery disease.\n 2. Sucecssful direct stenting of the distal RCA with two overlapping\n DES.\n 3. Vagal event following sheath exchange requiring IV fluids, Atropine\n and Dopamine.\n 4. Successful closure of the RCFA with a 6 French Angioseal.\n Assessment and Plan\n 49M with HTN and CAD s/p MI in with PCI of LAD and RCA, and CHF\n with LVEF 41% s/p cardiac cath and 2 overlapping DES to RCA c/b\n bradycardia/hypotension likely from vagal response admitted to CCU for\n observation and weaning off dopamine.\n .\n # TRANSIENT HYPOTENSION/BRADYCARDIA: Likely vagal response during\n sheath exchange during cardiac cath. By admission to floor, patient\n asymptomatic, on dopamine 5, HR in 90s.\n - monitor closely in CCU, monitor on telemetry\n - titrate down dopamine as tolerated\n - atropine at bedside for bradycardia\n - hold beta blocker, ACEi for now, but if HR remains stable, can\n restart slowly\n .\n # CORONARIES: Presented with UA/NSTEMI and now s/p 2 overlapping DES to\n distal RCA in cath lab today.\n - Fu final cath report\n - integrillin gtt for 18 hours\n - continue ASA, Plavix, Statin\n - hold beta blocker, ACEi for now, but if HR remains stable, can\n restart in AM (prior to cath was on Carvedilol 6.25 mg PO BID,\n Lisinopril 10)\n - trend post procedures CKs until peak\n .\n # PUMP: Patient with history of CHF following MI in . Last measured\n LVEF was 41%. No evidence of pump failure on exam. Patient appears\n euvolemic, with normal JVP.\n - Continue blood pressure management with BB, ACE-i\n - Consider TTE to assess LV function\n .\n # HTN: Hold BP meds overnight, restart in AM\n .\n # Hyperlipidemia\n - continue atorvastatin 80\n .\n FEN: Cardiac/Heart-healthy diet post procedure.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin.\n -Bowel regimen with colace, senna\n CODE: FULL CODE, ICU consent signed\n COMM: (wife) , \n DISPO: CCU for now, if stable and off pressors, can call back out to\n 3 service\n ICU Care\n Nutrition: Cardiac/Heart-healthy diet post procedure.\n Glycemic Control:\n Lines:\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Sc heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: (wife) , \n Code status: FULL CODE, ICU consent signed\n Disposition: CCU for now, if stable and off pressors, can call back out\n to 3 service\n ------ Protected Section ------\n Cardiology Fellow Addendum:\n Pt seen and examined, and discussed with CCU housestaff. Briefly, this\n is a 49yo male with HTN, HL, and CAD s/p AMI in s/p cypher to mLAD\n followed by cypher to pRCA, who presented with persisting intermittent\n nonexertional SSCP. He had recent ETT- (no priors for\n comparison) where he exercised 11 min on protocol (12 METS), with\n imaging showing a severe fixed apical defect, and moderate partially\n reversible defect of distal anterior wall and moderate, mild fixed\n anteroseptal and inferoseptal defects; the LEVF was 41%. He underwent\n cardiac cath today, and had 2 overlapping Cypher stents to the distal\n RCA (filling defect with plaque rupture), with the\n procedure complicated by hypotension and bradycardia to 50s during\n sheath exchange. He received atropine (1mg IV x 3) and was started on\n dopamine in cath lab. He is admitted to the CCU for overnight\n monitoring. He is currently hemodynamically stable and asymptomatic, on\n low dose dopamine (2mcg/kg/min) with SBP 90-100 and HR 110-120 (sinus\n tach). His exam is notable for clear lungs, tachycardic HR with mild\n SEM RLSB, and slight right groin ooze at the site of angioseal\n placement. Distal pulses are palpable and symmetric. Overnight, we will\n likely be able to wean off the dopamine (his baseline SBP is ~100 per\n pt report). He will continue on ASA, plavix, statin (Integrilin is\n off), and if his heart rate remains elevated off the dopamine, we will\n restart his carvedilol given sufficient BP room. The balance of the\n plans is as per CCU housestaff.\n , M.D.\n #\n ------ Protected Section Addendum Entered By: , MD\n on: 00:57 ------\n"
},
{
"category": "Physician ",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 381588,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient developed some bleeding from gums/cath site, integrillin\n stopped, bleeding improved.\n - Overnight, patient weaned off dopamine gtt at 10pm, given one time\n dose of coreg 3.125mg x 1 overnight, restarted on 6.25 starting in\n AM.\n - Small hematoma developed at Cath Site late last night, decreased\n overnight.\n This AM patient without complaints. No pain at cath site. No chest\n pain/shortness of breath/diaphoresis.\n Allergies:\n Morphine\n Nausea/Vomiting\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 73 (73 - 115) bpm\n BP: 92/49(59) {91/49(29) - 125/69(79)} mmHg\n RR: 16 (11 - 26) insp/min\n SpO2: 95% on RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 903 mL\n 531 mL\n PO:\n 500 mL\n TF:\n IVF:\n 403 mL\n 531 mL\n Blood products:\n Total out:\n 1,280 mL\n 605 mL\n Urine:\n 1,280 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n -377 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95% on RA\n ABG: ////\n Physical Examination\n GENERAL: Mildly overweight caucasian male in NAD. Oriented x3. Mood,\n affect appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma. No bleeding from the\n gums.\n NECK: Supple with JVP of 6 cm.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n CHEST: No chest wall deformities, scoliosis or kyphosis. No TTP over\n costochondral articulations. Resp were unlabored, no accessory muscle\n use. CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged\n by palpation. No abdominial bruits.\n EXTREMITIES: Right groin with clean dry dressing sp catheterization.\n Small quarter size hematoma which has decreased in size overnight.\n Excellent distal pulses bilaterally, warm lower extremity, no bruit\n ascultated over the cath sight. No lower extremity edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES: 2+ DP bilaterally\n Labs / Radiology\n 167 K/uL\n 13.3*\n 104\n 1.0 mg/dL\n 25\n 3.7 mEq/L\n 21 mg/dL\n 102\n 135\n 37.4* %\n 11.6*\n [image002.jpg]\n 12:00 AM\n Hct\n 40.1\n Plt\n 200\n Cr\n 1.1\n Other labs: CK / CKMB / Troponin-T:73//, Mg++:1.7 mg/dL\n Assessment and Plan\n 49M with HTN and CAD s/p MI in with PCI of LAD and RCA, and CHF\n with LVEF 41% s/p cardiac cath and 2 overlapping DES to RCA c/b\n bradycardia/hypotension likely from vagal response admitted to CCU for\n observation and weaning off dopamine.\n .\n # TRANSIENT HYPOTENSION/BRADYCARDIA: Likely vagal response during\n sheath exchange during cardiac cath. Patient weaned from Dopamine last\n night. Given 3.125 mg Coreg last night.\n - Monitor closely on telemetry\n - Can be discharged home today as patient is doing well\n - Continue with Coreg 6.25 mg Daily\n - Will restart his Diovan today\n .\n # CORONARIES: Presented with UA/NSTEMI and now s/p 2 overlapping DES to\n distal RCA in cath lab today. Integrillin stopped secondary to bleeding\n from the gums/cath site. CK trending down sp cath to 73 peak of 141.\n - FU final cath report\n - Continue ASA, Plavix, Statin\n - Carvedilol 6.25 mg PO BID\n - Restart Diovan today\n .\n # PUMP: Patient with history of CHF following MI in . Last measured\n LVEF was 41%. No evidence of pump failure on exam. Patient appears\n euvolemic, with normal JVP.\n - Continue blood pressure management with BB, ACE-i\n - No enzyme leak, but last echo in so will get follow-up TTE to\n assess LV function\n .\n # HTN: Beta-Blocker restarted overnight, restart ACE-I today per wishes\n of team.\n .\n # Hypokalemia\n K+ 3.7 this morning, will replete with 40mEq po. Also\n will replace Mag as low at 1.7 this morning.\n # Hyperlipidemia\n - continue atorvastatin 80\n # Urine function\n will d/c foley today\n .\n FEN: Cardiac/Heart-healthy diet procedure.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin.\n -Bowel regimen with colace, senna\n CODE: FULL CODE, ICU consent signed\n COMM: (wife) , \n DISPO: Like home today\n ICU Care\n Nutrition:\n Glycemic Control: None\n Lines:\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC Heparin TID\n Stress ulcer: Not High Risk\n Comments:\n Communication: Comments: (wife) \n Code status: Full code, ICU consent signed\n Disposition: CCU for now, if stable and off pressors, can call back out\n to 3 service\n"
},
{
"category": "Physician ",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 381596,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient developed some bleeding from gums/cath site, integrillin\n stopped, bleeding improved.\n - Overnight, patient weaned off dopamine gtt at 10pm, given one time\n dose of coreg 3.125mg x 1 overnight, restarted on 6.25 starting in\n AM.\n - Small hematoma developed at Cath Site late last night, decreased\n overnight.\n This AM patient without complaints. No pain at cath site. No chest\n pain/shortness of breath/diaphoresis.\n Allergies:\n Morphine\n Nausea/Vomiting\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 73 (73 - 115) bpm\n BP: 92/49(59) {91/49(29) - 125/69(79)} mmHg\n RR: 16 (11 - 26) insp/min\n SpO2: 95% on RA\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 903 mL\n 531 mL\n PO:\n 500 mL\n TF:\n IVF:\n 403 mL\n 531 mL\n Blood products:\n Total out:\n 1,280 mL\n 605 mL\n Urine:\n 1,280 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n -377 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95% on RA\n ABG: ////\n Physical Examination\n GENERAL: Mildly overweight caucasian male in NAD. Oriented x3. Mood,\n affect appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma. No bleeding from the\n gums.\n NECK: Supple with JVP of 6 cm.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n CHEST: No chest wall deformities, scoliosis or kyphosis. No TTP over\n costochondral articulations. Resp were unlabored, no accessory muscle\n use. CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged\n by palpation. No abdominial bruits.\n EXTREMITIES: Right groin with clean dry dressing sp catheterization.\n Small quarter size hematoma which has decreased in size overnight.\n Excellent distal pulses bilaterally, warm lower extremity, no bruit\n ascultated over the cath sight. No lower extremity edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES: 2+ DP bilaterally\n Labs / Radiology\n 167 K/uL\n 13.3*\n 104\n 1.0 mg/dL\n 25\n 3.7 mEq/L\n 21 mg/dL\n 102\n 135\n 37.4* %\n 11.6*\n [image002.jpg]\n 12:00 AM\n Hct\n 40.1\n Plt\n 200\n Cr\n 1.1\n Other labs: CK / CKMB / Troponin-T:73//, Mg++:1.7 mg/dL\n Assessment and Plan\n 49M with HTN and CAD s/p MI in with PCI of LAD and RCA, and CHF\n with LVEF 41% s/p cardiac cath and 2 overlapping DES to RCA c/b\n bradycardia/hypotension likely from vagal response admitted to CCU for\n observation and weaning off dopamine.\n .\n # TRANSIENT HYPOTENSION/BRADYCARDIA: Likely vagal response during\n sheath exchange during cardiac cath. Patient weaned from Dopamine last\n night. Given 3.125 mg Coreg last night.\n - Monitor closely on telemetry\n - Can be discharged home today as patient is doing well\n - Continue with Coreg 6.25 mg Daily\n - Will restart his Diovan today\n .\n # CORONARIES: Presented with UA/NSTEMI and now s/p 2 overlapping DES to\n distal RCA in cath lab today. Integrillin stopped secondary to bleeding\n from the gums/cath site. CK trending down sp cath to 73 peak of 141.\n - FU final cath report\n - Continue ASA, Plavix, Statin\n - Carvedilol 6.25 mg PO BID\n - Restart Diovan today\n .\n # PUMP: Patient with history of CHF following MI in . Last measured\n LVEF was 41%. No evidence of pump failure on exam. Patient appears\n euvolemic, with normal JVP.\n - Continue blood pressure management with BB, ACE-i\n - No enzyme leak, but last echo in so will get follow-up TTE to\n assess LV function\n .\n # HTN: Beta-Blocker restarted overnight, restart ACE-I today per wishes\n of team.\n .\n # Hypokalemia\n K+ 3.7 this morning, will replete with 40mEq po. Also\n will replace Mag as low at 1.7 this morning.\n # Hyperlipidemia\n - continue atorvastatin 80\n # Urine function\n will d/c foley today\n .\n FEN: Cardiac/Heart-healthy diet procedure.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin.\n -Bowel regimen with colace, senna\n CODE: FULL CODE, ICU consent signed\n COMM: (wife) , \n DISPO: Like home today\n ICU Care\n Nutrition:\n Glycemic Control: None\n Lines:\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC Heparin TID\n Stress ulcer: Not High Risk\n Comments:\n Communication: Comments: (wife) \n Code status: Full code, ICU consent signed\n Disposition: CCU for now, if stable and off pressors, can call back out\n to 3 service\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Stable with no pressor requirement overnight. No hypotension and no\n evidence of bleeding. Call out to floor today.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:52 ------\n"
},
{
"category": "Nursing",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 381599,
"text": "Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Stable vitals. Hypotension resolved. Dopamine gtt off since last night.\n Received low dose coreg last night. + flatus, no bm.\n Action:\n Received increase dose of coreg this am. Lytes repleted. R fem angio\n site soft and non tender. Sm amt of sanginous ooze noted. IVF hep\n locked. Ate 100% of breakfast this am. Foley dc\n Response:\n SBP 90-110 this am. No ectopy. No change in angio drainage- transparent\n dsg remains intact.\n Plan:\n Transfer to 3. Restart po diovan. Pt due to void 1630-1830.\n Increase act as tol. Cardiology to determine whether pt will be\n discharged to home later today.\n"
},
{
"category": "Nursing",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 381602,
"text": "49 year-old man presented on to cardiology floor service for\n intermittent dyspnea/CP. Stable over weekend and taken to cardiac cath\n on - s/p 2 overlapping DES to distal RCA c/b hypotension,\n bradycardia when sheath exchanged. The patient developed a vagal\n episode with decrease in SBP to 75 mmHg and HR to 40s bpm, requiring 2\n mg of IV Atropine, IV fluid, and Dopamine in escalating doses up to 20\n mcg/kg/min with good response. Admitted to CCU for observation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Stable vitals. No c/o chest pain. Hypotension resolved. Dopamine gtt\n off since last night. Received low dose coreg last night. + flatus, no\n bm.\n Action:\n Received increase dose of coreg this am. Lytes repleted. R fem angio\n site soft and non tender. Sm amt of sanginous ooze noted. IVF hep\n locked. Ate 100% of breakfast this am. Foley dc\n Response:\n SBP 90-110 this am. No ectopy. No change in angio drainage- transparent\n dsg remains intact.\n Plan:\n Transfer to 3. Restart po diovan. Pt due to void 1630-1830.\n Increase act as tol. Cardiology to determine whether pt will be\n discharged to home later today.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 96.2 kg\n Daily weight:\n 97.3 kg\n Allergies/Reactions:\n Morphine\n Nausea/Vomiting\n Precautions: No Additional Precautions\n CV-PMH: CAD, Hypertension\n Additional history: Dyslipidemia, s/p MI in s/p DES to LAD and RCA\n in , CPK peak of 3500 with ejection fraction of 41%\n Surgery / Procedure and date: cath stents from ' open, new\n distal RCA dz, DES placed.\n c/b vagal episode w/ sbp 60, required 3 amps atropine and started on\n dopamine. tx to CCU on 5 mcg/dopa. pain free.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:65\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,089 mL\n 24h total out:\n 1,445 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 06:15 AM\n Potassium:\n 3.7 mEq/L\n 06:15 AM\n Chloride:\n 102 mEq/L\n 06:15 AM\n CO2:\n 25 mEq/L\n 06:15 AM\n BUN:\n 21 mg/dL\n 06:15 AM\n Creatinine:\n 1.0 mg/dL\n 06:15 AM\n Glucose:\n 104 mg/dL\n 06:15 AM\n Hematocrit:\n 37.4 %\n 06:15 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 20g piv R arm , 20g piv L arm .\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: pt wearing yellow ring on L ring finger.\n Transferred from: ccu 718\n Transferred to: 3\n Date & time of Transfer: \n"
},
{
"category": "Physician ",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 381571,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient developed some bleeding from gums/cath site, integrillin\n stopped, bleeding improved\n - Overnight, patient weaned off dopamine gtt at 10pm, given one time\n dose of coreg 3.125mg x 1 overnight, restarted on 6.25 starting in\n AM.\n - Small hematoma developed at Cath Site late last night, decreased\n overnight.\n This AM patient without complaints. No pain at cath site. No chest\n pain/shortness of breath/diaphoresis .\n Allergies:\n Morphine\n Nausea/Vomiting\n Lisinopril\n Cough;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.6\n HR: 73 (73 - 115) bpm\n BP: 92/49(59) {91/49(29) - 125/69(79)} mmHg\n RR: 16 (11 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 903 mL\n 531 mL\n PO:\n 500 mL\n TF:\n IVF:\n 403 mL\n 531 mL\n Blood products:\n Total out:\n 1,280 mL\n 605 mL\n Urine:\n 1,280 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n -377 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ////\n Physical Examination\n GENERAL: Mildly overweight caucasian male in NAD. Oriented x3. Mood,\n affect appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma. No bleeding from the\n gums.\n NECK: Supple with JVP of 6 cm.\n CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n CHEST: No chest wall deformities, scoliosis or kyphosis. No TTP over\n costochondral articulations. Resp were unlabored, no accessory muscle\n use. CTAB, no crackles, wheezes or rhonchi.\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged\n by palpation. No abdominial bruits.\n EXTREMITIES: Right groin with clean dry dressing sp catheterization.\n Small quarter size hematoma which has decreased in size overnight.\n Excellent distal pulses bilaterally, warm lower extremity, no bruit\n ascultated over the cath sight. No lower extremity edema.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES: 2+ DP bilaterally\n Labs / Radiology\n 167 K/uL\n 13.3*\n 1.1 mg/dL\n 4.0 mEq/L\n 21 mg/dL\n 37.4* %\n 11.6*\n [image002.jpg]\n 12:00 AM\n Hct\n 40.1\n Plt\n 200\n Cr\n 1.1\n Other labs: CK / CKMB / Troponin-T:73//, Mg++:1.9 mg/dL\n Assessment and Plan\n 49M with HTN and CAD s/p MI in with PCI of LAD and RCA, and CHF\n with LVEF 41% s/p cardiac cath and 2 overlapping DES to RCA c/b\n bradycardia/hypotension likely from vagal response admitted to CCU for\n observation and weaning off dopamine.\n .\n # TRANSIENT HYPOTENSION/BRADYCARDIA: Likely vagal response during\n sheath exchange during cardiac cath. Patient weaned from Dopamine last\n night. Given 3.125 mg Coreg last night.\n - Monitor closely in CCU, monitor on telemetry\n - Continue with Coreg 6.25 mg Daily\n - Restart Lisinopril 10mg Daily\n .\n # CORONARIES: Presented with UA/NSTEMI and now s/p 2 overlapping DES to\n distal RCA in cath lab today. Integrillin stopped secondary to bleeding\n from the gums/cath site. CK trending down sp cath to 73 peak of 141.\n - Fu final cath report\n - continue ASA, Plavix, Statin\n - Carvedilol 6.25 mg PO BID\n - Restart Lisinopril 10mg Daily\n .\n # PUMP: Patient with history of CHF following MI in . Last measured\n LVEF was 41%. No evidence of pump failure on exam. Patient appears\n euvolemic, with normal JVP.\n - Continue blood pressure management with BB, ACE-i\n - Consider TTE to assess LV function\n .\n # HTN: Beta-Blocker restarted overnight, restart ACE-I today.\n .\n # Hyperlipidemia\n - continue atorvastatin 80\n .\n FEN: Cardiac/Heart-healthy diet procedure.\n ACCESS: PIV's\n PROPHYLAXIS:\n -DVT ppx with SC heparin.\n -Bowel regimen with colace, senna\n CODE: FULL CODE, ICU consent signed\n COMM: (wife) , \n DISPO: CCU for now, if stable and off pressors, can call back out to\n 3 service\n ICU Care\n Nutrition:\n Glycemic Control: None\n Lines:\n 20 Gauge - 06:00 PM\n Prophylaxis:\n DVT: SC Heparin TID\n Stress ulcer: Not High Risk\n Comments:\n Communication: Comments: (wife) \n Code status: Full code, ICU consent signed\n Disposition: CCU for now, if stable and off pressors, can call back out\n to 3 service\n"
},
{
"category": "Nursing",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 381513,
"text": "49 year-old man with HTN, Dyslipidemia and CAD s/p MI in s/p DES\n to LAD and RCA in , CPK peak of 3500 with ejection fraction of 41%\n presented on to cardiology floor service for intermittent\n dyspnea/CP. Stable over weekend and taken to cardiac cath on s/p 2\n overlapping DES to distal RCA c/b hypotension, bradycardia. When sheath\n exchanged the patient developed a vagal episode with decrease in SBP to\n 75 mmHg and HR to 49 bpm, requiring 2 mg of IV Atropine, IV fluid, and\n Dopamine in escalating doses up to 20 mcg/kg/min with good response.\n Admitted to CCU for observation, weaning off dopamine @ 5mcg/kg/min,\n integrillin but gtt d/c\nd shortly after arrival in CCU due to bleeding\n gums and ooze to Rt groin angioseal site. Dopamine gtt weaned off.\n Started back on coreg.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Dopamine @ 5mcg/kg/min. SBP 90-100s. ST 100-110s. no c/o CP or\n discomfort. Integrillin gtt remains off due to bleeding gums. Rt groin\n site with ooze. No hematoma. Palpable pulses.\n Action:\n Pt nauseous at beginning of shift, rec\nd zofran w/ good results. Weaned\n dopa to off. Pt stating his normal BP 90-100s. ST 100s. dsg changed to\n Rt groin site.\n Response:\n VSS. BP increased. Pt OOB to bathroom at midnite\n passing ++flatus, no\n BM. Post trip to bathroom, noted small quarter sized soft, nontender\n hematoma at groin site. CCU team aware. Checked overnite, and hematoma\n being reabsorbed, softer. Palpable pulses.\n Plan:\n Awaiting am labs. Am EKG. ? c/o to floor. Monitor groin site. Cardiac\n teaching.\n"
},
{
"category": "ECG",
"chartdate": "2145-08-24 00:00:00.000",
"description": "Report",
"row_id": 162231,
"text": "Sinus rhythm. Prior anteroseptal myocardial infarction, age undetermined.\nAnterior repolarization abnormalities are non-specific. Compared to the\nprevious tracing the rate has slowed.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-23 00:00:00.000",
"description": "Report",
"row_id": 162232,
"text": "Sinus tachycardia. Prior anterior myocardial infarction, age undetermined.\nCompared to the previous tracing the rate has increased somewhat.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-23 00:00:00.000",
"description": "Report",
"row_id": 162233,
"text": "Sinus rhythm. Wandering baseline. Delayed R wave progression may signify\nprior anteroseptal myocardial infarction. Non-specific anterior repolarization\nabnormalities. Compared to the previous tracing of there is no\nsignificant difference.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-20 00:00:00.000",
"description": "Report",
"row_id": 162234,
"text": "Sinus rhythm. Anterior myocardial infarction, age undetermined.\nNon-specific repolarization abnormalities. Compared to the previous tracing\nthere is no significant difference.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-20 00:00:00.000",
"description": "Report",
"row_id": 162235,
"text": "Sinus rhythm. Anteroseptal myocardial infarction, age undetermined.\nNon-specific repolarizatin abnormalities. Compared to the previous tracing\nof there is no significant difference.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-08-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1087803,
"text": " 2:59 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate, pulm edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with significant CAD p/w SOB and intermittent CP, recent fever\n and URI sx\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY, PA AND LATERAL\n\n REASON FOR EXAM: 49-year-old woman with intermittent chest pain. Evaluate\n for infiltrate.\n\n FINDINGS: The lungs are clear with no mass, pleural effusion, pneumothorax or\n consolidation. Heart and mediastinal structures are normal.\n\n CONCLUSION: Normal examination.\n\n\n"
}
] |
68,602 | 182,991 | 1. Diabetic Ketoacidosis: His DKA was most likely due to not taking any insulin for 3 days PTA. His initial leukocytosis suggested a possible infectious source, but blood cultures were negative, urine culture grew only mixed flora, and CXR was clear. His WBC count rapidly normalized during his stay. He ruled out for MI with three sets of cardiac enzymes, though initial EKG showed lateral depressions. team was following. He was treated with IVF and Insulin gtt, with serial labs. His initial anion gap closed, and he appeared clinically well. He was transitioned to Lantus SC QHS with a Humalog sliding scale, and transferred to the floor. His glucose levels remained somewhat labile, but was otherwise at baseline. He was discharged on Lantus 12 units QAM with a Humalog sliding scale TID. Followup appointments were scheduled with his PCP and with the Diabetes Center. 2. UTI: His UA on admission was unremarkable and grew only mixed flora consistent with fecal contamination. Repeat UA the next day, however, was positive with WBC 21-50, mod bacteria, mod LE, and pos nitrite. He was started on Ciprofloxacin 500 mg PO Q12H on for an apparent UTI. Cultures were later negative for both samples and Ciprofloxacin was discontinued on . 3. Leukocytosis: His WBC count was 30.4 on admission, but dropped to 16.7 the next day, and then to 9.9 the day after. His WBC count was 4.6 by the day of discharge and he had no localizing symptoms on exam. Blood cultures showed no growth and urine cultures showed only fecal contamination. CXR on admission showed no acute process. His WBC count elevation was likely secondary to stress response from his DKA and severe dehydration on admission. 4. Hypertension: His home Lisinopril 10 mg PO daily was held on admission. He did reach SBP 160 on , but was later close to normotensive. He was restarted on Lisinopril 10 mg PO daily prior to discharge. 5. Chronic Pain: Previous discharges showed Oxycodone and MS Contin. These were continued during his stay. 6. Dispo: Patient is currently homeless, and has been staying in a hotel. He reports multiple problems in past dealings with the Housing Authority. Social work consult was requested, and he was seen on . He refused discharge to a rehab facility against medical advice. Multiple discussions were held with the patient regarding the importance of his insulin injections. His post discharge care was discussed in detail with his significant other, , who agreed to assist him with his insulin injections. | Non-specific ST segment changes. Non-specific ST-T wave changes. Compared to theprevious tracing of anterior Q waves are new and right axis deviationis no longer present. Compared to the previoustracing of no definite change. Sinus rhythm. Sinus tachycardia. | 2 | [
{
"category": "ECG",
"chartdate": "2122-12-30 00:00:00.000",
"description": "Report",
"row_id": 280367,
"text": "Sinus rhythm. Non-specific ST segment changes. Compared to the previous\ntracing of no definite change.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-12-30 00:00:00.000",
"description": "Report",
"row_id": 280368,
"text": "Sinus tachycardia. There are Q waves in the anterior leads consistent with\nprior myocardial infarction. Non-specific ST-T wave changes. Compared to the\nprevious tracing of anterior Q waves are new and right axis deviation\nis no longer present.\n\n"
}
] |
4,557 | 169,275 | # Hypotension, concern for GI bleed - Blood pressure appeared to be at her baseline per ED records and according to her is similar to her baseline. Her blood pressure remained stable at all times. She was transferred to the ICU where HCT's were obtained q 6H. She was not transfused. Access was maintained via 2 IV's and the dialysis catheter. She received PPI IV BID. GI was consulted and performed a colonoscopy. The patient's initial INR was 1.9 so she was given 5 mg po vitamin K for reversal prior to colonoscopy and prep with Magnesium Citrate. The colonoscopy showed a small rectal ulcer. The patient will need to follow up with a flexible sigmoidoscopy in weeks as an outpatient. She should continue colace 200-400 mg until then. She can restart coumadin and aspirin now. . # ESRD: The patient received hemodialysis on with no complications via the catheter. Renal was consulted and recommended a fistulogram, which could not be performed during hospitalization, so she should have this arranged as an outpatient and receive dialysis through the catheter until then. | OOB to bedside commode with one assist. Peripheral edema noted.Resp: LS with Ins. resp. Colonoscopy done. Pt. Pt. Pt. Pt. Pt. Pt. Pt. denies pain.GU: HD Pt. Creatnine elevated. wheezes on assessment. 's status. soft, BS+. 's report. Sinus rhythm. Prolonged A-V conduction. HCT last night 32.2 and stable. Nursing Progress Note:Events: Pt. Renal following and plan for HD today. Abd. with AV fistula to L upper arm. Pt able to participate in care and am bath. Compared to the previous tracing of marked difference in tracing. status easy and unlabored with RR 10's-20's. alert and oriented x3. Lotion applied.Social; Pt. Shift Note: 1900-0700Neuro: Pt A+OX3, MAE, denies pain t/o shift though c/o leg cramping s/p HD as baseline per pt - resolved w/ positioning and rest. BBS somewhat diminshed t/o though otherwise CTA w/ no adventitious sounds noted. SBP 70's to 90's as per pt's baseline w/ MAP 48-63. 3.3L removed w/ HD. is alert, OX3, cooperative, moves independently in bed and is able to transfer to commode. Plan for HD catheter to remain in place for now w/ fistulogram to be done prior to using AV-fistula again. Clockwiserotation. P waves only seen in lead VI. HR 80's-90's NSR with occ PVCs. is a full code. Voltage for left ventricular hypertrophy waspreviously present with T wave inversions in leads VI-V3. dose not usually make urine.Skin; Intact. Left axis deviation. No cough, pt denies SOB t/o shift and remains free of distress.CV: HR 80's to 90's - afib - pt's baseline per hx and EKG obtained previous shift. C/O being itchy. HD catheter in place R chest wall and AV-fistual w/ +bruit and thrill L arm. Low voltage in the limb leads and precordial leads. had colonoscopy today which showed one ulcer with a clot, no active bleeding.Neuro: Pt. Minimal urine with stool this shift per Pt. AM labs pending. Repositions self in bed.CV: BP 77-97/39-61, BP usually low below 90 systolic due to hx. Pt mentating, reports mild dizziness w/ activity which pt reports to be her basline and remains otherwise asymptomatic.FEN: Pt tolerating renal diet per report and clear liquids t/o shift. Renal team will be in contact with pt's primary renal MD as to further management of fistula.Skin: IntactSocial: Son in to see pt. "Resp: SpO2 remains 96-99% on RA. All otherabnormalities have subsequently appeared. In otherleads there is an occasional pause of uncertain mechanism (P waves are notvisible). NPN 1900-0700Neuro: Pt. Reports comfortable and "slept well. She has no c/o pain.CV: HR 80s-90s, NBP 80s-90s/40s-50s. of cardiac amyloidosis. Preped with Magnesium citrate x2 bottles overnight. Lungs are clear to all lobes at this point but have had crackles to bases and wheezes at times which are treated with nebulizers.GI: BSX4, abdomen w/o tenderness. Stools liquid pink color and no frank blood noted. and was updated on plans to deal with fistula after discharge tomorrow. did c/o some slight lightheadedness when standing when asked on rounds but denied dizziness when transferring to the commode.Resp: RR teens, 02 sats >96% on room air. Pleasant and cooperative with care. O2 sat 98-100% on RA.GI: NPO since midnight today for colenoscopy today. was going to have a fistula-gram to evaluate bleeding (see admit hx) but this will be done outpatient as patient has a dialysis catheter to R chest as well which will be used at this time. given renal diet lunch which she tolerated well.GU: Dialysis started at 1500. Another son was in to visit as well.Plan: Monitor VS. Pt to be D/C'd to home today - will need VNA and other home services as well as ambulance transport. Plan is to folow-up on ulcer in 2 weeks to determine whether biopsy is needed. 's son in visiting last night and daughter called and updated on Pt. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2117-04-30 00:00:00.000",
"description": "Report",
"row_id": 1321042,
"text": "NPN 1900-0700\nNeuro: Pt. alert and oriented x3. Pleasant and cooperative with care. OOB to bedside commode with one assist. Repositions self in bed.\n\nCV: BP 77-97/39-61, BP usually low below 90 systolic due to hx. of cardiac amyloidosis. HR 80's-90's NSR with occ PVCs. HCT last night 32.2 and stable. AM labs pending. Peripheral edema noted.\n\nResp: LS with Ins. wheezes on assessment. Pt. resp. status easy and unlabored with RR 10's-20's. O2 sat 98-100% on RA.\n\nGI: NPO since midnight today for colenoscopy today. Preped with Magnesium citrate x2 bottles overnight. Stools liquid pink color and no frank blood noted. Abd. soft, BS+. Pt. denies pain.\n\nGU: HD Pt. with AV fistula to L upper arm. Renal following and plan for HD today. Minimal urine with stool this shift per Pt.'s report. Pt. dose not usually make urine.\n\nSkin; Intact. C/O being itchy. Creatnine elevated. Lotion applied.\n\nSocial; Pt.'s son in visiting last night and daughter called and updated on Pt.'s status. Pt. is a full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-04-30 00:00:00.000",
"description": "Report",
"row_id": 1321043,
"text": "Nursing Progress Note:\n\nEvents: Pt. had colonoscopy today which showed one ulcer with a clot, no active bleeding.\n\nNeuro: Pt. is alert, OX3, cooperative, moves independently in bed and is able to transfer to commode. She has no c/o pain.\n\nCV: HR 80s-90s, NBP 80s-90s/40s-50s. Pt. did c/o some slight lightheadedness when standing when asked on rounds but denied dizziness when transferring to the commode.\n\nResp: RR teens, 02 sats >96% on room air. Lungs are clear to all lobes at this point but have had crackles to bases and wheezes at times which are treated with nebulizers.\n\nGI: BSX4, abdomen w/o tenderness. Colonoscopy done. Plan is to folow-up on ulcer in 2 weeks to determine whether biopsy is needed. Pt. given renal diet lunch which she tolerated well.\n\nGU: Dialysis started at 1500. Pt. was going to have a fistula-gram to evaluate bleeding (see admit hx) but this will be done outpatient as patient has a dialysis catheter to R chest as well which will be used at this time. Renal team will be in contact with pt's primary renal MD as to further management of fistula.\n\nSkin: Intact\n\nSocial: Son in to see pt. and was updated on plans to deal with fistula after discharge tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-01 00:00:00.000",
"description": "Report",
"row_id": 1321044,
"text": "Shift Note: 1900-0700\nNeuro: Pt A+OX3, MAE, denies pain t/o shift though c/o leg cramping s/p HD as baseline per pt - resolved w/ positioning and rest. Pt able to participate in care and am bath. Reports comfortable and \"slept well.\"\n\nResp: SpO2 remains 96-99% on RA. BBS somewhat diminshed t/o though otherwise CTA w/ no adventitious sounds noted. No cough, pt denies SOB t/o shift and remains free of distress.\n\nCV: HR 80's to 90's - afib - pt's baseline per hx and EKG obtained previous shift. SBP 70's to 90's as per pt's baseline w/ MAP 48-63. Pt mentating, reports mild dizziness w/ activity which pt reports to be her basline and remains otherwise asymptomatic.\n\nFEN: Pt tolerating renal diet per report and clear liquids t/o shift. 3.3L removed w/ HD. HD catheter in place R chest wall and AV-fistual w/ +bruit and thrill L arm. Plan for HD catheter to remain in place for now w/ fistulogram to be done prior to using AV-fistula again. No am labs ordered for this am - discussed w/ Dr. who reports no need for labs today as plan for pt to be D/C'd to home.\n\nSocial: Call from pt's oldest son last , updated on pt status and POC, though pt did not want to speak w/ son on telephone reporting that she would speak to him tomorrow. Another son was in to visit as well.\n\nPlan: Monitor VS. Pt to be D/C'd to home today - will need VNA and other home services as well as ambulance transport.\n"
},
{
"category": "ECG",
"chartdate": "2117-04-30 00:00:00.000",
"description": "Report",
"row_id": 154428,
"text": "Sinus rhythm. Prolonged A-V conduction. P waves only seen in lead VI. In other\nleads there is an occasional pause of uncertain mechanism (P waves are not\nvisible). Low voltage in the limb leads and precordial leads. Clockwise\nrotation. Left axis deviation. Compared to the previous tracing of \nmarked difference in tracing. Voltage for left ventricular hypertrophy was\npreviously present with T wave inversions in leads VI-V3. All other\nabnormalities have subsequently appeared.\n\n"
}
] |
12,365 | 125,302 | 80M CKD, CAD s/p CABGx3, atrial fibrillation, DM2, systolic heart failure (last EF 40-45%), valvular heart disease, ESRD on HD (M,W,F) via right brachiocephalic fistula, PVD with venous stasis ulceration who presented to ER for fever after HD and was admitted to ICU for sepsis and hypotension requiring pressor support, also found to have acute encephalopathy. # Possible Sepsis Patient presented with fever & tachycardia with presumed infection although uncertain source. Labs were significant for normal WBC but with left shift on differential. CXR on revealed equivocal pneumonia and patient's only localizing symptom was dry cough. cultures were negative to date. He was started on vancomycin, cefepime, and flagyl with discontinuation of IV abx on and transition to levofloxacin. Most likely, pt had transient bacteremia from dialysis as pt uses "button-hole" method for access which has higher rates of infectious complications. The patient was well without fevers while on levofloxacin and given cough and question of pneumonia on chest x-ray, pt will be covered for 5 more days on levofloxacin for coverage of health care associated pneumonia. . # Hypotension Patient's baseline BP is SBP 70s-90s per notes and patient history. He presented with SBP 70 that was not responsive to 2 L NS, so was started on levophed. Given coincident fevers, there was concern for sepsis. Serial lactates within normal limits suggested good perfusion. Levophed was able to be weaned off and SBPs remained in his normal 70-90 range, with intermittent hypotension while sleeping which self-corrected to >70 systolic immediately when pt was awake. Mentation remained intact. Echo showed improved heart function compared to previous. # Acute encephalopathy Seemed to be related to patient being drowsy on admission. He improved markedly the morning after admission, mentated well thereafter. # Chronic systolic and diastolic heart failure Echo revealed improvement of heart function with LVEF >55% in setting of likely diastolic failure and some regional systolic wall motion abnormalities. The pt was switched from atenolol to metoprolol. Given his good EF and low pressures, ACE was deferred. Pt volume overloaded to heart failure and ESRD. Pt is anuric. Will need to continue to take off volume at dialysis. Reported baseline weight is 84kg. # Elevated INR Likely from poor nutrition/poor PO intake. Not on anticoagulation, no other LFT abnormalities. # ESRD on HD (M,W,F) Continued on same schedule. Pt's sevelamer was discontinued due to low phosphorous. # Atrial fibrillation ECG with atrial fibrillation on admission. Not on coumadin or aspirin secondary to massive GIB in . Switched to metoprolol 25mg for rate control. Can continue to uptitrate as tolerated for goal rates <90. . # CAD s/p CABGx3 Stable, continued on home meds. . # Normocytic, normochromic anemia Stable. Hct at baseline, 30-32, most likely from CKD. . # Thrombocytopenia Stable, pt possibly with MDS. Can defer workup to outpatient setting. . # Diabetes Mellitus type 2 Last A1c 6.5 on . Pt did not require any ISS while here. . # Hyperlipidemia Continued statin. LFTs wnl. . # PVD with venous stasis ulceration . # Chronic back pain Secondary to disc disease/spinal stenosis/nerve root compression. Held oxycontin, oxycodone, gabapentin on arrival while somnolent. Then restarted home meds without issue. . # Gout Continued allopurinol. . # Rash: Maculopapular and pruritic with prominence over back and thighs. Occurred after starting cefepime and vancomycin. Felt most likely to be from cefepime. Not c/w redman syndrome given distribution. Treated with sarna lotion and hydroxyzine with some improvement. No anaphylactic symptoms. TRANSITIONAL ISSUES - Continue rate control. - Pt's baseline pressures are 80-90 systolic. - Monitor and workup thrombocytopenia. | Abnormal septalmotion/position.AORTA: Normal aortic diameter at the sinus level. The right atrium is moderately dilated.There is mild symmetric left ventricular hypertrophy with normal cavity size.There is mild regional left ventricular systolic dysfunction with focaldyskinesis of the basal inferior wall. Moderate eccentric jet of mitral regurgitation. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- dyskinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Noaortic regurgitation is seen. Moderate [2+] tricuspidregurgitation is seen. Mild PAsystolic hypertension.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is mild pulmonary artery systolic hypertension.There is an anterior space which most likely represents a prominent fat pad.IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolicdysfunction c/w CAD. Ascites.Conclusions:The left atrium is moderately dilated. No AR.MITRAL VALVE: Calcified tips of papillary muscles. Moderate(2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. A non-specific intraventricularconduction delay is present. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is borderline prolongation of theQTc interval. Biatrial enlargement.Compared with the prior study (images reviewed) of , the severity ofmitral regurgitation and the estimated PA systolic pressure are slightlyreduced.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Pulmonaryartery hypertension. Moderate [2+] TR. Ischemic cardiomyopathy.Height: (in) 67Weight (lb): 185BSA (m2): 1.96 m2BP (mm Hg): 96/58HR (bpm): 97Status: InpatientDate/Time: at 14:53Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. An eccentric, inferolaterally directed jet ofmoderate (2+) mitral regurgitation is seen. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. There are severalmonomorphic ventricular premature beats. There is abnormal septal motion/position. Atrial fibrillation with a ventricular response rate of 109. FINDINGS: There is a new right IJ central line with tip in the distal SVC. Right ventricular chamber size and free wall motionare normal. Sternotomy wires are again seen. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Suboptimalimage quality - body habitus. There continues to be moderate cardiomegaly with pulmonary vascular redistribution, without focal infiltrate or effusion. Hyoptension. Compared to the previous tracing of there are nosignificant interval changes aside from the more rapid heart rate. Eccentric MR jet. No AS. 10:54 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please eval line placement Admitting Diagnosis: HYPOTENSION MEDICAL CONDITION: History: 80M with R IJ central line REASON FOR THIS EXAMINATION: please eval line placement No contraindications for IV contrast FINAL REPORT CHEST ON HISTORY: Right IJ central line. The remaining segments contractnormally (LVEF = 55 %). Clinical decisions regarding the needfor prophylaxis should be based on clinical and echocardiographic data. | 3 | [
{
"category": "Echo",
"chartdate": "2135-06-06 00:00:00.000",
"description": "Report",
"row_id": 98974,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hyoptension. Ischemic cardiomyopathy.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 96/58\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 14:53\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- dyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Calcified tips of papillary muscles. Eccentric MR jet. Moderate\n(2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Ascites.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with focal\ndyskinesis of the basal inferior wall. The remaining segments contract\nnormally (LVEF = 55 %). Right ventricular chamber size and free wall motion\nare normal. There is abnormal septal motion/position. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. An eccentric, inferolaterally directed jet of\nmoderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is an anterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic\ndysfunction c/w CAD. Moderate eccentric jet of mitral regurgitation. Pulmonary\nartery hypertension. Biatrial enlargement.\nCompared with the prior study (images reviewed) of , the severity of\nmitral regurgitation and the estimated PA systolic pressure are slightly\nreduced.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-03 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1238519,
"text": " 10:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval line placement\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80M with R IJ central line\n REASON FOR THIS EXAMINATION:\n please eval line placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Right IJ central line.\n\n FINDINGS: There is a new right IJ central line with tip in the distal SVC.\n There continues to be moderate cardiomegaly with pulmonary vascular\n redistribution, without focal infiltrate or effusion. Sternotomy wires are\n again seen. There is no pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2135-06-03 00:00:00.000",
"description": "Report",
"row_id": 278954,
"text": "Atrial fibrillation with a ventricular response rate of 109. There are several\nmonomorphic ventricular premature beats. A non-specific intraventricular\nconduction delay is present. There is borderline prolongation of the\nQTc interval. Compared to the previous tracing of there are no\nsignificant interval changes aside from the more rapid heart rate.\n\n"
}
] |
50,991 | 178,779 | 76M with a complex medical history, most notably including T1 esopheageal cancer s/p esophagectomy and colonic interposition/J-tube placement in , diastolic CHF, COPD, PVD, hypertension, recent bilateral PEs , multiple recent aspiration PNAs, who developed GIB in setting of being started on warfarin for PEs. Initially presented to OSH where he was transfused 2 units pRBCs and had SVC filter placement, transfered to for further evaluation of GIB, with course notable for LUL necrotizing pneumonia. | IMPRESSION: Non-occlusive DVT in the axillary and one of the brachial veins. Unchanged evidence of relatively massive consolidations in the left lung apex and apicolateral parts of the hemithorax. FINDINGS: As compared to the previous radiograph, there is unchanged evidence of right upper lobe clips projecting over the right lung apex. Sinus rhythm with bigeminal ventricular premature beats with inferior axis.Right bundle-branch block beats may be Verapamil sensitive ventricular ectopicactivity. FINDINGS: As compared to the previous radiograph, the extensive parenchymal opacity at the left lung apex is unchanged. Non-occlusive thrombus is also noted in one of the brachial veins and nearly occlusive thrombus is present in the right basilic vein. FINDINGS: Patient has apparently had prior gastric pull-up and esophagectomy superseded by a colonic interposition. Surgical anastamosis with jejenum in left upper quadrant appears intact. The right subclavian, axillary, brachial, radial, and ulnar arteries are patent presenting with triphasic Doppler waveforms throughout. Sinus rhythm with ventricular bigeminy. FINDINGS: There is dense alveolar consolidation found in the left upper lung zone in the area of recent biopsy. -Unchanged moderately severe emphysema. Worsened peribronchial infiltration around preexisting bibasilar bronchiectasis is another indication of aspiration. Nearly completely occlusive thrombus involving the basilic vein. FINDINGS: As compared to the previous radiograph, the pre-existing parenchymal opacities in the left upper lobe are stable. Sinus tachycardia with occasional ventricular premature beats. Lymph node enlargement at the thoracic inlet and in the upper and lower paratracheal stations of the mediastinum is stable. Unchanged appearance of the mediastinum, the heart and the right lung. Sinus tachycardia. Evaluate for extent of clot. REASON FOR THIS EXAMINATION: Please assess for acute cardiopulmonary process. There is diminished respiratory variability in the right subclavian vein compared to the left. Clips are again seen at the right apex with some associated chain sutures suggestive of prior surgery. Otherwise, the right lung is unremarkable. LINE PLACEMENT Clip # Reason: 46cm left picc. Left upper lobe opacity, consistent with known pneumonia, is grossly unchanged. change in PNA, LUL, aspiration, atalectasis, any fluid collections FINAL REPORT CHEST RADIOGRAPH INDICATION: Followup. 9:37 PM CHEST (PORTABLE AP) Clip # Reason: Please assess for acute cardiopulmonary process. -Stable hepatic and renal cysts. Mild generalized mediastinal adenopathy, unchanged since . There is non-occlusive thrombus in the axillary vein just prior to its confluence with, but not extending into, the distal left subclavian vein. Severe emphysema. One AP radiograph of the abdomen was obtained after injection of oral contrast through the jejunostomy tube. Mild irregular right pleural thickening is stable. New left hilar adenopathy could be reactive or malignant, mildly narrows but does not obstruct the upper lobe bronchus. Differential includes necrotic mass from metastatic disease - though much less likely given other associated findings and overall morphology. LEFT UPPER EXTREMITY ULTRASOUND: scale and Doppler son of the right internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins was performed. Evaluate possible pneumothorax. This adenopathy narrows the left upper lobe bronchus diameter by approximately a third but is not obstructive. Known extensive pulmonary emphysema. infiltrates/parenchymal disease Admitting Diagnosis: GASTROINTESTINAL BLEED Field of view: 36 FINAL REPORT (Cont) aspiration. The tip appears to be in the loops of the jejunum in the right mid-lower quadrant. TECHNIQUE AND FINDINGS: The right upper extremity was evaluated with B mode, color, and spectral Doppler ultrasound. Findings most suggest of necrotic pneumonia possibly due to aspiration. Interval placement of left subclavian PICC line with its tip at the superior aspect of a superior vena caval filter. FINDINGS: In comparison with the study of , there is little change in the extensive opacification involving the left mid and upper lung zones. There is scoliosis. Frequent ventricular ectopy. Left axis deviation.Non-specific ST-T wave changes. Non-specific ST-T wave abnormalities. Emphysema is severe. Right lung is grossly clear. Right lower lobe opacities could be atelectasis or pneumonia . infiltrates/parenchymal disease CONTRAINDICATIONS for IV CONTRAST: horseshoe kidney WET READ: GMSj TUE 9:02 PM -Large cavitary lesion in the left upper lobe. IMPRESSION: 1) Extensive left upper lobe alveolar consolidation may represent hemorrhage from procedure or infiltrate which developed since prior study 7 days ago. Borderline leftaxis deviation. The study is not designed for subdiaphragmatic diagnosis, but shows a gastrostomy tube in place at the pylorus and a large but stable left upper pole renal cyst. The cephalic vein and the second brachial vein demonstrate normal flow, compressibility and augmentation. The right lung is grossly clear. The peak systolic velocities are 65 cm/sec in the subclavian artery, 52 cm/sec in the axillary artery, 71 cm/sec in the brachial artery, 95 cm/sec in the radial artery, and 52 cm/sec in the ulnar artery. COMPARISON: Multiple chest radiographs dating back to , most recent study and CT chest . TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast infusion or oral contrast , reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and parasagittal images compared to chest CT, . | 17 | [
{
"category": "Radiology",
"chartdate": "2170-01-25 00:00:00.000",
"description": "R ART DUP EXT UP UNI OR LMTD RIGHT",
"row_id": 1227329,
"text": " 2:49 PM\n ART DUP EXT UP UNI OR LMTD RIGHT Clip # \n Reason: COOL RIGH UPPER EXTREMITY\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with PE and RUE clot s/p SVC filter, cool right arm\n REASON FOR THIS EXAMINATION:\n ? compromised arterial flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old male with history of pulmonary embolism presenting\n with cold right upper extremity.\n\n TECHNIQUE AND FINDINGS: The right upper extremity was evaluated with B mode,\n color, and spectral Doppler ultrasound.\n\n The right subclavian, axillary, brachial, radial, and ulnar arteries are\n patent presenting with triphasic Doppler waveforms throughout. The peak\n systolic velocities are 65 cm/sec in the subclavian artery, 52 cm/sec in the\n axillary artery, 71 cm/sec in the brachial artery, 95 cm/sec in the radial\n artery, and 52 cm/sec in the ulnar artery.\n\n COMPARISON: None available.\n\n IMPRESSION: There is no evidence of arterial stenosis in the right upper\n extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1227956,
"text": " 12:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p bronchoscopic biopsy\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LUL cavity\n REASON FOR THIS EXAMINATION:\n s/p bronchoscopic biopsy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old male with left upper lobe cavity seen on previous\n chest CT, now status post bronchoscopic biopsy of this lesion.\n\n COMPARISON: Multiple chest radiographs dating back to , most\n recent study and CT chest .\n\n TECHNIQUE: Portable upright AP chest radiograph.\n\n FINDINGS: There is dense alveolar consolidation found in the left upper lung\n zone in the area of recent biopsy. The consolidation may represent hemorrhage\n from the procedure or an infiltrate which has developed within the last seven\n days. Clinical correlation is advised. No significant pneumothorax is\n observed. An IVC filter is seen in the proximal SVC. Surgical clips are\n again seen in the right upper lobe. Otherwise, the right lung is\n unremarkable. Cardiomediastinal silhouette is stable and within normal\n limits. There is no pleural effusion observed. The visualized pleural\n surfaces are unremarkable.\n\n IMPRESSION:\n 1) Extensive left upper lobe alveolar consolidation may represent hemorrhage\n from procedure or infiltrate which developed since prior study 7 days ago.\n Clinical correlation is recommended.\n 2) No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1228228,
"text": " 9:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? change in PNA, LUL, aspiration, atalectasis, any fluid col\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with complex hx including T1 esopheageal cancer s/p\n colonic interposition, dCHF, COPD, PVD, HTN, recent bilateral PEs c/b\n multiple recent aspiration PNAs and GIB requiring 2U PBRCs + d/c of warfarin +\n SVC filter placement, now with necrotizing PNA/abcess (bronched ).\n REASON FOR THIS EXAMINATION:\n ? change in PNA, LUL, aspiration, atalectasis, any fluid collections\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the extensive parenchymal\n opacity at the left lung apex is unchanged. No newly appeared focal\n parenchymal opacities. Unchanged appearance of the mediastinum, the heart and\n the right lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-02-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1228816,
"text": " 12:35 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 46cm left picc. tip? \n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 46cm left picc. tip? \n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORT LINE PLACEMENT AT 12:29\n\n CLINICAL INDICATION: 76-year-old with new PICC. Question tip location.\n\n Comparison made to prior study of at 21:31.\n\n Single portable upright study at 12:29 is submitted.\n\n IMPRESSION:\n 1. Interval placement of left subclavian PICC line with its tip at the\n superior aspect of a superior vena caval filter. There is persistent opacity\n in the left upper and mid lung suggestive of pneumonia. The right lung is\n grossly clear. Overall cardiac and mediastinal contours are stable. Clips\n are again seen at the right apex with some associated chain sutures suggestive\n of prior surgery. No pneumothorax is seen. No evidence of pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-30 00:00:00.000",
"description": "O CHEST (SINGLE VIEW) IN O.R.",
"row_id": 1227952,
"text": " 11:54 AM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: LUL BX UNDER FLUORO\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LUL cavitation\n REASON FOR THIS EXAMINATION:\n patient is scheduled on \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Biopsy.\n\n FINDINGS: Images from the operating suite show stages in left upper lobe\n biopsy. Further information can be gathered from the procedure report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-23 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1227061,
"text": " 7:53 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infiltrates/parenchymal disease\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with esophageal cancer s/p colonic interposition, PE on\n warfarin, s/p SVC filter, p/w GI bleeding, pending advanced endoscopy.\n REASON FOR THIS EXAMINATION:\n ? infiltrates/parenchymal disease\n CONTRAINDICATIONS for IV CONTRAST:\n horseshoe kidney\n ______________________________________________________________________________\n WET READ: GMSj TUE 9:02 PM\n -Large cavitary lesion in the left upper lobe. Findings most suggest of\n necrotic pneumonia possibly due to aspiration. Differential includes necrotic\n mass from metastatic disease - though much less likely given other associated\n findings and overall morphology.\n\n -Bronchial wall thickening and distal mucous plugging in the bilateral lower\n lobes - findings concerning for infection.\n\n -No pleural effusions. Minimal dependent atelectasis.\n\n -Unchanged moderately severe emphysema.\n\n -S/p colonic interposition graft after esophagectomy. Surgical anastamosis\n with jejenum in left upper quadrant appears intact.\n\n -Stable hepatic and renal cysts.\n\n Findings d/w Dr. at 8:59 pm on by telephone.\n GSenapati \n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, \n\n HISTORY: Esophageal carcinoma with colonic interposition. PE, on warfarin.\n Question pneumonia.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n intravenous contrast infusion or oral contrast , reconstructed as\n contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and parasagittal\n images compared to chest CT, .\n\n FINDINGS:\n\n Patient has apparently had prior gastric pull-up and esophagectomy superseded\n by a colonic interposition.\n\n Emphysema is severe. Secretions in the trachea and bronchial tree suggest\n (Over)\n\n 7:53 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infiltrates/parenchymal disease\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n aspiration. A large region of necrotizing pneumonia in the left upper lobe is\n new since , may be progressing to a lung abscess. Worsened\n peribronchial infiltration around preexisting bibasilar bronchiectasis is\n another indication of aspiration. Lymph node enlargement at the thoracic\n inlet and in the upper and lower paratracheal stations of the mediastinum is\n stable. Left hilus has enlarged since , with an aggregate diameter\n at the level of the left upper lobe bronchus, currently 24 x 26 mm, 2:28,\n previously 21 x 23 mm, 5:64. This adenopathy narrows the left upper lobe\n bronchus diameter by approximately a third but is not obstructive.\n\n Mild irregular right pleural thickening is stable. There is no pericardial or\n left pleural effusion. The study is not designed for subdiaphragmatic\n diagnosis, but shows a gastrostomy tube in place at the pylorus and a large\n but stable left upper pole renal cyst.\n\n There are no bone findings in the sternum or spine suspicious for malignancy\n or infection.\n\n An umbrella filter is positioned in the superior vena cava, terminating\n approximately 16 mm from the superior cavoatrial junction. A gastrostomy\n balloon at the pylorus could interfere with gastric emptying.\n\n IMPRESSION:\n 1. Large necrotizing pneumonia, incipient lung abscess, left upper lobe,\n probably due to aspiration, given more severe bibasilar peribronchial\n infiltration around chronic bronchiectasis and retained secretions in the\n bronchial tree.\n 2. New left hilar adenopathy could be reactive or malignant, mildly narrows\n but does not obstruct the upper lobe bronchus. Mild generalized mediastinal\n adenopathy, unchanged since . No good evidence for active\n recurrence of esophageal carcinoma.\n 3. Severe emphysema.\n 4. Gastrostomy balloon at the pylorus might interfere with gastric emptying.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1226930,
"text": " 11:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: consolidation\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent admissions for aspiration who now with cough and\n increasing sputum, eval for evidence of pna\n REASON FOR THIS EXAMINATION:\n consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recent admission for aspiration, cough, evaluation for changes.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is unchanged evidence\n of right upper lobe clips projecting over the right lung apex. Known\n extensive pulmonary emphysema. Unchanged evidence of relatively massive\n consolidations in the left lung apex and apicolateral parts of the hemithorax.\n Given that these changes were not present on an outside CT examination from\n and given the complicated medical history of the patient\n (esophagectomy), a CT should be performed to evaluate the potential cause for\n the non-resolution of the pathologic process in the left upper lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-28 00:00:00.000",
"description": "G/GJ/GI TUBE CHECK",
"row_id": 1227667,
"text": " 3:28 PM\n G/GJ/GI TUBE CHECK Clip # \n Reason: ? location of J tube, obstruction\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with esophageal cancer s/p colonic interposition with J tube\n p/w GI bleed (stable), PE s/p SVC filter on heparin gtt now complaining of\n sharp J tube site pain.\n REASON FOR THIS EXAMINATION:\n ? location of J tube, obstructionKUB\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Assessment of the position of the J-tube.\n\n One AP radiograph of the abdomen was obtained after injection of oral contrast\n through the jejunostomy tube.\n\n The tip appears to be in the loops of the jejunum in the right mid-lower\n quadrant. No extravasation of contrast is demonstrated on this limited one\n static image.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1228011,
"text": " 6:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: see below\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with drop in O2 sat on room air and difficulty recovering,\n checking for pneumothorax\n REASON FOR THIS EXAMINATION:\n see below\n ______________________________________________________________________________\n WET READ: MXAk TUE 7:12 PM\n Little change from prior study from earlier today with a stable left upper\n lobe opacity.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:01 P.M., \n\n HISTORY: Hypoxia. Evaluate possible pneumothorax.\n\n IMPRESSION: AP chest compared to and :\n\n The substantial increase in consolidation in the necrotizing left upper lobe\n pneumonia that took place between and after left upper\n lobe bronchoscopic biopsy, has improved little, but is still quite\n substantial. There is no pneumothorax or appreciable left pleural effusion.\n Cardiac silhouette is normal. Right lung is grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1228650,
"text": " 9:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for acute cardiopulmonary process.\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with acute increase in O2 requirement.\n REASON FOR THIS EXAMINATION:\n Please assess for acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute increase in oxygen requirement.\n\n FINDINGS: In comparison with the study of , there is little change in the\n extensive opacification involving the left mid and upper lung zones.\n Remainder of the study is essentially unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1228114,
"text": " 1:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Any evidence of increase in conslidiation in LUL/RUL\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with recent IP procedure\n REASON FOR THIS EXAMINATION:\n Any evidence of increase in conslidiation in LUL/RUL\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Recent IP procedure, evaluation for changes.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the pre-existing\n parenchymal opacities in the left upper lobe are stable. No newly occurred\n parenchymal opacities. Unchanged radiographic appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1229320,
"text": " 4:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Concern for pulmonary edema\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with LUL necrotizing PNA, COPD, bilateral PEs, colonic\n interposition\n REASON FOR THIS EXAMINATION:\n Concern for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Necrotizing pneumonia, COPD.\n\n Comparison is made with prior study, .\n\n Cardiomediastinal contours are unchanged. Left upper lobe opacity, consistent\n with known pneumonia, is grossly unchanged. Increasing opacities in the left\n lower lobe are consistent with increasing atelectasis. Right lower lobe\n opacities could be atelectasis or pneumonia . Surgical clips project in the\n right upper hemithorax. There is scoliosis. Patient has severe emphysema.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-01-25 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1227323,
"text": " 2:11 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: PREVIOUS CLOT ASSESS FOR EXTENSION OF THE CLOT\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with PE and RUE clot s/p SVC filter, cool right arm\n REASON FOR THIS EXAMINATION:\n ? extend of the clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old male with PE and right upper extremity clot status\n post SVC filter and now with cool right arm. Evaluate for extent of clot.\n\n COMPARISON: No prior study available for comparison.\n\n LEFT UPPER EXTREMITY ULTRASOUND: scale and Doppler son of the right\n internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins\n was performed. There is diminished respiratory variability in the right\n subclavian vein compared to the left. There is non-occlusive thrombus in the\n axillary vein just prior to its confluence with, but not extending into, the\n distal left subclavian vein. Non-occlusive thrombus is also noted in one of\n the brachial veins and nearly occlusive thrombus is present in the right\n basilic vein. The cephalic vein and the second brachial vein demonstrate\n normal flow, compressibility and augmentation.\n\n IMPRESSION: Non-occlusive DVT in the axillary and one of the brachial veins.\n Nearly completely occlusive thrombus involving the basilic vein.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-01-30 00:00:00.000",
"description": "Report",
"row_id": 242049,
"text": "Sinus tachycardia. Frequent ventricular ectopy. Left axis deviation.\nNon-specific ST-T wave changes. Compared to the previous tracing\nof the rate is faster and ventricular ectopy is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-02-08 00:00:00.000",
"description": "Report",
"row_id": 242046,
"text": "Sinus rhythm with ventricular bigeminy. Compared to the previous tracing\nof no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-02-04 00:00:00.000",
"description": "Report",
"row_id": 242047,
"text": "Sinus rhythm with bigeminal ventricular premature beats with inferior axis.\nRight bundle-branch block beats may be Verapamil sensitive ventricular ectopic\nactivity. Since the previous tracing of the rate is somewhat slower and\nventricular premature beats are now more frequent. They are now monomorphic. On\nthe prior tracing they were of multiple morphologies. The axis is now less\nleftward. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2170-02-03 00:00:00.000",
"description": "Report",
"row_id": 242048,
"text": "Sinus tachycardia with occasional ventricular premature beats. Borderline left\naxis deviation. Non-specific ST-T wave abnormalities. No diagnostic change\ncompared to the previous tracing of .\n\n"
}
] |
7,809 | 114,247 | 55 year old female with type 1 diabetes mellitus with many admissions for DKA, who presented with DKA. 1. Diabetic Ketoacidosis, type I DM with complications: Patient has history of many admissions for DKA. It is not entirely clear what prompted this episode, likely viral syndrome as no evidence of UTI, pulmonary infection, no evidence of cardiac ischemia. Patient improved with IV fluids, and insulin. Pt initially received insulin drip, converted to SQ insulin, with fair control. At time of discharge, glucose 100-259; but generally in mid to high 100's. Pt was returned to her home insulin regimen, and will follow up with the day following discharge. 2. Global achiness: suspect viral syndrome as no clear evidence of other infection. Pt also with some localization to sacroiliac joints bilaterally. Pt was briefly given tramadol to treat pain, but this was not continued at discharge. 3. Hypertension: continued losartan, well-controlled. 4. disease: TSH 0.54. Methimazole continued at home dose. 5. Asthma: Asymptomatic. - Contiued home medications 6. Anemia: Normocytic. Near baseline. 7. GERD: Continued protonix 8. Depression, anxiety: Continue amitriptyline and diazepam 9. Chronic pain: Continue home regimen of percocet, neurontin, amitriptyline. Briefly treated with Tramadol as well, not continued at discharge. 10. Seronegative arthritis: continued sulfasalazine. Dispo: to home. F/u with as outpt. | # Hypertension: Currently normo-tensive upon arrival to the . # Acute renal failure: Resolved. # Acute renal failure: Resolved. # Hypertension: Currently normo-tensive - re-start home . HYPERTENSION, BENIGN: Anticipate restarting antihypertensives after further volume resusitation. Diabetic Ketoacidosis (DKA) Assessment: Action: Response: Plan: Diabetic Ketoacidosis (DKA) Assessment: Action: Response: Plan: # Anion gap acidosis: Closed after aggressive IVF resuscitation. # Anion gap acidosis: Closed after aggressive IVF resuscitation. History obtained from Patient Allergies: Penicillins Unknown; Urtica Last dose of Antibiotics: Ciprofloxacin - 06:00 AM Infusions: Insulin - Regular - 2 units/hour Other ICU medications: Heparin Sodium (Prophylaxis) - 08:19 AM Other medications: ASA simvastatin salmeterol discus reglan protonix neurontin fluticasone colace amitriptyline SQ heparin Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Gastrointestinal: Abdominal pain, improved Genitourinary: Foley Pain: Minimal Pain location: back pain, chronic unchanged Flowsheet Data as of 10:41 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.7C (98.1 Tcurrent: 36.6C (97.8 HR: 88 (85 - 108) bpm BP: 104/45(58) {104/45(58) - 135/71(83)} mmHg RR: 13 (13 - 21) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 62 Inch Total In: 4,039 mL PO: 100 mL TF: IVF: 3,939 mL Blood products: Total out: 0 mL 940 mL Urine: 440 mL NG: Stool: Drains: Balance: 0 mL 3,099 mL Respiratory support O2 Delivery Device: None SpO2: 99% ABG: ///20/ Physical Examination General Appearance: Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition, dry oropharynx Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: Soft, Bowel sounds present, diffuse mild tenderness; no rebound or guarding Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Musculoskeletal: Unable to stand Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed Labs / Radiology 8.8 g/dL 328 K/uL 186 mg/dL 0.9 mg/dL 20 mEq/L 4.9 mEq/L 18 mg/dL 107 mEq/L 136 mEq/L 26.2 % 6.4 K/uL [image002.jpg] 01:00 AM 05:12 AM WBC 6.0 6.4 Hct 31.1 26.2 Plt 351 328 Cr 1.2 0.9 TropT <0.01 Glucose 544 186 Other labs: PT / PTT / INR:12.4/23.2/1.0, CK / CKMB / Troponin-T:36/2/<0.01, ALT / AST:21/24, Alk Phos / T Bili:96/0.3, Lactic Acid:2.7 mmol/L, Albumin:3.3 g/dL, LDH:151 IU/L, Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:2.4 mg/dL Microbiology: UCx: Pending Blood cultures: Pending Assessment and Plan DIABETIC KETOACIDOSIS (DKA): Unclear what might have tipped her over. # Hypertension: Currently normo-tensive upon arrival to the . She does note she ran out of ketone testing strips. Review of systems: Per HPI, otherwise negative Flowsheet Data as of 04:49 AM Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since 12 AM Tmax: 36.7C (98.1 Tcurrent: 36.7C (98.1 HR: 99 (99 - 108) bpm BP: 112/59(72) {110/59(72) - 135/65(80)} mmHg RR: 16 (13 - 21) insp/min SpO2: 98% Heart rhythm: ST (Sinus Tachycardia) Height: 62 Inch Total In: 1,605 mL PO: TF: IVF: 1,605 mL Blood products: Total out: 0 mL 780 mL Urine: 280 mL NG: Stool: Drains: Balance: 0 mL 825 mL Respiratory O2 Delivery Device: None SpO2: 98% ABG: ///13/ Physical Examination BP: 135/65 P: 102 R: 18 O2: 99% on 1L nasal cannula General: Sleepy, thin, age appropriate female lying in bed on her right side, in NAD HEENT: Sclera anicteric, oropharynx clear with poor dentition, dry mucous membranes Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Borderline tachycardic, regular, normal S1 + S2, 2/6 SEM loudest at the RUSB, rubs, gallops Abdomen: soft, diffuse mild tenderness to palpation without any focal point tenderness, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Right femoral line in place, c/d/i Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, tenderness to palpation along bilateral shins, no calf tenderness Neuro: A&Ox3, CN's symmetric Labs / Radiology 351 K/uL 10.1 g/dL 544 mg/dL 1.2 mg/dL 22 mg/dL 13 mEq/L 98 mEq/L 4.5 mEq/L 133 mEq/L 31.1 % 6.0 K/uL [image002.jpg] 2:33 A9/11/ 01:00 AM 10:20 P 1:20 P 11:50 P 1:20 A 7:20 P 1//11/006 1:23 P 1:20 P 11:20 P 4:20 P WBC 6.0 Hct 31.1 Plt 351 Cr 1.2 Glucose 544 Other labs: PT / PTT / INR:12.3/26.4/1.0, Lactic Acid:2.7 mmol/L, Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL Microbiology: None new pending . | 22 | [
{
"category": "Physician ",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 386984,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - urine ketones: 10 -> 0\n - lactate, VBG: pH 7.33 pCO2 43 pO2 43 HCO3 24 Lactate:1.8\n - d/c'd Cipro bc urine cx neg at 24hr\n - started SC Insulin (28U glragine + ISS), d/c'd gtt\n - Lytes: K 4.2 -> 3.7, repleted; also repleted Mg (1.8)\n - LR x 2L, continued D5 1/2NS, another 1L LR\n - started diabetic diet\n - did not start BP med , consider in AM\n - emailed Dr. () about Ms. \n - tried to get PIV, unsuccessful, d/c fem line\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:01 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.4\nC (97.6\n HR: 81 (80 - 96) bpm\n BP: 104/54(66) {101/45(58) - 141/78(92)} mmHg\n RR: 13 (8 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 11,183 mL\n 74 mL\n PO:\n 1,160 mL\n TF:\n IVF:\n 10,023 mL\n 74 mL\n Blood products:\n Total out:\n 2,240 mL\n 605 mL\n Urine:\n 1,740 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,943 mL\n -531 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General: lying in bed comfortably\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: RRR, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, diffuse mild tenderness to palpation without any focal\n point tenderness, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 239 K/uL\n 7.9 g/dL\n 200 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 8 mg/dL\n 108 mEq/L\n 138 mEq/L\n 24.5 %\n 5.1 K/uL\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 10:42 AM\n 08:44 PM\n 05:37 AM\n WBC\n 6.0\n 6.4\n 5.1\n Hct\n 31.1\n 26.2\n 24.5\n Plt\n \n Cr\n 1.2\n 0.9\n 0.8\n 0.8\n 0.8\n TropT\n <0.01\n Glucose\n 544\n 186\n 175\n 162\n 200\n Other labs:\n Lactic Acid:1.8 mmol/L\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n 8:45p\n UA:\n Color\n Straw\n Appear\n Clear\n SpecGr\n 1.004\n pH\n 5.5\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Neg\n Bld\n Neg\n Nitr\n Neg\n Prot\n Neg\n Glu\n Neg\n Ket\n Neg\n :\n Urine and blood cx NTD\n Assessment and Plan\n Ms. is a 55 year old female with type 1 diabetes mellitus with\n many admissions for DKA, who presents with DKA.\n .\n # Diabetic Ketoacidosis: Patient has history of many admissions for\n DKA.\n It is not entirely clear what prompted this episode, though could be\n secondary to poor PO intake coupled with urinary tract infection. Urine\n anaylsis was unremarkable, EKG was overall unchanged. CXR without\n evidence of infiltrate. Pt is not on any medications / drugs that\n precipitate DKA.\n - Continue to hydrate with LR (at least 6L)\n - Monitoring q4hour electrolytes, especially potassium, anion gap\n - Continue insulin drip until anion gap closes and glucose <200, then\n start sub-cutaneous insulin (start with home dose of Lantus 28 units)\n to overlap with insulin gtt for an hour before insulin gtt is d/c\n - continue IVF with 1/2NS with D5\n - replete K when when <5\n - Checking VBG to get sense of pH\n - follow up blood and urine cultures\n - Will touch base with team in AM to let them know she has been\n admitted\n .\n # Question of urinary tract infection:\n - f/u repeat urine analysis and culture.\n - d/c cipro given no evidence of UTI\n - d/c Foley\n .\n # Hypertension: Currently normo-tensive\n - Will re-start and adjust home medications this afternoon when BP is\n stable.\n .\n # Hyponatremia: Patient's corrected sodium for her hyperglycemia is\n actually 135, so she is not truly hyponatremic. Will continue to\n monitor.\n .\n # Acute renal failure: Resolved. Baseline appears to be 0.7-0.8.\n Suspect this is due to poor PO intake in setting of nauesa and\n gastroparesis, coupled with osmotic diuresis from DKA and taking \n and NSAIDs.\n - can restart naproxen, if repeat lytes continue to show\n baseline Creatinine\n - IVF for treatment of DKA as discussed above\n - Should renal function not return to baseline, would further work-up\n with renal ultrasound, FeNa, etc.\n .\n # Anion gap acidosis: Closed after aggressive IVF resuscitation.\n Suspect largely due to DKA, however patient does have elevated lactate\n that may also be playing a role. BUN also elevated above her baseline\n (10->20). No gap of the gap (no secondary acid-base disorder) appears\n to be present.\n - Continue to monitor\n - Checking VBG to get sense of pH\n .\n # disease: TSH was 0.068 during last admission, however\n difficult to interpret as this is checked in setting of acute infection\n and DKA admission.\n - Continue methimazole\n .\n # Asthma: No significant wheezing on examination to suggest\n exacerbation.\n - Contiue home medications\n .\n # Anemia: Currently HCT much better than baseline (27ish), likely\n representing hemoconcentration.\n - Guaiac stools, continue to monitor.\n .\n # GERD: Continue protonix\n .\n # Depression, anxiety: Continue amitriptyline and diazepam\n .\n # Chronic pain: Continue home regimen of percocet, neurontin\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control: 28U glargine + ISS\n Lines:\n Multi Lumen - 01:34 AM\n d/c today prior to transfer\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: on PPI at home\n VAP: N/A\n Comments:\n Communication: Comments: Patient and daughter (.\n Daughter called and updated.\n Code status: Full code\n Disposition: transfer to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 386991,
"text": "Chief Complaint: DKA\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CALLED OUT\n -Patient with urine ketones resolved\n -Patient Rx with Cipro for possible UTI but D/C'd with negative culture\n -Insulin gtt D/C'd and move to sq insulin\n -PO diet restarted\n -Femoral line in place but unable to get peripheral lines\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:01 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain\n Endocrine: Hyperglycemia\n Heme / Lymph: Anemia\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.4\nC (97.6\n HR: 81 (80 - 96) bpm\n BP: 104/54(66) {101/45(58) - 141/78(92)} mmHg\n RR: 13 (8 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 11,183 mL\n 80 mL\n PO:\n 1,160 mL\n TF:\n IVF:\n 10,023 mL\n 80 mL\n Blood products:\n Total out:\n 2,240 mL\n 605 mL\n Urine:\n 1,740 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,943 mL\n -525 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Musculoskeletal: No(t) Unable to stand\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\npatient complain of LE discomfort\nshe has no clonus,\n decreaed reflexes and mild decrease in strength in left LE which is\n complicated by pain limiting effort in regards to exam. No suggestion\n of upper motor compromise outside of mild asymetry on motor exam\n limited by pain.\n Labs / Radiology\n 7.9 g/dL\n 239 K/uL\n 200 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 8 mg/dL\n 108 mEq/L\n 138 mEq/L\n 24.5 %\n 5.1 K/uL\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 10:42 AM\n 08:44 PM\n 05:37 AM\n WBC\n 6.0\n 6.4\n 5.1\n Hct\n 31.1\n 26.2\n 24.5\n Plt\n \n Cr\n 1.2\n 0.9\n 0.8\n 0.8\n 0.8\n TropT\n <0.01\n Glucose\n 544\n 186\n 175\n 162\n 200\n Other labs: PT / PTT / INR:12.4/23.2/1.0, CK / CKMB /\n Troponin-T:36/2/<0.01, ALT / AST:21/24, Alk Phos / T Bili:96/0.3,\n Lactic Acid:1.8 mmol/L, Albumin:3.3 g/dL, LDH:151 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Fluid analysis / Other labs: U/A--negative ketones\n Microbiology: Blood and Urine Cultures-Negative\n Assessment and Plan\n 55 yo female with h/o type I DM--admit with DKA\n 1)DIABETIC KETOACIDOSIS (DKA)-\n -Glargine 28 Units \n -PO diet\n -Continue sliding scale\n -Will need Endo follow up\n 2)Pain\nAppears to be components of back pain possibly from local disc\n involvement, peripheral neuropathy in the setting of DM and arthritis\n -Continue neurontin\n -Will need close monitoring of exam as patient moves to floor\n -Percocet as needed\n 2)Anemia-Near baseline and will have to monitor over time\n ICU Care\n Nutrition: Diabetic Diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 01:34 AM\nd and will need to consider PICC\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386927,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with\n hyperglycemia.She has had multiple admissions to for DKA, most\n recently discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 387016,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with hyperglycemia.\n She has had multiple admissions to for DKA, most recently\n discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, off insulin drip for almost 24hrs now, blood sugar 200\n Action:\n Continues on glargine and RISS\n Response:\n Tolerating diabetic diet, FS 308 latest, covered with 8 units RI\n Plan:\n Continue QID FS check and cover with RISS\n Lung sounds clear, sats >95% at room air; advair and flovent for hx of\n COPD\n Hct 24 with am, labs recheck this pm, 25.6 latest.\n No bowel movement for 2 days, continues on colace\n Received electrolyte repletion yesterday, serum Na, K and Phos wnl\n today\n Foley to be dc\nd today UO ranges, 40-80cc/hr; no ketones in urine,\n ciprofloxacin IV dc\nd. afebrile, WBC 5.1 today lactate down to 0.8\n Skin intact, takes gabapentin for peripheral neuropathy\n Fem line dc\nd, patient no IV access, house staff aware and sign out\n given to floor MDs, need PICC line of necessary.\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 386920,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 01:34 AM\n NASAL SWAB - At 02:20 AM\n URINE CULTURE - At 03:25 AM\n - Received 2L of LR, currently getting 1L of D5 1/2NS at 250cc/hr\n - Currently on insulin gtt at 3u/hr down from the initial 7u/hr\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 89 (89 - 108) bpm\n BP: 119/66(79) {110/57(68) - 135/66(80)} mmHg\n RR: 15 (13 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,452 mL\n PO:\n TF:\n IVF:\n 2,452 mL\n Blood products:\n Total out:\n 0 mL\n 780 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,672 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///20/\n VBG: 7.25/35/58/16\n Physical Examination\n General: Sleepy, thin, age appropriate female lying in bed on her right\n side, in NAD\n HEENT: Sclera anicteric, oropharynx clear with poor dentition, mucous\n membranes less dry\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Borderline tachycardic, regular, normal S1 + S2, no murmurs, rubs,\n gallops\n Abdomen: soft, diffuse mild tenderness to palpation without any focal\n point tenderness, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly\n GU: Right femoral line in place, c/d/i\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,\n tenderness to palpation along bilateral shins, no calf tenderness\n Neuro: A&Ox3, CN's symmetric\n Labs / Radiology\n 328 K/uL\n 8.8 g/dL\n 186 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 4.9 mEq/L\n 18 mg/dL\n 107 mEq/L\n 136 mEq/L\n 26.2 %\n 6.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n WBC\n 6.0\n 6.4\n Hct\n 31.1\n 26.2\n Plt\n 351\n 328\n Cr\n 1.2\n 0.9\n TropT\n <0.01\n Glucose\n 544\n 186\n Other labs:\n PT / PTT / INR:12.4/23.2/1.0,\n CK / CKMB / Troponin-T:36/2/<0.01,\n ALT / AST:21/24, Alk Phos / T Bili:96/0.3, Lactic Acid:2.7 mmol/L,\n Albumin:3.3 g/dL, LDH:151 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:2.4 mg/dL\n UA: neg\n MICRO: blood culture and urine culture pending from \n IMAGING: none today, CXR from admission unremarkable, no acute\n cardiopulmonary process\n Assessment and Plan\n Ms. is a 55 year old female with type 1 diabetes mellitus with\n many admissions for DKA, who presents with DKA.\n .\n # Diabetic Ketoacidosis: Patient has history of many admissions for\n DKA.\n It is not entirely clear what prompted this episode, though could be\n secondary to poor PO intake coupled with urinary tract infection. Urine\n anaylsis was unremarkable, EKG was overall unchanged. CXR without\n evidence of infiltrate. Pt is not on any medications / drugs that\n precipitate DKA.\n - Continue to hydrate with LR (at least 6L)\n - Monitoring q4hour electrolytes, especially potassium, anion gap\n - Continue insulin drip until anion gap closes and glucose <200, then\n start sub-cutaneous insulin (start with home dose of Lantus 28 units)\n to overlap with insulin gtt for an hour before insulin gtt is d/c\n - continue IVF with 1/2NS with D5\n - replete K when when <5\n - Checking VBG to get sense of pH\n - follow up blood and urine cultures\n - Will touch base with team in AM to let them know she has been\n admitted\n .\n # Question of urinary tract infection:\n - f/u repeat urine analysis and culture.\n - d/c cipro given no evidence of UTI\n .\n # Hypertension: Currently normo-tensive\n - Will re-start and adjust home medications this afternoon when BP is\n stable.\n .\n # Hyponatremia: Patient's corrected sodium for her hyperglycemia is\n actually 135, so she is not truly hyponatremic. Will continue to\n monitor.\n .\n # Acute renal failure: Resolved. Baseline appears to be 0.7-0.8.\n Suspect this is due to poor PO intake in setting of nauesa and\n gastroparesis, coupled with osmotic diuresis from DKA and taking \n and NSAIDs.\n - can restart naproxen, Cozaar if repeat lytes continue to show\n baseline Creatinine\n - IVF for treatment of DKA as discussed above\n - Should renal function not return to baseline, would further work-up\n with renal ultrasound, FeNa, etc.\n .\n # Anion gap acidosis: Closed after aggressive IVF resuscitation.\n Suspect largely due to DKA, however patient does have elevated lactate\n that may also be playing a role. BUN also elevated above her baseline\n (10->20). No gap of the gap (no secondary acid-base disorder) appears\n to be present.\n - Continue to monitor\n - Checking VBG to get sense of pH\n .\n # disease: TSH was 0.068 during last admission, however\n difficult to interpret as this is checked in setting of acute infection\n and DKA admission.\n - Continue methimazole\n .\n # Asthma: No significant wheezing on examination to suggest\n exacerbation.\n - Contiue home medications\n .\n # Anemia: Currently HCT much better than baseline (27ish), likely\n representing hemoconcentration.\n - Guaiac stools, continue to monitor.\n .\n # GERD: Continue protonix\n .\n # Depression, anxiety: Continue amitriptyline and diazepam\n .\n # Chronic pain: Continue home regimen of percocet, neurontin\n ICU Care\n Nutrition: NPO currently, can switch to diabetic diet today\n Glycemic Control: insulin gtt continued, sc insulin started (with the\n two overlapping for an hour)\n Lines:\n Multi Lumen - 01:34 AM : Right femoral TLC for now, patient\n has very difficult access, will likely need PICC line if anticipated\n hospital stay beyond 1-2 days\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: on PPI at home\n VAP: N/A\n Comments:\n Communication: Comments: Patient and daughter (.\n Daughter called and updated.\n Code status: Full code\n Disposition: ICU for now. Can transfer to floor once pt does not\n require insulin gtt\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386897,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with\n hyperglycemia.She has had multiple admissions to for DKA, most\n recently discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n FSBS: initially critically high, now 215 at 0700, see flowsheet for lab\n data\n Action:\n Given 3 L NS and started on d5w1/2NS at 250/hr, q1hr FSBS, titrating\n insulin gtt, blood cultures sent, antibiotics given as ordered\n Response:\n FSBS trending down, gap closing\n Plan:\n Continue insulin gtt, continue fluids, continue q1hr FSBS, f/u culture\n data,continue antibiotics\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386893,
"text": "Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 386895,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 01:34 AM\n NASAL SWAB - At 02:20 AM\n URINE CULTURE - At 03:25 AM\n Received 2L of NS, currently getting 1L of D5 1/2NS at 250cc/hr\n Currently on insulin gtt at 3u/hr down from the initial 7u/hr\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 3 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 89 (89 - 108) bpm\n BP: 119/66(79) {110/57(68) - 135/66(80)} mmHg\n RR: 15 (13 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,452 mL\n PO:\n TF:\n IVF:\n 2,452 mL\n Blood products:\n Total out:\n 0 mL\n 780 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,672 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///20/\n Physical Examination\n General: Sleepy, thin, age appropriate female lying in bed on her right\n side, in NAD\n HEENT: Sclera anicteric, oropharynx clear with poor dentition, dry\n mucous membranes\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Borderline tachycardic, regular, normal S1 + S2, 2/6 SEM loudest at\n the RUSB, rubs, gallops\n Abdomen: soft, diffuse mild tenderness to palpation without any focal\n point tenderness, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly\n GU: Right femoral line in place, c/d/i\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,\n tenderness to palpation along bilateral shins, no calf tenderness\n Neuro: A&Ox3, CN's symmetric\n Labs / Radiology\n 328 K/uL\n 8.8 g/dL\n 186 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 4.9 mEq/L\n 18 mg/dL\n 107 mEq/L\n 136 mEq/L\n 26.2 %\n 6.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n WBC\n 6.0\n 6.4\n Hct\n 31.1\n 26.2\n Plt\n 351\n 328\n Cr\n 1.2\n 0.9\n TropT\n <0.01\n Glucose\n 544\n 186\n Other labs:\n PT / PTT / INR:12.4/23.2/1.0,\n CK / CKMB / Troponin-T:36/2/<0.01,\n ALT / AST:21/24, Alk Phos / T Bili:96/0.3, Lactic Acid:2.7 mmol/L,\n Albumin:3.3 g/dL, LDH:151 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:2.4 mg/dL\n MICRO: blood culture and urine culture pending from \n IMAGING: none today, CXR from admission unremarkable, no acute\n cardiopulmonary process\n Assessment and Plan\n Ms. is a 55 year old female with type 1 diabetes mellitus with\n many admissions for DKA, who presents with DKA.\n .\n # Diabetic Ketoacidosis: Patient has history of many admissions for\n DKA.\n It is not entirely clear what prompted this episode, though could be\n secondary to poor PO intake coupled with urinary tract infection. Urine\n anaylsis was unremarkable, EKG was overall unchanged. CXR without\n evidence of infiltrate.\n - Continue to hydrate with normal saline or lactated ringers (given\n wish to avoid hyperchloriemic acidosis), with 1 L boluses until fluid\n status improved\n - Monitoring q4hour electrolytes, especially potassium, anion gap\n - Continue insulin drip until anion gap closes, glucose <200, then\n start sub-cutaneous insulin (start with home dose of Lantus 28 units)\n and IVF with 1/2NS with D5\n - Initiate IVF with potassium for goal potassium , starting when\n potassium <5\n - Send blood and urine cultures\n - Follow up final read on chest x-ray\n - Will touch base with team in AM to let them know she has been\n admitted\n .\n # Question of urinary tract infection: Sending repeat urine analysis\n and culture.\n - Will initiate ciprofloxacin for now after repeat culture sent, can\n stop if negative\n .\n # Hypertension: Currently normo-tensive upon arrival to the .\n - Will re-start and adjust home medications as needed\n .\n # Hyponatremia: Patient's corrected sodium for her hyperglycemia is\n actually 135, so she is not truly hyponatremic. Will continue to\n monitor.\n .\n # Acute renal failure: Baseline appears to be 0.7-0.8. Suspect this is\n due to poor PO intake in setting of nauesa and gastroparesis, coupled\n with osmotic diuresis from DKA and taking and NSAIDs.\n - Holding naproxen, Cozaar\n - IVF for treatment of DKA as discussed above\n - Should renal function not return to baseline, would further work-up\n with renal ultrasound, FeNa, etc.\n .\n # Anion gap acidosis: Suspect largely due to DKA, however patient does\n have elevated lactate that may also be playing a role. BUN also\n elevated above her baseline (10->20). No gap of the gap (no secondary\n acid-base disorder) appears to be present.\n - Continue to monitor\n - Checking albumin to further assess gap\n - Checking VBG to get sense of pH\n .\n # disease: TSH was 0.068 during last admission, however\n difficult to interpret as this is checked in setting of acute infection\n and DKA admission.\n - Continue methimazole\n .\n # Asthma: No significant wheezing on examination to suggest\n exacerbation.\n - Contiue home medications\n .\n # Anemia: Currently HCT much better than baseline (27ish), likely\n representing hemoconcentration.\n - Guaiac stools, continue to monitor.\n .\n # GERD: Continue protonix\n .\n # Depression, anxiety: Continue amitriptyline and diazepam\n .\n # Chronic pain: Continue home regimen of percocet, neurontin\n ICU Care\n Nutrition: NPO currently, can switch to diabetic diet today\n Glycemic Control: insulin gtt discontinued, sc insulin started (with\n the two overlapping for an hour)\n Lines:\n Multi Lumen - 01:34 AM : Right femoral TLC for now, patient\n has very difficult access, will likely need PICC line if anticipated\n hospital stay beyond 1-2 days\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: on PPI at home\n VAP: N/A\n Comments:\n Communication: Comments: Patient and daughter (.\n Daughter called and updated.\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 386911,
"text": "Chief Complaint: DKA\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 55 y.o. woman with type I DM, disease, gastroparesis. Hx of\n multiple admissions for DKA, most recently . In past two days,\n serum glucose has been elevated to 500's. Has had some nausea typical\n of her gastroparesis. One episode of emesis. Has had fever to 101. Had\n dysuria as well.\n In the ED she was afebrile. O2 sat 98% without supplemental oxygen.\n Right groin central line placed for access. Started on IV insulin (no\n apparent bolus given) and IV fluids. Denied visual changes, dyspnea. No\n recent contacts with individuals.\n 24 Hour Events:\n MULTI LUMEN - START 01:34 AM\n NASAL SWAB - At 02:20 AM\n URINE CULTURE - At 03:25 AM\n Received 2 L LR in ICU, then switched to D5 1/2 NS given gap closed.\n History obtained from Patient\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:19 AM\n Other medications:\n ASA\n simvastatin\n salmeterol discus\n reglan\n protonix\n neurontin\n fluticasone\n colace\n amitriptyline\n SQ heparin\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Gastrointestinal: Abdominal pain, improved\n Genitourinary: Foley\n Pain: Minimal\n Pain location: back pain, chronic unchanged\n Flowsheet Data as of 10:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.6\nC (97.8\n HR: 88 (85 - 108) bpm\n BP: 104/45(58) {104/45(58) - 135/71(83)} mmHg\n RR: 13 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 4,039 mL\n PO:\n 100 mL\n TF:\n IVF:\n 3,939 mL\n Blood products:\n Total out:\n 0 mL\n 940 mL\n Urine:\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,099 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, dry oropharynx\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, diffuse mild tenderness; no\n rebound or guarding\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.8 g/dL\n 328 K/uL\n 186 mg/dL\n 0.9 mg/dL\n 20 mEq/L\n 4.9 mEq/L\n 18 mg/dL\n 107 mEq/L\n 136 mEq/L\n 26.2 %\n 6.4 K/uL\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n WBC\n 6.0\n 6.4\n Hct\n 31.1\n 26.2\n Plt\n 351\n 328\n Cr\n 1.2\n 0.9\n TropT\n <0.01\n Glucose\n 544\n 186\n Other labs: PT / PTT / INR:12.4/23.2/1.0, CK / CKMB /\n Troponin-T:36/2/<0.01, ALT / AST:21/24, Alk Phos / T Bili:96/0.3,\n Lactic Acid:2.7 mmol/L, Albumin:3.3 g/dL, LDH:151 IU/L, Ca++:7.9 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.4 mg/dL\n Microbiology: UCx: Pending\n Blood cultures: Pending\n Assessment and Plan\n DIABETIC KETOACIDOSIS (DKA): Unclear what might have tipped her\n over. Had compliants with urination albeit UA looks benign. Cultures\n pending. Does not appear toxic. ECG without acute changes.\n Troponin/CPK flat. be viral syndrome, poor po intake. Still\n appears clinically dry. Likely under resusitated from a volume\n standpoint. Advance diet as tolerated. Will get regular insulin and\n glargine when stopping insulin drip. Replete electrolytes as needed.\n ANEMIA: Hct down to 26 (from 31) with volume replacement overnight.\n This is closer to her baseline. Guaiac stools, follow serial hcts.\n CHRONIC PAIN: Getting percocet for chronic back pain, will continue\n here.\n ACUTE RENAL FAILURE: In setting of DKA and volume depletion, likely\n prerenal. Cr has improved with volume resusitation.\n UTI: Given ciprofloxicin but given low suspicion for infection will\n stop now.\n HYPERTENSION, BENIGN: Anticipate restarting antihypertensives after\n further volume resusitation.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 01:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 386993,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with hyperglycemia.\n She has had multiple admissions to for DKA, most recently\n discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, off insulin drip for almost 24hrs now, blood sugar 200\n Action:\n Continues on glargine and RISS\n Response:\n Tolerating diabetic diet\n Plan:\n Continue QID FS check and cover with RISS\n Lung sounds clear, sats >95% at room air\n No bowel movement for 2 days, continues on colace\n Received electrolyte repletion yesterday, serum Na, K and Phos wnl\n today\n Foley to be dc\nd today UO ranges, 40-80cc/hr; no ketones in urine,\n ciprofloxacin IV dc\nd. afebrile, WBC 5.1 today lactate down to 0.8\n Skin intact, takes gabapentin for peripheral neuropathy\n Fem line dc\nd, patient no IV access, house staff aware and sign out\n given to floor MDs, need PICC line of necessary.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n DIABETIC KETOACIDOSIS\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 65.5 kg\n Daily weight:\n Allergies/Reactions:\n Penicillins\n Unknown; Urtica\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: diabetic polyneuropathy and gastroparesis, grave's\n disease, reactive airway disease, seronegative arthritis, hep c, gerd,\n migraines, bilateral knee arthroscopy, TAH, depression, bone spurs in\n feet, bilat foot drop requiring wheelchair\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:100\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 92 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 320 mL\n 24h total out:\n 725 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:37 AM\n Potassium:\n 4.1 mEq/L\n 05:37 AM\n Chloride:\n 108 mEq/L\n 05:37 AM\n CO2:\n 24 mEq/L\n 05:37 AM\n BUN:\n 8 mg/dL\n 05:37 AM\n Creatinine:\n 0.8 mg/dL\n 05:37 AM\n Glucose:\n 200 mg/dL\n 05:37 AM\n Hematocrit:\n 24.5 %\n 05:37 AM\n Finger Stick Glucose:\n 228\n 06:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: 1 bag of clothing and personal effects\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 1178\n Date & time of Transfer: 10:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 386998,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - urine ketones: 10 -> 0\n - lactate, VBG: pH 7.33 pCO2 43 pO2 43 HCO3 24 Lactate:1.8\n - d/c'd Cipro bc urine cx neg at 24hr\n - started SC Insulin (28U glragine + ISS), d/c'd gtt\n - Lytes: K 4.2 -> 3.7, repleted; also repleted Mg (1.8)\n - LR x 2L, continued D5 1/2NS, another 1L LR\n - started diabetic diet\n - did not start BP med , consider in AM\n - emailed Dr. () about Ms. \n - tried to get PIV, unsuccessful, d/c fem line\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:01 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.4\nC (97.6\n HR: 81 (80 - 96) bpm\n BP: 104/54(66) {101/45(58) - 141/78(92)} mmHg\n RR: 13 (8 - 22) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 11,183 mL\n 74 mL\n PO:\n 1,160 mL\n TF:\n IVF:\n 10,023 mL\n 74 mL\n Blood products:\n Total out:\n 2,240 mL\n 605 mL\n Urine:\n 1,740 mL\n 605 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,943 mL\n -531 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n General: lying in bed comfortably\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: RRR, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, diffuse mild tenderness to palpation without any focal\n point tenderness, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 239 K/uL\n 7.9 g/dL\n 200 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 4.1 mEq/L\n 8 mg/dL\n 108 mEq/L\n 138 mEq/L\n 24.5 %\n 5.1 K/uL\n [image002.jpg]\n 01:00 AM\n 05:12 AM\n 10:42 AM\n 08:44 PM\n 05:37 AM\n WBC\n 6.0\n 6.4\n 5.1\n Hct\n 31.1\n 26.2\n 24.5\n Plt\n \n Cr\n 1.2\n 0.9\n 0.8\n 0.8\n 0.8\n TropT\n <0.01\n Glucose\n 544\n 186\n 175\n 162\n 200\n Other labs:\n Lactic Acid:1.8 mmol/L\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n 8:45p\n UA:\n Color\n Straw\n Appear\n Clear\n SpecGr\n 1.004\n pH\n 5.5\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Neg\n Bld\n Neg\n Nitr\n Neg\n Prot\n Neg\n Glu\n Neg\n Ket\n Neg\n :\n Urine and blood cx NTD\n Assessment and Plan\n Ms. is a 55 year old female with type 1 diabetes mellitus with\n many admissions for DKA, who presents with DKA.\n .\n # Diabetic Ketoacidosis: now resolved with hydration and insulin gtt,\n now on sc insulin. Urine ketones, anion gap have corrected. Blood\n sugars in good range.\n - continue 28U Glargine + ISS\n - continue PO intake\n - follow up blood and urine cultures\n - f/u with pt\n \ns physician : current insulin regimen\n .\n # Question of urinary tract infection:\n - f/u repeat urine analysis and culture\n - currently no abx\n - d/c Foley today\n .\n # Hypertension: Currently normo-tensive\n - re-start home \n .\n # Acute renal failure: Resolved with hydration.\n .\n # disease: TSH was 0.068 during last admission, however\n difficult to interpret as this is checked in setting of acute infection\n and DKA admission.\n - Continue methimazole\n .\n # Asthma: No significant wheezing on examination to suggest\n exacerbation.\n - Contiue home medications\n .\n # Anemia: Currently HCT much better than baseline (27ish), likely\n representing hemoconcentration.\n - check PM Hct\n .\n # GERD: Continue protonix\n .\n # Depression, anxiety: Continue amitriptyline and diazepam\n .\n # Chronic pain: Continue home regimen of percocet, neurontin\n ICU Care\n Nutrition: diabetic diet\n Glycemic Control: 28U glargine + ISS\n Lines:\n Multi Lumen - 01:34 AM\n d/c today prior to transfer\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: on PPI at home\n VAP: N/A\n Comments:\n Communication: Comments: Patient and daughter (.\n Daughter called and updated.\n Code status: Full code\n Disposition: transfer to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 386875,
"text": "Chief Complaint: Hyperglycemia\n HPI:\n Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with hyperglycemia.\n She has had multiple admissions to for DKA, most recently\n discharged .\n .\n She presented to the ED today after noting fevers, dysuria, thirst, and\n nausea and vomiting. She reports that she has been feeling relatively\n unwell for the last several days. Her finger stick blood glucose\n readings have been high, 300-600, for the last 3-4 days. Today when the\n readings were \"critically high\" she called her physician to come in to\n the ED. She also reports that she has had poor PO intake secondary to\n nausea that she attributes to her gastroparesis, with one episode of\n emesis that was non-bloody and non-bilious. She also noted fevers over\n the last few days up to 102. She has noted urinary frequency and\n dysuria. No cough or sputum production. She did have one episode of\n diarrhea that she attributed to the weather changing. She also is\n bothered by chronic lower leg and back pain, both of which also\n prompted her ED presentation. She reports some mild abdominal pain\n which is typical for her when she has DKA. She reports she has been\n compliant with taking her Lantus and sliding scale. She does note she\n ran out of ketone testing strips.\n .\n In the ED, her initial vital signs were: temperature of 98.8, blood\n pressure of 124/65, heart rate of 95, respiratory rate of 20, and\n oxygen saturation of 98% on RA. A finger stick glucose was critically\n high at triage. The ED team had a difficult time obtaining access, so a\n right femoral central line was placed. She was started on an insulin\n drip at 7 units per hour and she was started on intravenous fluids, on\n her first liter at time of transfer.\n .\n On arrival to the , she reports that she feels \"lousy.\" She denies\n any visual changes, chest pain, shortness of breath.\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 4 units/hour\n Other ICU medications:\n Home medications:\n - Amitriptyline 25 mg\n - Cozaar 50 mg\n - Diazepam 5 mg \n - Colace 100 mg\n - Flovent\n - Humalog 100 units TID\n - Lantus 28 units \n - Naprosyn 500 mg \n - Neurontin 900 mg TID\n - Percocet q6H PRN Pain\n - Protonix 40 mg daily\n - Reglan 10 mg daily\n - Singulair 10 mg daily\n - Serevent diskus\n - Sulfasalazine 1000 mg \n - Tapazole 10 mg TID\n - Zocor 10 mg\n - Zomig 2.5 mg\n - ASA 81 mg\n Past medical history:\n Family history:\n Social History:\n 1. Diabetes Mellitus Type 1: 5 years old at age of diagnosis. Several\n episodes of DKA, managed on 28 units Lantus plus HISS, followed by\n Dr. at \n 2. Diabetic polyneuropathy and gastroparesis\n 3. Hypertension\n 4. Grave's disease s/p RAI \n 5. Reactive airway disease\n 6. Seronegative arthritis, followed in rheumatology\n 7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, never\n been on antiviral therapy, acquired via blood transfusion during\n surgery in \n 8. GERD\n 9. Migraines\n 10. Bilateral knee arthroscopy in \n 11. s/p TAH and pelvic floor surgery with bladder lift\n 12. Depression\n 13. Bone spurs in feet\n 14. Bilateral foot drop requiring wheelchair use\n 15. Coagulase negative staph bacteremia \n (per OMR)\n Her mother died of colon cancer. There are multiple family members with\n DM.\n (Per OMR)\n Patient lives in a multi apartment building in the same apartment with\n a daughter, grandaughter, and grandson. She has a son, daughter and\n another brother who live on another floor. She is a never smoker and\n does not use alcohol or drugs. She has not worked for many years.\n Review of systems:\n Per HPI, otherwise negative\n Flowsheet Data as of 04:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 99 (99 - 108) bpm\n BP: 112/59(72) {110/59(72) - 135/65(80)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 62 Inch\n Total In:\n 1,605 mL\n PO:\n TF:\n IVF:\n 1,605 mL\n Blood products:\n Total out:\n 0 mL\n 780 mL\n Urine:\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 825 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///13/\n Physical Examination\n BP: 135/65 P: 102 R: 18 O2: 99% on 1L nasal cannula\n General: Sleepy, thin, age appropriate female lying in bed on her right\n side, in NAD\n HEENT: Sclera anicteric, oropharynx clear with poor dentition, dry\n mucous membranes\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Borderline tachycardic, regular, normal S1 + S2, 2/6 SEM loudest at\n the RUSB, rubs, gallops\n Abdomen: soft, diffuse mild tenderness to palpation without any focal\n point tenderness, non-distended, bowel sounds present, no rebound\n tenderness or guarding, no organomegaly\n GU: Right femoral line in place, c/d/i\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema,\n tenderness to palpation along bilateral shins, no calf tenderness\n Neuro: A&Ox3, CN's symmetric\n Labs / Radiology\n 351 K/uL\n 10.1 g/dL\n 544 mg/dL\n 1.2 mg/dL\n 22 mg/dL\n 13 mEq/L\n 98 mEq/L\n 4.5 mEq/L\n 133 mEq/L\n 31.1 %\n 6.0 K/uL\n [image002.jpg]\n \n 2:33 A9/11/ 01:00 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 6.0\n Hct\n 31.1\n Plt\n 351\n Cr\n 1.2\n Glucose\n 544\n Other labs: PT / PTT / INR:12.3/26.4/1.0, Lactic Acid:2.7 mmol/L,\n Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Microbiology:\n None new pending\n .\n Urine analysis:\n Glucose 1000, Ketone 150\n .\n Images:\n CXR: (My read) Lungs clear bilaterally, no evidence of effusion,\n consolidation or infiltrate.\n .\n EKG:\n Sinus, normal axis, normal intervals, no ST/TW changes. No changes as\n compared to prior.\n .\n TTE \n LVEF >55%\n Assessment and Plan\n Ms. is a 55 year old female with type 1 diabetes mellitus with\n many admissions for DKA, who presents with DKA.\n .\n # Diabetic Ketoacidosis: Patient has history of many admissions for\n DKA.\n It is not entirely clear what prompted this episode, though could be\n secondary to poor PO intake coupled with urinary tract infection. Urine\n anaylsis was unremarkable, EKG was overall unchanged. CXR without\n evidence of infiltrate.\n - Continue to hydrate with normal saline or lactated ringers (given\n wish to avoid hyperchloriemic acidosis), with 1 L boluses until fluid\n status improved\n - Monitoring q4hour electrolytes, especially potassium, anion gap\n - Continue insulin drip until anion gap closes, glucose <200, then\n start sub-cutaneous insulin (start with home dose of Lantus 28 units)\n and IVF with 1/2NS with D5\n - Initiate IVF with potassium for goal potassium , starting when\n potassium <5\n - Send blood and urine cultures\n - Follow up final read on chest x-ray\n - Will touch base with team in AM to let them know she has been\n admitted\n .\n # Question of urinary tract infection: Sending repeat urine analysis\n and culture.\n - Will initiate ciprofloxacin for now after repeat culture sent, can\n stop if negative\n .\n # Hypertension: Currently normo-tensive upon arrival to the .\n - Will re-start and adjust home medications as needed\n .\n # Hyponatremia: Patient's corrected sodium for her hyperglycemia is\n actually 135, so she is not truly hyponatremic. Will continue to\n monitor.\n .\n # Acute renal failure: Baseline appears to be 0.7-0.8. Suspect this is\n due to poor PO intake in setting of nauesa and gastroparesis, coupled\n with osmotic diuresis from DKA and taking and NSAIDs.\n - Holding naproxen, Cozaar\n - IVF for treatment of DKA as discussed above\n - Should renal function not return to baseline, would further work-up\n with renal ultrasound, FeNa, etc.\n .\n # Anion gap acidosis: Suspect largely due to DKA, however patient does\n have elevated lactate that may also be playing a role. BUN also\n elevated above her baseline (10->20). No gap of the gap (no secondary\n acid-base disorder) appears to be present.\n - Continue to monitor\n - Checking albumin to further assess gap\n - Checking VBG to get sense of pH\n .\n # disease: TSH was 0.068 during last admission, however\n difficult to interpret as this is checked in setting of acute infection\n and DKA admission.\n - Continue methimazole\n .\n # Asthma: No significant wheezing on examination to suggest\n exacerbation.\n - Contiue home medications\n .\n # Anemia: Currently HCT much better than baseline (27ish), likely\n representing hemoconcentration.\n - Guaiac stools, continue to monitor.\n .\n # GERD: Continue protonix\n .\n # Depression, anxiety: Continue amitriptyline and diazepam\n .\n # Chronic pain: Continue home regimen of percocet, neurontin\n .\n # FEN: IVF as discussed above, replete electrolytes, sips until out of\n DKA\n .\n # Prophylaxis: Subcutaneous heparin, bowel regimen, outpatient PPI\n .\n # Access: Right femoral TLC for now, patient has very difficult access,\n will likely need PICC line if anticipated hospital stay beyond \n days\n .\n # Code: Full\n .\n # Communication: Patient and daughter (\n .\n # Disposition: Pending above\n .\n , MD\n PGY-3 Internal Medicine\n Pager \n ICU Care\n Nutrition: NPO for now as discussed above\n Glycemic Control: Insulin drip, transitioning to SQ as noted above\n Lines:\n Multi Lumen - 01:34 AM, will plan for PICC when able\n Prophylaxis:\n DVT: Heparin SQ\n Stress ulcer: on PPI at home\n VAP: N/A\n Comments:\n Communication: Comments: See above. Daughter called and\n updated.\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386963,
"text": "Diabetic Ketoacidosis (DKA)\n Assessment:\n Blood sugars 161.. bs 220 . pt reports feeling better with improved\n appetite. Mag 1.8, K=3.7\n Action:\n Blood sugars covered with regular insulin and glargine dose 28 units q\n 12 hours\n Response:\n Labs improved, pt feeling betterlactate decreased to 0.8\n Plan:\n Am labs, check blood sugars qid and tx,glargine dose . After am labs\n return.. check with team regarding d/c fem aline. Pt is a difficult\n stick and will need a picc if access required. Fem aline must come out\n in am d/t 24 hours.\n"
},
{
"category": "Physician ",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 386865,
"text": "Chief Complaint: ADMIT Note:\n Diabetic ketoacidosis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Hx of type I DM, disease, gastroparesis. Hx of multiple\n admissions for DKA, most recently . In past two days, serum\n glucose has been elevated to 500's. Has had some nausea typical of her\n gastroparesis. One episode of emesis. Has had fever to 101. Had dysuria\n as well.\n Came to ED where she was afebrile. O2 sat 98% without supplemental\n oxygen. Right groin central line placed for access. Started on IV\n insulin (no apparent bolus given) and IV fluids. Denied visual changes,\n dyspnea. No recent contacts with individuals.\n PH:\n Diabetes mellitus, type I\n Gastroparesis\n Disease\n Polyneuropathy\n Hypertension\n Asthma\n Arthritis\n Hepatitis C\n GERD\n Migraine headache\n Depression\n Meds at home: include among others - colace, insulin, naproxyn,\n protonix, singulair, reglan, zocor, ASA\n FH/SH/ROS - see resident note\n History obtained from Medical records\n Allergies:\n Penicillins\n Unknown; Urtica\n Last dose of Antibiotics:\n Infusions:\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 101 (101 - 106) bpm\n BP: 135/65(80) {110/59(73) - 135/65(80)} mmHg\n RR: 13 (13 - 17) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 62 Inch\n Total In:\n 99 mL\n PO:\n TF:\n IVF:\n 99 mL\n Blood products:\n Total out:\n 0 mL\n 660 mL\n Urine:\n 160 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -561 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube, Dry mucus membranes\n Lymphatic: No(t) Cervical WNL\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , Crackles : Few, which cleared with deep\n breathing, No(t) Bronchial: , No(t) Wheezes : , No(t) Diminished: ,\n No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, diffuse tenderness; no rebound, Bowel sounds soft,\n No(t) Distended, No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent edema, Left lower\n extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand, Lower\n back pain; no clear CVA tenderness\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 10.1 g/dL\n 351 K/uL\n 544\n 1.2 mg/dL\n 13\n 4.5 mEq/L\n 22 mg/dL\n 98 mEq/L\n 133 mEq/L\n 31.1 %\n 6.0 K/uL\n [image002.jpg]\n 01:00 AM\n WBC\n 6.0\n Hct\n 31.1\n Plt\n 351\n Cr\n 1.2\n Other labs: PT / PTT / INR:12.3/26.4/1.0, Lactic Acid:2.7 mmol/L,\n Ca++:8.6 mg/dL, Mg++:1.8 mg/dL, PO4:3.4 mg/dL\n Imaging: CXR: no infiltrates or effusions\n Assessment and Plan\n DIABETIC KETOACIDOSIS\n FEVER\n ANEMIA\n GASTROPARESIS\n =================\n Patient with evidence of diabetic ketoacidosis. Had fever with symptoms\n of urinary tract infection, although UA not impressive. Would treat for\n UTI at this time. CXR clear; no acute ECG changes. Patient still with\n evidence of volume depletion by exam and labs (blood sugar > 500). Need\n to increase fluids (at least 4L down) and increase insulin (bicarb has\n dropped from admission to ED). Would bolus with 7 units of insulin and\n continue insulin infusion. be somewhat insulin resistant with\n possible infection. Would begin to replete potassium now along with\n magnesium. No need to give bicarbonate now. Contact team later\n today.\n Hct down chronically. No evidence of active bleeding. Will probably\n drop with volume resuscitation. Not at transfusion threshold.\n Try to place PIC line later today and remove groin line.\n ICU Care\n Nutrition: oral as tolerated\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 01:34 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386941,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with\n hyperglycemia.She has had multiple admissions to for DKA, most\n recently discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, FS Q1hr while on insulin drip, blood sugars trending\n down, anion gap closing; received KCl and Magnesium replacement, no\n nausea and vomiting but complained of diffuse abdominal pain, soft but\n tender to touch, not common to this patient whenever she is admitted\n with DKA c/w her severe gastroparesis\n no diarrhea\n Action:\n Insulin drip dc\nd at 1100, started on glargine 28 units and RISS to\n cover FS q4hrs, received additional 2 liters of LR as fluid\n resuscitation and 1L of D5 0.45 NS at 250 cc/hr while patient on NPO;\n diabetic diet started;\n Response:\n Tolerating PO\ns, latest FS 263\n covered with Regular insulin\n Plan:\n Continue FS q4hrs, cover with RISS; give glargine due at 10pm; ? change\n to humalog sliding scale in am\n Lung sounds clear, sats >95% at room air\n No bowel movement to day, continues on colace\n Receiving NaPhos 15 mmol Phos of 1.8, repeat lytes at 9pm instead\n of 7pm to finish phos repletion\n Foley intact, 40-80cc/hr; ketones in urine trending down from 150 to\n 10; few bacteria, denies dysuria\n ciprofloxacin IV dc\nd. afebrile, WBC\n wnl\n Skin intact, takes gabapentin for peripheral neuropathy\n Patient\ns daughter called, updates given by the patient\n Femoral line in place, PICC placement dc\nd. medical team aware of\n patient having poor access, no PIV.\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386945,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with\n hyperglycemia.She has had multiple admissions to for DKA, most\n recently discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, FS Q1hr while on insulin drip, blood sugars trending\n down, anion gap closing; received KCl and Magnesium replacement, no\n nausea and vomiting but complained of diffuse abdominal pain, soft but\n tender to touch, not common to this patient whenever she is admitted\n with DKA c/w her severe gastroparesis\n no diarrhea\n Action:\n Insulin drip dc\nd at 1100, started on glargine 28 units and RISS to\n cover FS q4hrs, received additional 2 liters of LR as fluid\n resuscitation and 1L of D5 0.45 NS at 250 cc/hr while patient on NPO;\n diabetic diet started;\n Response:\n Tolerating PO\ns, latest FS 263\n covered with Regular insulin\n Plan:\n Continue FS q4hrs, cover with RISS; give glargine due at 10pm; ? change\n to humalog sliding scale in am\n Lung sounds clear, sats >95% at room air\n No bowel movement to day, continues on colace\n Receiving NaPhos 15 mmol Phos of 1.8, repeat lytes at 9pm instead\n of 7pm to finish phos repletion\n Foley intact, 40-80cc/hr; ketones in urine trending down from 150 to\n 10; few bacteria, denies dysuria\n ciprofloxacin IV dc\nd. afebrile, WBC\n wnl\n Skin intact, takes gabapentin for peripheral neuropathy\n Patient\ns daughter called, updates given by the patient\n Femoral line in place, PICC placement dc\nd. medical team aware of\n patient having poor access, no PIV.\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386929,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with\n hyperglycemia.She has had multiple admissions to for DKA, most\n recently discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, FS Q1hr while on insulin drip, blood sugars trending\n down, anion gap closing; received KCl and Magnesium replacement, no\n nausea and vomiting but complained of diffuse abdominal pain, soft but\n tender to touch, not common to this patient whenever she is admitted\n with DKA c/w her severe gastroparesis\n no diarrhea\n Action:\n Insulin drip dc\nd at 1100, started on glargine 28 units and RISS to\n cover FS QID and at HS, received additional 2 liters of LR as fluid\n resuscitation and 1L of D5 0.45 NS at 250 cc/hr while patient on NPO;\n diabetic diet started; lytes followed q4hrs\n Response:\n Tolerating PO\n Plan:\n Lung sounds clear, sats >95% at room air\n No bowel movement to day, continues on colace\n Foley intact, 40-80cc/hr; ketones in urine trending down from 150 to\n 10; few bacteria, denies dysuria\n ciprofloxacin IV dc\nd. afebrile, WBC\n wnl\n Skin intact, takes gabapentin for peripheral neuropathy\n Patient\ns daughter called, updates given by the patient\n Femoral line in place, PICC placement dc\nd. medical team aware of\n patient having poor access, no PIV.\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 386926,
"text": "Diabetic Ketoacidosis (DKA)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 387025,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with hyperglycemia.\n She has had multiple admissions to for DKA, most recently\n discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, off insulin drip for almost 24hrs now, blood sugar 200\n Action:\n Continues on glargine and RISS\n Response:\n Tolerating diabetic diet, FS 308 latest, covered with 8 units RI\n Plan:\n Continue QID FS check and cover with the new RISS coverage, glargine\n changed to breakfast and bedtime\n Lung sounds clear, sats >95% at room air; advair and flovent for hx of\n COPD\n Hct 24 with am, labs recheck this pm, 25.6 latest. No signs of bleeding\n might be dilutional\n received about 7 L fluid IV yesterday. Continue\n to follow, guaic all stools\n No bowel movement for 2 days, continues on colace\n Received electrolyte repletion yesterday, serum Na, K and Phos wnl\n today\n Foley dc\nd today UO ranges, adequate urine output, no ketones in\n urine, ciprofloxacin IV dc\nd. afebrile, WBC 5.1 today lactate down to\n 0.8\n Skin intact, takes gabapentin for peripheral neuropathy\n Fem line dc\nd, patient no IV access, house staff aware and sign out\n given to floor MDs, need PICC line of necessary.\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 387030,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with hyperglycemia.\n She has had multiple admissions to for DKA, most recently\n discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, off insulin drip for almost 24hrs now, blood sugar 200\n Action:\n Continues on glargine and RISS\n Response:\n Tolerating diabetic diet, FS 308 latest, covered with 8 units RI\n Plan:\n Continue QID FS check and cover with the new RISS coverage, glargine\n changed to breakfast and bedtime\n Lung sounds clear, sats >95% at room air; advair and flovent for hx of\n COPD\n Hct 24 with am, labs recheck this pm, 25.6 latest. No signs of bleeding\n might be dilutional\n received about 7 L fluid IV yesterday. Continue\n to follow, guaic all stools\n No bowel movement for 2 days, continues on colace\n Received electrolyte repletion yesterday, serum Na, K and Phos wnl\n today\n Foley dc\nd today UO ranges, adequate urine output, no ketones in\n urine, ciprofloxacin IV dc\nd. afebrile, WBC 5.1 today lactate down to\n 0.8\n Skin intact, takes gabapentin for peripheral neuropathy\n Fem line dc\nd, patient no IV access, house staff aware and sign out\n given to floor MDs, need PICC line of necessary.\n ------ Protected Section ------\n 9 pm FS 219\n pt received 28 units Glargine sq and 4 units Humalog sq\n (decreased dose from sliding scale x 1)\n VSS afebrile, HR 104, bp 113/64 pt eating snack, voided 700 cc\n on bedpan.\n IV Nurse called at 9 pm ~ will try to place peripheral access.\n Femoral line d\ncd on days. Pt turning side to side, back pain\n unchanged\n due for Percocet at 12 midnight.\n Pt stable for transfer to 11R\n ------ Protected Section Addendum Entered By: , RN\n on: 21:40 ------\n"
},
{
"category": "Nursing",
"chartdate": "2134-10-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 387031,
"text": "Ms. is a 55 year-old female with DMI, severe gastroparesis,\n HTN, Grave's Disease and Hepatitis C who presents with hyperglycemia.\n She has had multiple admissions to for DKA, most recently\n discharged .\n Pt presents to EW from home after one week of fever and feeling\n generally unwell. Reports FSBS at home >600 for one week. Pt avoids\n coming into the EW as she is a difficult stick and frequently requires\n fem line placements. In Ew FEM line was placed, insulin gtt was started\n at 7 units/hr and pt was transferred to MICU for further management.\n Diabetic Ketoacidosis (DKA)\n Assessment:\n Oriented x 3, off insulin drip for almost 24hrs now, blood sugar 200\n Action:\n Continues on glargine and RISS\n Response:\n Tolerating diabetic diet, FS 308 latest, covered with 8 units RI\n Plan:\n Continue QID FS check and cover with the new RISS coverage, glargine\n changed to breakfast and bedtime\n Lung sounds clear, sats >95% at room air; advair and flovent for hx of\n COPD\n Hct 24 with am, labs recheck this pm, 25.6 latest. No signs of bleeding\n might be dilutional\n received about 7 L fluid IV yesterday. Continue\n to follow, guaic all stools\n No bowel movement for 2 days, continues on colace\n Received electrolyte repletion yesterday, serum Na, K and Phos wnl\n today\n Foley dc\nd today UO ranges, adequate urine output, no ketones in\n urine, ciprofloxacin IV dc\nd. afebrile, WBC 5.1 today lactate down to\n 0.8\n Skin intact, takes gabapentin for peripheral neuropathy\n Fem line dc\nd, patient no IV access, house staff aware and sign out\n given to floor MDs, need PICC line of necessary.\n ------ Protected Section ------\n 9 pm FS 219\n pt received 28 units Glargine sq and 4 units Humalog sq\n (decreased dose from sliding scale x 1)\n VSS afebrile, HR 104, bp 113/64 pt eating snack, voided 700 cc\n on bedpan.\n IV Nurse called at 9 pm ~ will try to place peripheral access.\n Femoral line d\ncd on days. Pt turning side to side, back pain\n unchanged\n due for Percocet at 12 midnight.\n Pt stable for transfer to 11R\n ------ Protected Section Addendum Entered By: , RN\n on: 21:40 ------\n 9:45 pm update\n Temp 98.8 HR 90 SR, no vea noted, BP 147/83\n ------ Protected Section Addendum Entered By: , RN\n on: 21:43 ------\n"
},
{
"category": "ECG",
"chartdate": "2134-09-30 00:00:00.000",
"description": "Report",
"row_id": 274518,
"text": "Sinus rhythm. Poor R wave progression. Non-specific ST-T wave abnormalities.\nCompared to the previous tracing of the QRS voltage is decreased and\nsinus bradycardia is absent.\n\n"
}
] |
90,720 | 151,648 | 85 yo man with multiple myeloma as well as a history neurogenic presyncope secondary to dysfunction presents with weakness, fall and near syncope. | Prominent ventricles, and extra-axial CSF spaces and cerebral sulci are noted, related to mild diffuse parenchymal volume loss, likely age appropriate and are unchanged. Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Normal aortic diameter at the sinus level. Trivial MR. LV inflow pattern c/w impairedrelaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal main PA. No Doppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. The aortic valve leaflets(3) are mildly thickened but aortic stenosis is not present. Amyloid involvementHeight: (in) 70Weight (lb): 141BSA (m2): 1.80 m2BP (mm Hg): 130/80HR (bpm): 85Status: OutpatientDate/Time: at 15:58Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH. Both medial cerebral arteries demonstrates tortuosity and lack of flow in the M2 and M3 segments, possibly related with arteriosclerotic changes versus artifact, correlation with CTA of the head and neck is recommended if clinically warranted. Trivial mitral regurgitation is seen. Mildly dilated ascending aorta. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is reduced. The left ventricularend diastolic cavity dimension remains quite low, suggesting significantdiastolic filling impairment or volume depletion or both. TECHNIQUE: Non-contrast CT of the head was performed. CONCLUSION: Diffuse signal intensity abnormalities in the vertebral bodies compatible with the history of multiple myeloma. The patient currently remains asymptomatic. Unchanged mucus retention cyst noted in the left maxillary sinus. - F/u I/O - F/U JVP - 500cc NS bolus if hypotensive - Move slowly from one position to another (avoid orhtostatics) - Telemetry - EKG . No 2D or Doppler evidence of distal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace aorticregurgitation is seen. No contraindications for IV contrast FINAL REPORT MR LUMBAR SPINE, HISTORY: Multiple myeloma and autonomic neuropathy with urinary retention. 1)Altered Mental Status- -Orthostatic Hypotension- -Salt Tabs -Fludricort -Maintain optimal fluid status -Rx with Vanco -Return to oncology floor today. Hypotension (not Shock) Assessment: SBP at start of shift up to 170s systolic. Hypotension (not Shock) Assessment: SBP at start of shift up to 170s systolic. Unfortunately, his SBP dropped again, aphasia returned and he was transferred to the . Unfortunately, his SBP dropped again, aphasia returned and he was transferred to the . Unfortunately, his SBP dropped again, aphasia returned and he was transferred to the . Chief Complaint: 85 yo man with multiple myeloma as well as a history neurogenic presyncope secondary to autonomic dysfunction presenting initially with weakness and UTI, now with aphasia in the setting of hypotension, both have resolved with fluid repletion. ), BPH c/b urinary tract obstruction necessitating foley who was admitted with weakness and "near syncope" observed by VNA. ), BPH c/b urinary tract obstruction necessitating foley who was admitted with weakness and "near syncope" observed by VNA. ), BPH c/b urinary tract obstruction necessitating foley who was admitted with weakness and "near syncope" observed by VNA. Chief Complaint: Hypotension 24 Hour Events: CALLED OUT Allergies: Sulfa (Sulfonamides) Hives; Rash; Last dose of Antibiotics: Cefipime - 10:00 AM Vancomycin - 09:00 PM Infusions: Other ICU medications: Pantoprazole (Protonix) - 09:01 PM Heparin Sodium (Prophylaxis) - 12:00 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 07:53 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.6C (97.8 Tcurrent: 35.4C (95.7 HR: 84 (75 - 97) bpm BP: 155/71(92) {104/43(58) - 191/142(125)} mmHg RR: 17 (11 - 31) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Total In: 915 mL 117 mL PO: 250 mL TF: IVF: 665 mL 117 mL Blood products: Total out: 850 mL 810 mL Urine: 850 mL 810 mL NG: Stool: Drains: Balance: 65 mL -693 mL Respiratory support O2 Delivery Device: None SpO2: 99% ABG: ///25/ Physical Examination General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese Extremities: Right: 1+, Left: 1+ Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal Labs / Radiology 217 K/uL 10.1 g/dL 98 mg/dL 0.6 mg/dL 25 mEq/L 3.1 mEq/L 10 mg/dL 105 mEq/L 139 mEq/L 29.2 % 5.8 K/uL [image002.jpg] 12:29 PM 01:12 PM 01:30 PM 04:42 AM 04:21 AM WBC 9.2 4.4 5.8 Hct 20.6 30.4 29.1 29.2 Plt 154 207 217 Cr 0.6 0.7 0.6 TropT <0.01 Glucose 123 97 98 Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB / Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4, Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL, Mg++:1.6 mg/dL, PO4:3.6 mg/dL Assessment and Plan ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 04:30 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: 1)Altered Mental Status- -Orthostatic Hypotension- -Salt Tabs -Fludricort -Maintain optimal fluid status -Rx with Vanco -Return to oncology floor today. Hypotension (not Shock) Assessment: SBP at start of shift up to 170s systolic. Hypotension (not Shock) Assessment: SBP at start of shift up to 170s systolic. Chief Complaint: 85 yo man with multiple myeloma as well as a history neurogenic presyncope secondary to autonomic dysfunction presenting initially with weakness and UTI, now with aphasia in the setting of hypotension, both have resolved with fluid repletion. Pt discharged from after he had an episode of expressive aphasia, & SBP 90. Pt discharged from after he had an episode of expressive aphasia, & SBP 90. Again his SBP dropped to 110 and his aphasia returned. Again his SBP dropped to 110 and his aphasia returned. Again his SBP dropped to 110 and his aphasia returned. Again his SBP dropped to 110 and his aphasia returned. Again his SBP dropped to 110 and his aphasia returned. Again his SBP dropped to 110 and his aphasia returned. Assessment and Plan assessment and plan: 85 yo man with multiple myeloma as well as a history neurogenic presyncope secondary to autonomic dysfunction presenting initially with weakness and UTI, now with aphasia in the setting of hypotension, both have resolved with fluid repletion. He has a picture of orthostatic instability and in the setting of mild hypovolemia he has had recurrent altered mental status. Plan: Monitor orthostatic BP, continue florinef, IV fluid boluses for hypotension. Altered mental status (not Delirium) Assessment: At start of shift pt A&O x 3. | 49 | [
{
"category": "Echo",
"chartdate": "2123-11-02 00:00:00.000",
"description": "Report",
"row_id": 93410,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Amyloid involvement\nHeight: (in) 70\nWeight (lb): 141\nBSA (m2): 1.80 m2\nBP (mm Hg): 130/80\nHR (bpm): 85\nStatus: Outpatient\nDate/Time: at 15:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Mildly depressed LVEF. No\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild [1+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is small. Overall left ventricular\nsystolic function is mildly depressed (LVEF= 40-50 %) at least in part due to\ncontractile dyssynchrony. Right ventricular chamber size and free wall motion\nare normal. The ascending aorta is mildly dilated. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. There\nis no mitral valve prolapse. Trivial mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation. The tricuspid valve\nleaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is reduced. The left ventricular\nend diastolic cavity dimension remains quite low, suggesting significant\ndiastolic filling impairment or volume depletion or both.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-24 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1035271,
"text": " 8:50 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please evaluate for cord compression.\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MM and autonomic neuropathy with persistent urinary\n retension.\n REASON FOR THIS EXAMINATION:\n Please evaluate for cord compression.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR LUMBAR SPINE, \n\n HISTORY: Multiple myeloma and autonomic neuropathy with urinary retention.\n\n Sagittal imaging was performed with long TR, long TE fast spin echo, STIR, and\n short TR, short TE spin echo technique. Axial long TR, long TE fast spin echo\n imaging was performed. Comparison to a lumbar spine MR .\n\n FINDINGS: Again identified are extensive vertebral body signal intensity\n abnormalities compatible with a diagnosis of multiple myeloma. Again seen is\n loss of height of the T12 and L1 vertebral bodies. These findings appear\n unchanged since the previous study. Again seen is a spherical region of\n hypointensity on the short TR images in the L2 vertebral body. This is also\n unchanged. There is no evidence of cauda equina compression. Alignment of\n the spine appears normal. Axial images at T11-12, , , and \n demonstrate mild degenerative disc disease with no evidence of canal or\n foraminal encroachment.\n\n At L3-4, there is a protrusion of the intervertebral disc entering the right\n side of the spinal canal. This causes posterior displacement of the right L4\n nerve root. The neural foramina appear normal.\n\n At L4-5, there is asymmetric bulge of the intervertebral disc with no evidence\n of nerve root compression. There is right-sided facet joint osteophyte\n formation.\n\n At L5-S1, there is a minimal bulge of the intervertebral disc with no\n encroachment on the thecal sac or neural foramina.\n\n Signal intensity abnormalities compatible with the history of myeloma are also\n noted in the visualized portions of the sacrum and the iliac bones.\n\n CONCLUSION: Diffuse signal intensity abnormalities in the vertebral bodies\n compatible with the history of multiple myeloma.\n\n No evidence of cauda equina compression.\n\n Right-sided disc protrusion at L3-4.\n\n (Over)\n\n 8:50 AM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Please evaluate for cord compression.\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1035420,
"text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infection or other abnormalities.\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MM, autonomic dysfunction with acute onset of hypotension\n and mental status change.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infection or other abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Follow-up.\n\n As compared to the previous examination, there is no relevant change. No\n newly occurred focal parenchymal opacity suggestive of pneumonia, no\n overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1035064,
"text": " 4:27 PM\n CHEST (PA & LAT) Clip # \n Reason: infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with weakness near syncopal episode\n REASON FOR THIS EXAMINATION:\n infectious process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old male with weakness and syncopal episode, to rule out a\n cardiopulmonary process.\n\n TECHNIQUE: AP and lateral radiographs of the chest were performed.\n Comparison is made with CT chest of .\n\n FINDINGS:\n\n There are multiple surgical sutures at the right lung base from a prior\n resection. There is stable cardiomegaly. There are no acute focal\n consolidations. There is raised right hemidiaphragm consistent with lung\n resection.\n\n Multiple gas-filled distended loops of colon are seen in the upper abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-26 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1035638,
"text": " 10:27 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: eval for stenosis\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with expressive aphasia in the setting of hypotension\n REASON FOR THIS EXAMINATION:\n eval for stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Expressive aphasia, evaluate for stenosis.\n\n FINDINGS: Areas of plaque formation are noted at the proximal right ICA, as\n well as the proximal left ICA extending into the bulb. No hemodynamically\n significant stenosis is identified. Velocities are as follows.\n\n For the right, proximal CCA 44 cm/sec, distal CCA 49 cm/sec, proximal ICA 34\n cm/sec, distal ICA 42 cm/sec, additional distal ICA 35 cm/sec, ECA 48 cm/sec,\n with antegrade flow in the vertebral artery. ICA/CCA ratio 0.83.\n\n For the left, proximal CCA 64 cm/sec, distal CCA 52 cm/sec, proximal ICA 47\n cm/sec, mid ICA 45.2 cm/sec, distal ICA 41 cm/sec, ECA 69 cm/sec, with\n antegrade flow in the vertebral artery. ICA/CCA ratio 0.74.\n\n IMPRESSION: No evidence of hemodynamically significant stenosis. Plaque\n formation involving the origin of the internal carotid arteries bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-25 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 1035484,
"text": " 2:35 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute stroke or for stenosis of intracranial vessel\n Admitting Diagnosis: WEAKNESS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with expressive aphasia in the setting of hypotension\n REASON FOR THIS EXAMINATION:\n eval for acute stroke or for stenosis of intracranial vessels. PLEASE PERFORM\n MRI AND MRA OF HEAD.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RXRa MON 7:25 PM\n There is no evidence of acute ischemic changes. Prominence of the ventricles\n and sulci, likely age-related and developmental in nature. There is no shift\n or normally placed midline structures. M2 segments bilaterally versus\n artifact.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN\n\n CLINICAL INDICATION: 85-year-old man with expressive aphasia in the setting\n of hypotension, please evaluate for stroke or stenosis of the intracranial\n vessels.\n\n COMPARISON: Prior MRI of the head and CT of the head dated .\n\n TECHNIQUE: MRI of the head. Pre-contrast axial and sagittal T1-weighted\n images were obtained, axial FLAIR, axial T2, axial magnetic susceptibility,\n diffusion-weighted sequences. After the administration of intravenous\n gadolinium contrast material, the T1-weighted images were repeated and axial\n T1, sagittal MP-RAGE and multiplanar reconstructions.\n\n MRI OF THE HEAD:\n\n 3D time-of-flight arteriography was obtained, multiple rotational images were\n submitted for interpretation as well as the axial source images.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect or\n large territorial infarction. The ventricles and sulci are slightly\n prominent, likely age-related and involutional in nature.\n\n On T2 and FLAIR sequences, there are multiple scattered hyperintense foci\n likely consistent with chronic microvascular ischemic changes. No diffusion\n abnormalities are detected. The orbits appear unremarkable, the paranasal\n sinuses again demonstrate mucus retention cyst in the left maxillary sinus,\n the mastoid air cells appear unremarkable. After the administration of\n intravenous gadolinium contrast, there is no evidence of abnormal enhancement.\n\n IMPRESSION: There is no evidence of acute ischemic changes. After the\n administration of gadolinium contrast, there is no evidence of abnormal\n enhancement. No diffusion abnormalities are detected. Prominence of the\n (Over)\n\n 2:35 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute stroke or for stenosis of intracranial vessel\n Admitting Diagnosis: WEAKNESS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sulci and ventricles, likely age-related and involutional nature.\n\n Unchanged mucus retention cyst noted in the left maxillary sinus.\n\n MRA OF THE HEAD.\n\n FINDINGS: There is evidence of vascular flow in both internal carotids as\n well as the vertebrobasilar system. Both medial cerebral arteries\n demonstrates tortuosity and lack of flow in the M2 and M3 segments, possibly\n related with arteriosclerotic changes versus artifact, correlation with CTA of\n the head and neck is recommended if clinically warranted. In the posterior\n circulation, there is no evidence of stenosis or narrowing of the vessels.\n\n IMPRESSION: Possible narrowing of the M2 and M3 segments bilaterally, more\n evident on the right, possibly arteriosclerotic in nature, however, artifact\n cannot be completely ruled out, correlation with CTA of the head and neck is\n recommended if clinically warranted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-25 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 1035485,
"text": ", S. MED 2:35 PM\n MRA BRAIN W/O CONTRAST; MR HEAD W & W/O CONTRAST Clip # \n Reason: eval for acute stroke or for stenosis of intracranial vessel\n Admitting Diagnosis: WEAKNESS\n Contrast: MAGNEVIST Amt: 13\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with expressive aphasia in the setting of hypotension\n REASON FOR THIS EXAMINATION:\n eval for acute stroke or for stenosis of intracranial vessels. PLEASE PERFORM\n MRI AND MRA OF HEAD.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n There is no evidence of acute ischemic changes. Prominence of the ventricles\n and sulci, likely age-related and developmental in nature. There is no shift\n or normally placed midline structures. M2 segments bilaterally versus\n artifact.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1035482,
"text": " 2:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with expressive aphasia in setting of hypotension\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 7:25 PM\n No acute intracranial process, including no evidence for hemorrhage, edema,\n mass effect, or acute ischemia. Please note that MRI is more sensitive for\n evaluation of ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old male with expressive aphasia in the setting of\n hypertension.\n\n COMPARISON: CT of chest from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n administration of IV contrast.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\n infarction. The ventricles and sulci are normal in caliber and configuration.\n The -white matter differentiation is preserved. Again noted are carotid\n artery calcifications and a large mucus retention cyst in the left maxillary\n sinus. Remainder of the paranasal sinuses and mastoid air cells are normally\n pneumatized and clear.\n\n IMPRESSION: No acute intracranial process. However, MRI is more sensitive\n for acute ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1035483,
"text": ", S. MED 2:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with expressive aphasia in setting of hypotension\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No acute intracranial process, including no evidence for hemorrhage, edema,\n mass effect, or acute ischemia. Please note that MRI is more sensitive for\n evaluation of ischemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1036189,
"text": " 4:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for acute bleed, evidence of stroke.\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypotension, confusion and elevated PTT.\n REASON FOR THIS EXAMINATION:\n Please assess for acute bleed, evidence of stroke.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:41 PM\n Noa cute intracranial hemorrhage or large acute infarction. MR is more\n sensitive for acute ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old male patient, with hypertension, confusion and\n elevated PTT, to evaluate for acute bleed, evidence of stroke.\n\n COMPARISON: CT of the head done on .\n\n TECHNIQUE: Non-contrast CT of the head was performed.\n\n FINDINGS: There is no acute intracranial hemorrhage, mass effect, shift of\n normally midline structures, or hydrocephalus. Prominent ventricles, and\n extra-axial CSF spaces and cerebral sulci are noted, related to mild diffuse\n parenchymal volume loss, likely age appropriate and are unchanged.\n Atherosclerotic calcifications are noted in the cavernous segments of the\n internal carotid arteries and their distal vertebral arteries. No large\n hypodense areas are seen to suggest large areas of acute infarction.\n No osseous lytic or sclerotic lesions are noted.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage. No obvious large acute infarct. However,\n MRI is more sensitive for acute ischemia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2123-10-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1036190,
"text": ", E. OMED 4:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for acute bleed, evidence of stroke.\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with hypotension, confusion and elevated PTT.\n REASON FOR THIS EXAMINATION:\n Please assess for acute bleed, evidence of stroke.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Noa cute intracranial hemorrhage or large acute infarction. MR is more\n sensitive for acute ischemia.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-28 00:00:00.000",
"description": "Report",
"row_id": 245346,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-25 00:00:00.000",
"description": "Report",
"row_id": 245347,
"text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-25 00:00:00.000",
"description": "Report",
"row_id": 245348,
"text": "Sinus rhythm\nLeft bundle branch block\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2123-10-22 00:00:00.000",
"description": "Report",
"row_id": 245349,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof there is no significant diagnostic change.\n\n"
},
{
"category": "Social Work",
"chartdate": "2123-10-27 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 636216,
"text": "Progress Note:\n Spoke briefly with pt\ns daughter, , who is in the process of trying\n to arrange for an alternative living situation for her sister who has\n CP. Currently, she is in the process of applying for Mass Health and\n meeting with a lawyer to make changes in her father\ns will. Mr. \n wants his daughter to remain at home with him and his wife until he\n dies, but that is not an option. She would like her father to be at\n home with hospice, but she first needs to know what the financial\n situation is, as he would need 24-hour care. said that she\n several in the fire\n; it seems as though she is trying to resolve\n this critical matters as quickly as she can.\n Plan:\n 1. Pt is being transferred to 7F, so there will be no f/u.\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 636457,
"text": "Chief Complaint: Hypotension\n HPI:\n 85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .\n The patient currently remains asymptomatic. He does not feel confused,\n felt lightheaded during the episodes but not currently. As above ROS\n is negative. No F/C.\n History obtained from Patient\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n MM, diagnosed , followed by Heme, on Velcade/mephalan/prednisone\n for past month , c/b lytic lesions/compression fractures - recnet\n XRT to spine.\n BPH (meds were d/c'ed due to hypotension)\n dyslipidemia\n X2 : reported normal Echo, unremarkable holter per chart\n IVCD/LBBB-old\n LBP- pathological compression fx T12/L1 s/p choley 10years ago\n lung nodule s/p resection many years ago, reported benign\n Mother died uterine Ca, Father died PNA, has one brother/one sister who\n are alive and well at age 80s\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 11:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 87 (77 - 97) bpm\n BP: 151/96(104) {104/43(58) - 191/142(125)} mmHg\n RR: 31 (15 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 913 mL\n PO:\n 250 mL\n TF:\n IVF:\n 663 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 63 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : Bibasilary)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 207 K/uL\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 9 mg/dL\n 23 mEq/L\n 105 mEq/L\n 3.4 mEq/L\n 134 mEq/L\n 29.1 %\n 4.4 K/uL\n [image002.jpg]\n \n 2:33 A9/22/ 12:29 PM\n \n 10:20 P9/22/ 01:12 PM\n \n 1:20 P9/22/ 01:30 PM\n \n 11:50 P9/23/ 04:42 AM\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.2\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 85 yo man with MM, neurogenic orthostatics ( autonomic dysfunction),\n with UTI and now transfered to ICU for hypotension and AMS that are now\n resolved.\n .\n # AMS: Patient with hypotension and AMS that responded to position and\n 500cc fluid bolus. Patient at baseline on arrival to the ICU. Most\n likely etiology patient had low fluid intake and got dehydrated.\n - F/u I/O\n - F/U JVP\n - 500cc NS bolus if hypotensive\n - Move slowly from one position to another (avoid orhtostatics)\n - Telemetry\n - EKG\n .\n # Multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt was going to\n get radiation today.\n - F/u BMT recs\n - Possible radiotherapy tomorrow\n .\n # chronic lower back pain:\n - due to malignant compression fractures multiple\n myeloma.\n continue oxycodone prn.\n .\n # prophylaxis:\n - ppi and subcut heparin\n .\n # Access: peripherals\n .\n #) full code.\n .\n # Contact: (wife) \n .\n # Dispo: Floor tomorrow morning if stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-28 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 636445,
"text": "Chief Complaint: Altered mental status / low SBP\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85yo man with a h/o MM, autonomic dysfunction (on florinef, possibly\n amyloid?), BPH c/b urinary tract obstruction necessitating foley\n who was admitted with weakness and \"near syncope\" observed by VNA. male\n with multiple myeloma and as well as autonomic dysfunction on florinef\n ? secondary to amyloid.He was on the Medicine floor when on the AM of\n he developed expressive aphasia while working with PT; SBP found\n to be ~90. He received a 500cc bolus and his SBP improved to 120 and\n his aphasia resolved. Unfortunately, his SBP dropped again, aphasia\n returned and he was transferred to the . He was confused in\n addition to being aphasic, but otherwise asymptomatic. Neuro evaluated\n him, head CT, MRI/A were unrevealing for acute pathology. He was found\n to have a urinary tract infection; with treatment his delirium /\n aphasia resolved. Returned to the floor on .\n Unfortunately, on he had recurrence of his neurological symptoms\n with borderline BP and was again transferred to the for\n monitoring. This morning he was found to be lethargic and minimally\n responsive; SBP was 80/60. He became spontaneously responsive and was\n confused and disoriented. He received a 500cc bolus and SBP increased\n to 90s but he remained disoriented.\n No new recent med changes or other localizing symptoms. He did receive\n an extra dose of Oxycodone 5mg at noon prior to this episode of altered\n mental status.\n After arriving in the , his SBP was ~150 and he was at his baseline\n -- A&Ox 3. He remembers the team members by name. He has no\n complaints. He doesn't have a clear recollection of the episode of\n unresponsiveness from this morning.\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:45 AM\n Cefipime - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Aspirin 325\n Finesteride 5\n Mag sulfate\n Florinef .1\n Lipitor 10\n Eye gtts\n Heparin subQ\n Protonix 40 \n RSSI\n Oxycodone 2.5-5mg PO Q4hr STANDING and intermittent PRN doses\n Cefepime\n Vanc\n Past medical history:\n Family history:\n Social History:\n 1) Multiple myeloma c/b chronic back pain\n 2) Dysautonomia (some suspicion of amyloid as the cause?)\n 3) BPH requiring foley c/b UTIs\n Mother with uterine cancer, otherwise non-contributory.\n Occupation: Was a job placement coordinator\n Drugs: None\n Tobacco: Quit > 20 years ago\n Alcohol: None\n Other: Lives with his wife who is healthy, has a disabled daughter.\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Suicidal\n Flowsheet Data as of 06:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (77 - 86) bpm\n BP: 191/142(125) {157/85(104) - 191/142(125)} mmHg\n RR: 22 (15 - 22) insp/min\n SpO2: 100%\n Total In:\n 187 mL\n PO:\n TF:\n IVF:\n 187 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 187 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal), S3, No(t) S4,\n No(t) Rub, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 207 K/uL\n 29.1 %\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 9 mg/dL\n 23 mEq/L\n 105 mEq/L\n 3.4 mEq/L\n 134 mEq/L\n 4.4 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n WBC\n 4.5\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Imaging: Head CT (): No acute process.\n Microbiology: No new micro data.\n Assessment and Plan\n Impression: 85yo man with a h/o MM, autonomic dysfunction (on florinef,\n possibly amyloid?), BPH c/b urinary tract obstruction necessitating\n foley who was admitted with weakness and \"near syncope\" now with a\n second episode of in-hospital altered mental status / delirium of\n unclear etiology.\n 1) Altered mental status: It's difficult to ascribe his altered mental\n status to transient hypotension alone, however this may be palying a\n role. It's possible that his opiates precipitated this episode given\n that he received an extra dose of Oxycodone at noon and was\n subsequently found to be altered. His SBP may have been decreased due\n to the extra opiate dose as well. He has no obvious signs of an\n infectious, cardiac or primary neurologic process causing these\n symptoms.\n 2) Pain: Will start a Lidocaine patch in an effort to better treat his\n pain. Minimizing / avoiding opiates may be warranted given there's a\n possible association with his delirium.\n 3) F/E/N: Regular diet. Follow / replete 'lytes.\n 4) CV: Transient hypotension as above. No EKG e/o infarct. Consider TTE\n to evaluate although his last TTE in revealed a EF of 50-55%\n 5) Full code, access pIV, PPI and subQ heparin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 04:30 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636517,
"text": "Chief Complaint: Hypotension\n 24 Hour Events:\n CALLED OUT\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.4\nC (95.7\n HR: 84 (75 - 97) bpm\n BP: 155/71(92) {104/43(58) - 191/142(125)} mmHg\n RR: 17 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 915 mL\n 117 mL\n PO:\n 250 mL\n TF:\n IVF:\n 665 mL\n 117 mL\n Blood products:\n Total out:\n 850 mL\n 810 mL\n Urine:\n 850 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 65 mL\n -693 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 217 K/uL\n 10.1 g/dL\n 98 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 105 mEq/L\n 139 mEq/L\n 29.2 %\n 5.8 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n 04:21 AM\n WBC\n 9.2\n 4.4\n 5.8\n Hct\n 20.6\n 30.4\n 29.1\n 29.2\n Plt\n 154\n 207\n 217\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n <0.01\n Glucose\n 123\n 97\n 98\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 636535,
"text": "Chief Complaint: Sepsis\n Bradycardia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:30 AM\n EKG - At 09:30 AM\n Patient with improved alterness and responsiveness\n Pressors required for continued support of blood pressure\n TTE--Nl LV size and function with dilated hypokinetic RV and mod/seve\n TR\n CVO2=78\n History obtained from Medical records\n Allergies:\n Zocor (Oral) (Simvastatin)\n myalgias;\n Flagyl (Oral) (Metronidazole)\n Diarrhea;\n Last dose of Antibiotics:\n Vancomycin - 06:57 PM\n Ceftriaxone - 04:18 PM\n Metronidazole - 08:00 PM\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 08:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 56 (45 - 59) bpm\n BP: 101/38(59) {89/36(54) - 131/54(80)} mmHg\n RR: 20 (10 - 20) insp/min\n SpO2: 87%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 61 Inch\n CVP: 24 (7 - 24)mmHg\n Mixed Venous O2% Sat: 78 - 78\n Total In:\n 3,382 mL\n 626 mL\n PO:\n TF:\n IVF:\n 3,382 mL\n 626 mL\n Blood products:\n Total out:\n 695 mL\n 350 mL\n Urine:\n 695 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,687 mL\n 276 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 87%\n ABG: 7.30/37/70/17/-7\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n Bilaterally, Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.1 g/dL\n 132 K/uL\n 177 mg/dL\n 4.2 mg/dL\n 17 mEq/L\n 4.5 mEq/L\n 115 mg/dL\n 95 mEq/L\n 127 mEq/L\n 30.0 %\n 30.2 K/uL\n [image002.jpg]\n 10:06 PM\n 10:35 PM\n 12:30 AM\n 03:46 AM\n 04:24 AM\n 08:50 AM\n 04:26 PM\n 04:36 PM\n 04:23 AM\n 08:29 AM\n WBC\n 36.0\n 30.2\n Hct\n 32\n 31.5\n 30.0\n Plt\n 167\n 132\n Cr\n 4.1\n 3.9\n 3.9\n 4.1\n 4.2\n TropT\n 0.05\n TCO2\n 14\n 17\n 19\n 18\n 19\n Glucose\n 150\n 240\n 331\n 175\n 177\n Other labs: PT / PTT / INR:17.3//1.6, CK / CKMB /\n Troponin-T:384/17/0.05, Differential-Neuts:92.0 %, Band:6.0 %,\n Lymph:2.0 %, Mono:0.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, LDH:615\n IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL, PO4:6.0 mg/dL\n Fluid analysis / Other labs: 7.29/35/95\n 7.30/37/70/19 on 4 liters NC\n Imaging: CXR--increased right sided pulmonary parenchymal opacities and\n suggestion of small right sided effusion.\n Assessment and Plan\n 67 yo female admit with hypotension and bradycardia now with findings\n on ECHO to suggest significant impairment in RV function and\n significant increase in pulmonary artery pressures noted (mod PAH and\n TR). This in in the setting of persistent bradycardia suggesting\n possible RV vascular distribution ischemia. In addition the elevations\n in pulmonary artery pressure remain to be defined in regards to\n source. Finally--she retains a significant bandemia in the setting of\n elevated WBC count.\n The source of persistent hypotension seems in large part to be driven\n by cardiac compromise (high BNP, ECHO findings) in the setting of\n persistent bradycardia\nperhaps increased RV afterload and difficulty\n with maintenance of effective CO with increased demand in the setting\n of likely systemic infection with possible urinary source as evidenced\n by the elevated WBC count and bandemia. GI source with diarrhea\n suspected but diarrhea not clearly confirmed. The current source of\n the elevated PA pressures in the setting of preserved LV function\n remains to be defined.\n 1)Shock-\n Vasodilatory Component-\n -CTX/Flagyl for possible bacterial infection and C. Diff\n -Neosynephrine/Levophed continue and hope to wean\n -Cultures pending\n Cardiogenic Component-\n -Possible PE raised as source of obstruction, may be tumor embolus as\n well\nwould like to treat for possible PE and favor treatment if we can\n find reassurance that bleeding risk is reasonable and head CT negative\n for CNS lesion/mass and study for PE is positive\n -Bradycardia persistent, BNP is up, do not see evidence of acute MI on\n findings thus far\nmild elevations in enzymes have decreased and may be\n evidence of remote insult or current area at risk\n -Favor change to IV Beta specific agonists for support\nwith Dopamine\n representing reasonable compromise as with fixed and impaired RV stroke\n volume and peripheral beta effects Dobutamine represents a second\n choice.\n -LV function is preserved\n Hypovolemia-\n -Has been resolved with UVF to the point of likely volume overload\n 2)Bradycardia-\n -Telemetry\n -Consider inotrope and chronotrope support for pressors\n -Will look to RV leads to help assure no ongoing insult in the setting\n of stable enzymes\n 3)Acute Renal Failure-\n -Likley ATN\n -Continue support of BP\n FeNa=low and poor perfusion but now evolving a process consistent with\n ATN\n ICU Care\n Nutrition: Po diet of clears\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 07:03 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 60 minutes\n ------ Protected Section ------\n PATIENT CODE STATUS IS DNR/DNI\n ------ Protected Section Addendum Entered By: , MD\n on: 09:18 ------\n Chief Complaint: Altered Mental Status\n Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CALLED OUT\n Patient with much improved stability with IVF given. No evidence of\n recurrent events with overnight monitoring\n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 09:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.4\n HR: 80 (75 - 97) bpm\n BP: 137/86(99) {104/43(58) - 191/142(125)} mmHg\n RR: 23 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 915 mL\n 343 mL\n PO:\n 250 mL\n TF:\n IVF:\n 665 mL\n 343 mL\n Blood products:\n Total out:\n 850 mL\n 900 mL\n Urine:\n 850 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 65 mL\n -557 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Place and Person, Movement: Purposeful, Tone:\n Not assessed\n Labs / Radiology\n 10.1 g/dL\n 217 K/uL\n 98 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 105 mEq/L\n 139 mEq/L\n 29.2 %\n 5.8 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n 04:21 AM\n WBC\n 9.2\n 4.4\n 5.8\n Hct\n 20.6\n 30.4\n 29.1\n 29.2\n Plt\n 154\n 207\n 217\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n <0.01\n Glucose\n 123\n 97\n 98\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n yo male with recurrent ICU admission with a repeat of similar\n scenario to prior admission. He has a picture of orthostatic\n instability and in the setting of mild hypovolemia he has had recurrent\n altered mental status. In the setting of ongoing treatment--certainly\n maintenance of optimal volume status is essential.\n 1)Altered Mental Status-\n -Orthostatic Hypotension-\n -Salt Tabs\n -Fludricort\n -Maintain optimal fluid status\n -Rx with Vanco\n -Return to oncology floor today.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636441,
"text": "85 yo male with multiple myeloma as well as autonomic dysfunction on\n florinef ? secondary to amyloid. He also has BPH and a recent history\n of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea. On vanco for RX\n of UTI ( staph).\n Pt discharged from after he had an episode of expressive\n aphasia, & SBP 90. Ct scan negative Responded to fld bolus. Aphasia\n resolved.\n Today pt found\nasleep\n When awakened oriented to person only. SP\n 84/60, RR 25, HR 75. Sats975 on RA. Given cefipime 2 gm & NS 500 cc\n with improvement in MS & BP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, OX3. Conversing on phone. MEA.\n Action:\n Ct scan done prior to ICU admission. Results pnd\n Response:\n Oriented\n Plan:\n Cont to assess MS, neuro status\n Hypotension (not Shock)\n Assessment:\n Bp 157/86, hr 80\nS. Receiving maint IVF at 100 c chr X 5 hrs.\n Action:\n Ongoing assessment\n Response:\n Normotensive at present\n Plan:\n Cont to asses BP\n Urinary tract infection (UTI)\n Assessment:\n Afeb, Received dose cefipime prior to ICU transfer. On vanco\n Action:\n Response:\n Afeb\n Plan:\n Cont to assess for S&Sx of infection, MS changes\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636549,
"text": "Chief Complaint: Hypotension\n 24 Hour Events:\n CALLED OUT\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.4\nC (95.7\n HR: 84 (75 - 97) bpm\n BP: 155/71(92) {104/43(58) - 191/142(125)} mmHg\n RR: 17 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 915 mL\n 117 mL\n PO:\n 250 mL\n TF:\n IVF:\n 665 mL\n 117 mL\n Blood products:\n Total out:\n 850 mL\n 810 mL\n Urine:\n 850 mL\n 810 mL\n NG:\n Stool:\n Drains:\n Balance:\n 65 mL\n -693 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Obese\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 217 K/uL\n 10.1 g/dL\n 98 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 105 mEq/L\n 139 mEq/L\n 29.2 %\n 5.8 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n 04:21 AM\n WBC\n 9.2\n 4.4\n 5.8\n Hct\n 20.6\n 30.4\n 29.1\n 29.2\n Plt\n 154\n 207\n 217\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n <0.01\n Glucose\n 123\n 97\n 98\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n 85 yo man with MM, neurogenic orthostatics ( autonomic dysfunction),\n with UTI and now transfered to ICU for hypotension and AMS that are now\n resolved.\n .\n # AMS: Patient with hypotension and AMS that responded to position and\n 500cc fluid bolus. Patient at baseline on arrival to the ICU. Most\n likely etiology patient had low fluid intake and got dehydrated.\n - F/u I/O\n - F/U JVP\n - 500cc NS bolus if hypotensive\n - Move slowly from one position to another (avoid orhtostatics)\n - Telemetry\n - EKG\n .\n # Multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt was going to\n get radiation today.\n - F/u BMT recs\n - Possible radiotherapy tomorrow\n .\n # chronic lower back pain:\n - due to malignant compression fractures multiple\n myeloma.\n continue oxycodone prn.\n .\n # prophylaxis:\n - ppi and subcut heparin\n .\n # Access: peripherals\n .\n #) full code.\n .\n # Contact: (wife) \n .\n # Dispo: Floor tomorrow morning if stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636610,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\n for T11/sacral spine related to multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt had\n radiation today no c/o back pain no Oxycodone given\n Action:\n Radiation today. Pt on Lidocaine patch 5% for lower back.\n Response:\n Tolerated well\n Plan:\n Continue radiation Mon-Thursday of next week. Pt called out to\n Hem/Onc.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\n 120/64 HR 70\ns SR no vea noted\n Action:\n None required\n Response:\n Pt back to baseline mental status\n Plan:\n Continue to observe for changes in mental status Florinef increased\n to .1 mg ?tilt table test to be done inpatient.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley, pt has foley , draining clear yellow\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\n cultures done x 2, urine cx sent\n Action:\n Vanco \n Response:\n Afebrile, no complaints, good urine output 30 cc/hr\n Plan:\n Continue with antibx, monitor urine output\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636611,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\n for T11/sacral spine related to multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt had\n radiation today no c/o back pain no Oxycodone given\n Action:\n Radiation today. Pt on Lidocaine patch 5% for lower back.\n Response:\n Tolerated well\n Plan:\n Continue radiation Mon-Thursday of next week. Pt called out to\n Hem/Onc.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\n 120/64 HR 70\ns SR no vea noted\n Action:\n None required\n Response:\n Pt back to baseline mental status\n Plan:\n Continue to observe for changes in mental status Florinef increased\n to .1 mg ?tilt table test to be done inpatient.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley, pt has foley , draining clear yellow\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\n cultures done x 2, urine cx sent\n Action:\n Vanco \n Response:\n Afebrile, no complaints, good urine output 30 cc/hr\n Plan:\n Continue with antibx, monitor urine output\n"
},
{
"category": "General",
"chartdate": "2123-10-25 00:00:00.000",
"description": "ICU Event Note",
"row_id": 635911,
"text": "Clinician: Attending\n 85 yo male patient with history of MM and orthostatic hypotension who\n on the oncology floor was admitted with malaise, fatigue and near\n sycope. He had evolution of UTI by U/A with staph species identified\n and despite initial treatment with Cipro has evolved evidence of\n persistent infection and limited response to ABX treatment to date.\n On the floor he did evolve an pattern of hypotension which has been\n raised as concern for both his orthostatic hypotension and persistent\n infection. In that setting he did develop an expressive aphasia and\n neurology service was consulted for aid in evlauation and patient\n transferred to ICU for further care.\n Here--patient is comfortable, no focal complaints but states \"feels\n lousy\"\n Patient has significant word finding difficulties but not aphasia\n He is A+O x1 by my exam\n Lungs-CTA\n Heart-regular\n Abd-NT, normal BS\n 85 yo male with presentation with urinary tract infection and Staph\n species identified and only recently changed to Vanco/Cefepime for\n broader coverage. He will be maintained on Florinef for orthostatic\n hypotension along with NaCl tablets.\n In regards to his aphasia reported he will have neuro exam on regular\n basis and in consultation with neurology will pursue MRI/MRA and CT\n Head to evaluate for region at risk.\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 636601,
"text": "Chief Complaint: Altered mental status / low SBP\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85yo man with a h/o MM, autonomic dysfunction (on florinef, possibly\n amyloid?), BPH c/b urinary tract obstruction necessitating foley\n who was admitted with weakness and \"near syncope\" observed by VNA. male\n with multiple myeloma and as well as autonomic dysfunction on florinef\n ? secondary to amyloid.He was on the Medicine floor when on the AM of\n he developed expressive aphasia while working with PT; SBP found\n to be ~90. He received a 500cc bolus and his SBP improved to 120 and\n his aphasia resolved. Unfortunately, his SBP dropped again, aphasia\n returned and he was transferred to the . He was confused in\n addition to being aphasic, but otherwise asymptomatic. Neuro evaluated\n him, head CT, MRI/A were unrevealing for acute pathology. He was found\n to have a urinary tract infection; with treatment his delirium /\n aphasia resolved. Returned to the floor on .\n Unfortunately, on he had recurrence of his neurological symptoms\n with borderline BP and was again transferred to the for\n monitoring. This morning he was found to be lethargic and minimally\n responsive; SBP was 80/60. He became spontaneously responsive and was\n confused and disoriented. He received a 500cc bolus and SBP increased\n to 90s but he remained disoriented.\n No new recent med changes or other localizing symptoms. He did receive\n an extra dose of Oxycodone 5mg at noon prior to this episode of altered\n mental status.\n After arriving in the , his SBP was ~150 and he was at his baseline\n -- A&Ox 3. He remembers the team members by name. He has no\n complaints. He doesn't have a clear recollection of the episode of\n unresponsiveness from this morning.\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:45 AM\n Cefipime - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Aspirin 325\n Finesteride 5\n Mag sulfate\n Florinef .1\n Lipitor 10\n Eye gtts\n Heparin subQ\n Protonix 40 \n RSSI\n Oxycodone 2.5-5mg PO Q4hr STANDING and intermittent PRN doses\n Cefepime\n Vanc\n Past medical history:\n Family history:\n Social History:\n 1) Multiple myeloma c/b chronic back pain\n 2) Dysautonomia (some suspicion of amyloid as the cause?)\n 3) BPH requiring foley c/b UTIs\n Mother with uterine cancer, otherwise non-contributory.\n Occupation: Was a job placement coordinator\n Drugs: None\n Tobacco: Quit > 20 years ago\n Alcohol: None\n Other: Lives with his wife who is healthy, has a disabled daughter.\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Suicidal\n Flowsheet Data as of 06:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (77 - 86) bpm\n BP: 191/142(125) {157/85(104) - 191/142(125)} mmHg\n RR: 22 (15 - 22) insp/min\n SpO2: 100%\n Total In:\n 187 mL\n PO:\n TF:\n IVF:\n 187 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 187 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal), S3, No(t) S4,\n No(t) Rub, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 207 K/uL\n 29.1 %\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 9 mg/dL\n 23 mEq/L\n 105 mEq/L\n 3.4 mEq/L\n 134 mEq/L\n 4.4 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n WBC\n 4.5\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Imaging: Head CT (): No acute process.\n Microbiology: No new micro data.\n Assessment and Plan\n Impression: 85yo man with a h/o MM, autonomic dysfunction (on florinef,\n possibly amyloid?), BPH c/b urinary tract obstruction necessitating\n foley who was admitted with weakness and \"near syncope\" now with a\n second episode of in-hospital altered mental status / delirium of\n unclear etiology.\n 1) Altered mental status: It's difficult to ascribe his altered mental\n status to transient hypotension alone, however this may be palying a\n role. It's possible that his opiates precipitated this episode given\n that he received an extra dose of Oxycodone at noon and was\n subsequently found to be altered. His SBP may have been decreased due\n to the extra opiate dose as well. He has no obvious signs of an\n infectious, cardiac or primary neurologic process causing these\n symptoms.\n 2) Pain: Will start a Lidocaine patch in an effort to better treat his\n pain. Minimizing / avoiding opiates may be warranted given there's a\n possible association with his delirium.\n 3) F/E/N: Regular diet. Follow / replete 'lytes.\n 4) CV: Transient hypotension as above. No EKG e/o infarct. Consider TTE\n to evaluate although his last TTE in revealed a EF of 50-55%\n 5) Full code, access pIV, PPI and subQ heparin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 04:30 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 636602,
"text": "Chief Complaint: Altered mental status / low SBP\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 85yo man with a h/o MM, autonomic dysfunction (on florinef, possibly\n amyloid?), BPH c/b urinary tract obstruction necessitating foley\n who was admitted with weakness and \"near syncope\" observed by VNA. male\n with multiple myeloma and as well as autonomic dysfunction on florinef\n ? secondary to amyloid.He was on the Medicine floor when on the AM of\n he developed expressive aphasia while working with PT; SBP found\n to be ~90. He received a 500cc bolus and his SBP improved to 120 and\n his aphasia resolved. Unfortunately, his SBP dropped again, aphasia\n returned and he was transferred to the . He was confused in\n addition to being aphasic, but otherwise asymptomatic. Neuro evaluated\n him, head CT, MRI/A were unrevealing for acute pathology. He was found\n to have a urinary tract infection; with treatment his delirium /\n aphasia resolved. Returned to the floor on .\n Unfortunately, on he had recurrence of his neurological symptoms\n with borderline BP and was again transferred to the for\n monitoring. This morning he was found to be lethargic and minimally\n responsive; SBP was 80/60. He became spontaneously responsive and was\n confused and disoriented. He received a 500cc bolus and SBP increased\n to 90s but he remained disoriented.\n No new recent med changes or other localizing symptoms. He did receive\n an extra dose of Oxycodone 5mg at noon prior to this episode of altered\n mental status.\n After arriving in the , his SBP was ~150 and he was at his baseline\n -- A&Ox 3. He remembers the team members by name. He has no\n complaints. He doesn't have a clear recollection of the episode of\n unresponsiveness from this morning.\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Vancomycin - 07:45 AM\n Cefipime - 10:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Aspirin 325\n Finesteride 5\n Mag sulfate\n Florinef .1\n Lipitor 10\n Eye gtts\n Heparin subQ\n Protonix 40 \n RSSI\n Oxycodone 2.5-5mg PO Q4hr STANDING and intermittent PRN doses\n Cefepime\n Vanc\n Past medical history:\n Family history:\n Social History:\n 1) Multiple myeloma c/b chronic back pain\n 2) Dysautonomia (some suspicion of amyloid as the cause?)\n 3) BPH requiring foley c/b UTIs\n Mother with uterine cancer, otherwise non-contributory.\n Occupation: Was a job placement coordinator\n Drugs: None\n Tobacco: Quit > 20 years ago\n Alcohol: None\n Other: Lives with his wife who is healthy, has a disabled daughter.\n Review of systems:\n Constitutional: No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley\n Integumentary (skin): No(t) Rash\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Suicidal\n Flowsheet Data as of 06:52 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 86 (77 - 86) bpm\n BP: 191/142(125) {157/85(104) - 191/142(125)} mmHg\n RR: 22 (15 - 22) insp/min\n SpO2: 100%\n Total In:\n 187 mL\n PO:\n TF:\n IVF:\n 187 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 187 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Anxious\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n Sclera edema\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (S1: No(t) Normal), (S2: No(t) Normal), S3, No(t) S4,\n No(t) Rub, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 207 K/uL\n 29.1 %\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 9 mg/dL\n 23 mEq/L\n 105 mEq/L\n 3.4 mEq/L\n 134 mEq/L\n 4.4 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n WBC\n 4.5\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Imaging: Head CT (): No acute process.\n Microbiology: No new micro data.\n Assessment and Plan\n Impression: 85yo man with a h/o MM, autonomic dysfunction (on florinef,\n possibly amyloid?), BPH c/b urinary tract obstruction necessitating\n foley who was admitted with weakness and \"near syncope\" now with a\n second episode of in-hospital altered mental status / delirium of\n unclear etiology.\n 1) Altered mental status: It's difficult to ascribe his altered mental\n status to transient hypotension alone, however this may be palying a\n role. It's possible that his opiates precipitated this episode given\n that he received an extra dose of Oxycodone at noon and was\n subsequently found to be altered. His SBP may have been decreased due\n to the extra opiate dose as well. He has no obvious signs of an\n infectious, cardiac or primary neurologic process causing these\n symptoms.\n 2) Pain: Will start a Lidocaine patch in an effort to better treat his\n pain. Minimizing / avoiding opiates may be warranted given there's a\n possible association with his delirium.\n 3) F/E/N: Regular diet. Follow / replete 'lytes.\n 4) CV: Transient hypotension as above. No EKG e/o infarct. Consider TTE\n to evaluate although his last TTE in revealed a EF of 50-55%\n 5) Full code, access pIV, PPI and subQ heparin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 22 Gauge - 04:30 PM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n ------ Protected Section ------\n Agree with assessment and plan as stated above\n ------ Protected Section Addendum Entered By: , MD\n on: 18:35 ------\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635956,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Altered mental status (not Delirium)\n Assessment:\n At start of shift pt A&O x 3. Appropriate with words and responses to\n questions. Followed all commands, PERRL.\n Action:\n Full neuro assessment performed. Head CT and MRI done yesterday on\n days. Reported results negative.\n Response:\n Around midnight MS started to change. Pt had expressive asphasia, was\n A&O x 2\n unaware of time as he thought it was ^th. No\n facial droop noted, followed commands and had adequate strength in all\n four extremities. Team aware of MS change.\n Plan:\n Con\nt to monitor mental status and reorient pt as needed. Con\nt to\n monitor neuro status.\n Hypotension (not Shock)\n Assessment:\n SBP at start of shift up to 170\ns systolic. Team aware.\n Action:\n Started on 200mg PO Labetalol .\n Response:\n SBP down to 100\ns and pt\ns mental status started to deteriorate as he\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\n d/c\nd. BP has been normotensive throughout noc.\n Plan:\n Con\nt to monitor BP and treat as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635957,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Altered mental status (not Delirium)\n Assessment:\n At start of shift pt A&O x 3. Appropriate with words and responses to\n questions. Followed all commands, PERRL.\n Action:\n Full neuro assessment performed. Head CT and MRI done yesterday on\n days. Reported results negative.\n Response:\n Around midnight MS started to change. Pt had expressive asphasia, was\n A&O x 2\n unaware of time as he thought it was ^th. No\n facial droop noted, followed commands and had adequate strength in all\n four extremities. Team aware of MS change.\n Plan:\n Con\nt to monitor mental status and reorient pt as needed. Con\nt to\n monitor neuro status.\n Hypotension (not Shock)\n Assessment:\n SBP at start of shift up to 170\ns systolic. Team aware.\n Action:\n Started on 200mg PO Labetalol .\n Response:\n SBP down to 100\ns and pt\ns mental status started to deteriorate as he\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\n d/c\nd. BP has been normotensive throughout noc.\n Plan:\n Con\nt to monitor BP and treat as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636051,
"text": "Chief Complaint: 85 yo man with multiple myeloma as well as a history\n neurogenic presyncope secondary to autonomic dysfunction presenting\n initially with weakness and UTI, now with aphasia in the setting of\n hypotension, both have resolved with fluid repletion. Head ct and mri\n negative so far for evidence of stroke.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 03:00 PM\n Head\n Patient with head ct showing no acute bleed and mri without evidence of\n acute stroke. Patient vital signs stable. showing signs of delirium\n with agitation, disorientation. MRA with possible narrowing of m2/m3\n region bilaterally more on the right\n possibly arteriosclerotic\n however cannot rule out artifact.\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:23 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 35.8\nC (96.5\n HR: 81 (70 - 93) bpm\n BP: 154/82(101) {105/50(65) - 162/97(113)} mmHg\n RR: 16 (14 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,800 mL\n 500 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,560 mL\n 500 mL\n Blood products:\n Total out:\n 1,295 mL\n 520 mL\n Urine:\n 1,295 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,505 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 207 K/uL\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 134 mEq/L\n 29.1 %\n 4.4 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n WBC\n 9.2\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 85 yo man with multiple myeloma as well as a history neurogenic\n presyncope secondary to autonomic dysfunction presenting initially with\n weakness and UTI, now with aphasia in the setting of hypotension, both\n have resolved with fluid repletion.\n .\n #) Hypotension: low reserve for hypotensive insult given baseline\n orthostatic hypotension.\n -likely infection related given + u/a with urine culture growing staph\n aureus, that is sensitive to vanco. Contact precautions for MRSA but\n no previous resistent bacteria on previous culture data.\n - urine culture data:\n STAPH AUREUS COAG +\n |\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- =>8 R\nNITROFURANTOIN-------- <=16 S\nOXACILLIN------------- =>4 R\nPENICILLIN G---------- =>0.5 R\nTETRACYCLINE---------- 2 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n -vanc 1g IV q12hrs\n - will d/c cefepime now that sensitives are back\n - follow CBC / diff\n -lactate 1.0\n -rec'd 2 liter bolus IVF, continue at rate of 250cc/hr, now currently\n normotensive\n CXr - As compared to the previous examination, there is no relevant\n change. No\n newly occurred focal parenchymal opacity suggestive of pneumonia, no\n overhydration.\n -resend U/a, ucx\n -send blood cultures and f/u previously send blood cx\n -if diarrhea will send C diff\n -continue florinef at home dose and salt tabs\n -troponins were negative so unlikely MI\n .\n #) Mental Status Changes: apparently these were expressive aphasia. He\n has no known cerebrovascular disease in the past but given the nature\n of these episodes he likley has some cerebrovascular stenosis which\n cause some reversible hypoperfusion during episodes of hypotension.\n - as patient currently normotensive will hold off on additional fluid\n bolus at this time\n -head CT wet read: No acute intracranial process, including no evidence\n for hemorrhage, edema,\n mass effect, or acute ischemia. Please note that MRI is more sensitive\n for\n evaluation of ischemia.\n - MRI of head wet read: There is no evidence of acute ischemic changes.\n Prominence of the ventricles\n and sulci, likely age-related and developmental in nature. There is no\n shift\n or normally placed midline structures. M2 segments bilaterally versus\n artifact.\n - started on aspirin 325mg po daily, will follow-up with neurology\n regarding plan for this , if no acute stroke and no acute MI, then\n should be changed to 81 mg PO daily instead\n #) chronic lower back pain:\n - due to malignant compression fractures multiple myeloma.\n - MRI l spine - CONCLUSION: Diffuse signal intensity abnormalities in\n the vertebral bodies\n compatible with the history of multiple myeloma.\n No evidence of cauda equina compression.\n Right-sided disc protrusion at L3-4.\n - continue oxycodone prn.\n .\n #) multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression\n -s/p bone marrow biopsy to evaluate for amyloid, still pending\n - plan for radiation-oncology today\n - would consider lumbar puncture if patient does not improve to rule\n out leptomeningeal disease in the setting of word finding difficulties\n without MRI findings -\n .\n #) prophylaxis:\n - ppi and subcut heparin\n .\n #) full code.\n #) dispo: call out to OMED today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 12:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636057,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O back pain\n Assessment:\n Chronic back pain due to compression fractures multiple myeloma. No\n complaints of back pain today. Tolerated oob to chair and stretcher\n multiple times today. His gait is slow and shuffling, but strength OK.\n Action:\n Received planned treatments to T11-sacrum.\n Response:\n No c/o back pain.\n Plan:\n Continue XRT as ordered and oxycodone prn.\n Hypotension (not Shock)\n Assessment:\n Given labetolol last night for SBP in the 170\ns but d/c\nd due to BP\n dropping to the 100\ns. Today BP 105-159/48-82; HR 63-81, LBBB no\n ectopy. Denies dizziness/lightheadedness. No orthostatic BP changes or\n symptoms noted.\n Action:\n Continues on florinef and sodium tabs. No fluid boluses given. Urine\n output is adequate. Fluid status is +400cc.\n Response:\n BP stable, no orthostatic changes.\n Plan:\n Continue florinef, sodium tabs, monitor fluid/electrolyte status.\n Altered mental status (not Delirium)\n Assessment:\n Confused overnight and restless at times. A&O X3 most of the day.\n Mental status waxes and wanes and pt still has trouble with word\n finding. He is aware of it and expresses frustration. MAE\ns, no\n hemiparesis/weakness.\n Action:\n Carotid U/S done today, results pending. Head CT and MRI negative for\n bleed/ischemia, although some artherosclerosis noted. Receiving\n aspirin, lipitor and heparin sq.\n Response:\n Mental status waxes and wanes.\n Plan:\n Continue to monitor neuro status and electrolytes. Discuss probable\n need for increased care and supervision of pt when discharged.\n Urinary tract infection (UTI)\n Assessment:\n +MRSA in urine. Afebrile, wbc\ns 4.4, blood cultures pending.\n Action:\n Receiving vanco/cefipime.\n Response:\n Improving\n Plan:\n Continue antibiotics. Remove foley and attempt voiding trial, reinsert\n new foley if unable to void.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n WEAKNESS\n Code status:\n Full code\n Height:\n Admission weight:\n 65.5 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Precautions: Contact\n PMH:\n CV-PMH:\n Additional history: Multiple myeloma, BPH, dyslipidemia, \n orthostatic hypotension w/ autonomic dysfunction (reported normal echo,\n unremarkable holter per chart), IVCD/LBBB, LBP pathological\n compression fx T12/L1, s/p chole 10 yrs ago, lung nodule s/p resection\n many years ago reported benign.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:63\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 73 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,123 mL\n 24h total out:\n 730 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 04:42 AM\n Potassium:\n 3.4 mEq/L\n 04:42 AM\n Chloride:\n 105 mEq/L\n 04:42 AM\n CO2:\n 23 mEq/L\n 04:42 AM\n BUN:\n 9 mg/dL\n 04:42 AM\n Creatinine:\n 0.7 mg/dL\n 04:42 AM\n Glucose:\n 97 mg/dL\n 04:42 AM\n Hematocrit:\n 29.1 %\n 04:42 AM\n Finger Stick Glucose:\n 108\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: Watch\n Transferred from: \n Transferred to: 7F\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Social Work",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 636060,
"text": "Progress Note:\n Spoke briefly with pt\ns daughter who is in the process of trying to\n arrange for alternative living situation for her sister who has CP.\n Currently, she is in the process of applying for Mass Health and\n meeting with a lawyer to make changes in her father\ns will. Mr. \n wants his daughter remain at home with him and his wife until he dies,\n but that is not an option.\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 636491,
"text": "Chief Complaint: Hypotension\n HPI:\n Mr. is a 85 yo male with multiple myeloma and as well as\n autonomic dysfunction on florinef ? secondary to amyloid, BPH who was\n transfered back to the ICU for AMS and hypotension. He was in his prior\n state of health in the morning, excercised with PT, was mentating fine\n until ~2:30 when he was found sleepy. He was awakaned and he was\n disoriented in place and time. His SBP was in the low 80s. He was put\n in trendelemburg and was given 500cc of NS bolus. After 25 minutes he\n was still confused with an SBP in the 90s, so he was transfered to the\n ICU. On arrival he was oriented x3, his SBP was in the 150s and he was\n absolutely fine.\n History obtained from Patient\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n MM, diagnosed , followed by Heme, on Velcade/mephalan/prednisone\n for past month , c/b lytic lesions/compression fractures - recnet\n XRT to spine.\n BPH (meds were d/c'ed due to hypotension)\n dyslipidemia\n syncope X2 : reported normal Echo, unremarkable holter per chart\n IVCD/LBBB-old\n LBP- pathological compression fx T12/L1 s/p choley 10years ago\n lung nodule s/p resection many years ago, reported benign\n Mother died uterine Ca, Father died PNA, has one brother/one sister who\n are alive and well at age 80s\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 11:55 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 87 (77 - 97) bpm\n BP: 151/96(104) {104/43(58) - 191/142(125)} mmHg\n RR: 31 (15 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 913 mL\n PO:\n 250 mL\n TF:\n IVF:\n 663 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 63 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : Bibasilary)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 207 K/uL\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 9 mg/dL\n 23 mEq/L\n 105 mEq/L\n 3.4 mEq/L\n 134 mEq/L\n 29.1 %\n 4.4 K/uL\n [image002.jpg]\n \n 2:33 A9/22/ 12:29 PM\n \n 10:20 P9/22/ 01:12 PM\n \n 1:20 P9/22/ 01:30 PM\n \n 11:50 P9/23/ 04:42 AM\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.2\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 85 yo man with MM, neurogenic orthostatics ( autonomic dysfunction),\n with UTI and now transfered to ICU for hypotension and AMS that are now\n resolved.\n .\n # AMS: Patient with hypotension and AMS that responded to position and\n 500cc fluid bolus. Patient at baseline on arrival to the ICU. Most\n likely etiology patient had low fluid intake and got dehydrated.\n - F/u I/O\n - F/U JVP\n - 500cc NS bolus if hypotensive\n - Move slowly from one position to another (avoid orhtostatics)\n - Telemetry\n - EKG\n .\n # Multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt was going to\n get radiation today.\n - F/u BMT recs\n - Possible radiotherapy tomorrow\n .\n # chronic lower back pain:\n - due to malignant compression fractures multiple\n myeloma.\n continue oxycodone prn.\n .\n # prophylaxis:\n - ppi and subcut heparin\n .\n # Access: peripherals\n .\n #) full code.\n .\n # Contact: (wife) \n .\n # Dispo: Floor tomorrow morning if stable\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 04:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636583,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\n for T11/sacral spine related to multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt had\n radiation today no c/o back pain no Oxycodone given\n Action:\n Radiation today. Pt on Lidocaine patch 5% for lower back.\n Response:\n Tolerated well\n Plan:\n Continue radiation Mon-Thursday of next week. Pt called out to\n Hem/Onc.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\n 120/64 HR 70\ns SR no vea noted\n Action:\n None required\n Response:\n Pt back to baseline mental status\n Plan:\n Continue to observe for changes in mental status Florinef increased\n to .1 mg ?tilt table test to be done inpatient.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley, pt has foley , draining clear yellow\n urine. Afebrile on Vanco for treatment of a staph UTI,\n Action:\n Vanco \n Response:\n Afebrile, no complaints, good urine output 30 cc/hr\n Plan:\n Continue with antibx, monitor urine output\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636588,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\n for T11/sacral spine related to multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt had\n radiation today no c/o back pain no Oxycodone given\n Action:\n Radiation today. Pt on Lidocaine patch 5% for lower back.\n Response:\n Tolerated well\n Plan:\n Continue radiation Mon-Thursday of next week. Pt called out to\n Hem/Onc.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\n 120/64 HR 70\ns SR no vea noted\n Action:\n None required\n Response:\n Pt back to baseline mental status\n Plan:\n Continue to observe for changes in mental status Florinef increased\n to .1 mg ?tilt table test to be done inpatient.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley, pt has foley , draining clear yellow\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\n cultures done x 2, urine cx sent\n Action:\n Vanco \n Response:\n Afebrile, no complaints, good urine output 30 cc/hr\n Plan:\n Continue with antibx, monitor urine output\n"
},
{
"category": "General",
"chartdate": "2123-10-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 636589,
"text": "Clinician: Attending Physician Progress Note\n Chief Complaint: Altered Mental Status\n Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n CALLED OUT\n Patient with much improved stability with IVF given. No evidence of\n recurrent events with overnight monitoring\n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 09:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.4\n HR: 80 (75 - 97) bpm\n BP: 137/86(99) {104/43(58) - 191/142(125)} mmHg\n RR: 23 (11 - 31) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 915 mL\n 343 mL\n PO:\n 250 mL\n TF:\n IVF:\n 665 mL\n 343 mL\n Blood products:\n Total out:\n 850 mL\n 900 mL\n Urine:\n 850 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n 65 mL\n -557 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///25/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Place and Person, Movement: Purposeful, Tone:\n Not assessed\n Labs / Radiology\n 10.1 g/dL\n 217 K/uL\n 98 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 3.1 mEq/L\n 10 mg/dL\n 105 mEq/L\n 139 mEq/L\n 29.2 %\n 5.8 K/uL\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n 04:21 AM\n WBC\n 9.2\n 4.4\n 5.8\n Hct\n 20.6\n 30.4\n 29.1\n 29.2\n Plt\n 154\n 207\n 217\n Cr\n 0.6\n 0.7\n 0.6\n TropT\n <0.01\n Glucose\n 123\n 97\n 98\n Other labs: PT / PTT / INR:12.9/40.9/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, ALT / AST:13/12, Alk Phos / T Bili:50/0.4,\n Differential-Neuts:82.9 %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic\n Acid:1.0 mmol/L, Albumin:3.3 g/dL, LDH:142 IU/L, Ca++:8.8 mg/dL,\n Mg++:1.6 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n yo male with recurrent ICU admission with a repeat of similar\n scenario to prior admission. He has a picture of orthostatic\n instability and in the setting of mild hypovolemia he has had recurrent\n altered mental status. In the setting of ongoing treatment--certainly\n maintenance of optimal volume status is essential.\n 1)Altered Mental Status-\n -Orthostatic Hypotension-\n -Salt Tabs\n -Fludricort\n -Maintain optimal fluid status\n -Rx with Vanco\n -Return to oncology floor today.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 22 Gauge - 04:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636591,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\n for T11/sacral spine related to multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt had\n radiation today no c/o back pain no Oxycodone given\n Action:\n Radiation today. Pt on Lidocaine patch 5% for lower back.\n Response:\n Tolerated well\n Plan:\n Continue radiation Mon-Thursday of next week. Pt called out to\n Hem/Onc.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\n 120/64 HR 70\ns SR no vea noted\n Action:\n None required\n Response:\n Pt back to baseline mental status\n Plan:\n Continue to observe for changes in mental status Florinef increased\n to .1 mg ?tilt table test to be done inpatient.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley, pt has foley , draining clear yellow\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\n cultures done x 2, urine cx sent\n Action:\n Vanco \n Response:\n Afebrile, no complaints, good urine output 30 cc/hr\n Plan:\n Continue with antibx, monitor urine output\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 636010,
"text": "Chief Complaint: 85 yo man with multiple myeloma as well as a history\n neurogenic presyncope secondary to autonomic dysfunction presenting\n initially with weakness and UTI, now with aphasia in the setting of\n hypotension, both have resolved with fluid repletion. Head ct and mri\n negative so far for evidence of stroke.\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 03:00 PM\n Head\n Patient with head ct showing no acute bleed and mri without evidence of\n acute stroke. Patient vital signs stable. showing signs of delirium\n with agitation, disorientation.\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:23 PM\n Cefipime - 10:30 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:11 PM\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history: none\n Review of systems is unchanged from admission except as noted below\n Review of systems: none\n Flowsheet Data as of 07:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 35.8\nC (96.5\n HR: 81 (70 - 93) bpm\n BP: 154/82(101) {105/50(65) - 162/97(113)} mmHg\n RR: 16 (14 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,800 mL\n 500 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,560 mL\n 500 mL\n Blood products:\n Total out:\n 1,295 mL\n 520 mL\n Urine:\n 1,295 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,505 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 207 K/uL\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 134 mEq/L\n 29.1 %\n 4.4 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n WBC\n 9.2\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 85 yo man with multiple myeloma as well as a history neurogenic\n presyncope secondary to autonomic dysfunction presenting initially with\n weakness and UTI, now with aphasia in the setting of hypotension, both\n have resolved with fluid repletion.\n .\n #) Hypotension: low reserve for hypotensive insult given baseline\n orthostatic hypotension.\n -likely infection related given + u/a with urine culture growing staph\n aureus, f/u sensitivities but currently will cover with vancomycin.\n Contact precautions for MRSA but no previous resistent bacteria on\n previous culture data.\n -vanc 1g IV q12hrs, cefepime 1g q 12 hrs\n -follow CBC / diff\n -lactate 1.0\n -rec'd 2 liter bolus IVF, continue at rate of 250cc/hr, now currently\n normotensive\n CXr - As compared to the previous examination, there is no relevant\n change. No\n newly occurred focal parenchymal opacity suggestive of pneumonia, no\n overhydration.\n -resend U/a, ucx\n -send blood cultures and f/u previously send blood cx\n -if diarrhea will send C diff\n -given staph aureus obtain echo to r/o valvular / regurgitant lesions\n -continue florinef at home dose and salt tabs\n -rule out MI with 2 sets of enzymes 12 hours apart\n .\n #) Mental Status Changes: apparently these were expressive aphasia. He\n has no known cerebrovascular disease in the past but given the nature\n of these episodes he likley has some cerebrovascular stenosis which\n cause some reversible hypoperfusion during episodes of hypotension.\n -continue to bolus IVF for hypotension and mental status changes\n -head CT wet read: No acute intracranial process, including no evidence\n for hemorrhage, edema,\n mass effect, or acute ischemia. Please note that MRI is more sensitive\n for\n evaluation of ischemia.\n - MRI of head wet read: There is no evidence of acute ischemic changes.\n Prominence of the ventricles\n and sulci, likely age-related and developmental in nature. There is no\n shift\n or normally placed midline structures. M2 segments bilaterally versus\n artifact.\n -aspirin 325mg po daily\n #) chronic lower back pain:\n - due to malignant compression fractures multiple myeloma.\n - MRI l spine - CONCLUSION: Diffuse signal intensity abnormalities in\n the vertebral bodies\n compatible with the history of multiple myeloma.\n No evidence of cauda equina compression.\n Right-sided disc protrusion at L3-4.\n - continue oxycodone prn.\n .\n #) multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression\n -s/p bone marrow biopsy to evaluate for amyloid, still pending\n .\n #) prophylaxis:\n - ppi and subcut heparin\n .\n #) full code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 12:55 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 636028,
"text": "Chief Complaint: Hypotension\n Aphasia\n HPI:\n patient at home with episode of pre-syncope and had \"slumping into a\n chair\" reported by VNA and sent to where he was diagnosed with\n UTI and started on Cipro.\n During PT evaluation he has difficulty with ambulation with PT eval and\n upon lying down had SBP=90 and expressive aphasia. This was Rx'd with\n ICF at 500cc with good improvement in BP and aphasia.\n Given in instability in BP and neuro exam patient to ICU for further\n care where ASA was given and CT and MRI pursued.\n Of note patient urine culture revealed S. Aureus\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Cefipime - 10:30 PM\n Vancomycin - 07:45 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Pantoprazole (Protonix) - 07:46 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Multiple Myeloma-Dx , complicated by Amyloid\n BPH-chronic indwelling catheter\n Autonomic Dysfunction--with primary issue orthostatic hypotension\n LBBB\n Non-contributory\n Occupation: Ret'd\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Tachypnea\n Genitourinary: Foley\n Psychiatric / Sleep: Daytime somnolence\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:52 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 35.7\nC (96.2\n HR: 76 (70 - 93) bpm\n BP: 126/48(55) {105/48(55) - 162/97(113)} mmHg\n RR: 20 (14 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,800 mL\n 730 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,560 mL\n 730 mL\n Blood products:\n Total out:\n 1,295 mL\n 730 mL\n Urine:\n 1,295 mL\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,505 mL\n -1 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, not place or year by my exam, Movement:\n Not assessed, Tone: Not assessed\n Labs / Radiology\n 207 K/uL\n 29.1 %\n 9.9 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 9 mg/dL\n 23 mEq/L\n 105 mEq/L\n 3.4 mEq/L\n 134 mEq/L\n 4.4 K/uL\n [image002.jpg]\n 12:29 PM\n 01:12 PM\n 01:30 PM\n 04:42 AM\n WBC\n 9.2\n 4.4\n Hct\n 20.6\n 30.4\n 29.1\n Plt\n 154\n 207\n Cr\n 0.6\n 0.7\n TropT\n <0.01\n Glucose\n 123\n 97\n Other labs: PT / PTT / INR:12.9/46.6/1.1, CK / CKMB /\n Troponin-T:36/3/<0.01, Alk Phos / T Bili:/0.6, Differential-Neuts:82.9\n %, Lymph:11.6 %, Mono:3.9 %, Eos:1.4 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL, PO4:3.5 mg/dL\n Imaging: MRI--Narrowing of M2, M3 noted but will need final read\n confirmed.\n CT Head-No acute CVA appreciated\n Assessment and Plan\n 85 yo male with presentation with persistence of his autonomic\n dysfunction and instability of BP with body position change now\n presenting with aphasia with changes in BP. He has on MRI a suggestion\n of significant changes in MCA distribution which may represent a marker\n for risk of vascular disease in a relevant distribution for placing an\n area at risk for symptomatic ischemia with blood pressure changes.\n Events have not recurred since admission to ICU.\n Urinary Tract Infection-\n -continue Vanco/Cefepime\n -Continue Foley\n -Given significant insult from local infection would suggest\n consideration of alternative therapeutic approach if possible for BPH\n Aphasia-\n -Will review with neurology the area at risk as described in MRI\n findings\n -Continue with ASA\n -Will have follow up evaluation for stabilization of perfusion\n Multiple Myeloma-\n -Further Rx by oncology service\n -Expect return to oncology floor today\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 22 Gauge - 12:55 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636481,
"text": "Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley. Pt has foley with clear yellow urine. Also\n on vanco for treatment of a staph uti.\n Action:\n Vanco .\n Response:\n Is afebrile. No complaints of painful urination. Very good urine\n output.\n Plan:\n Hypotension (not Shock)\n Assessment:\n pt was hypotensive with systolic b/p 84\n Action:\n Pt received 500cc of ivf on previous shift.\n Response:\n Has not required any ivf or pressors this shift.\n Plan:\n Cont to assess b/p.\n Altered mental status (not Delirium)\n Assessment:\n Pt has remained alert and oriented x3 this entire shift with no\n confusion noted. Speaking in very pleasant conversation.\n Action:\n None required.\n Response:\n Pt is back to baseline mental status.\n Plan:\n Cont to observe for changes in mental status and infection.\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636482,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley. Pt has foley with clear yellow urine. Also\n on vanco for treatment of a staph uti.\n Action:\n Vanco .\n Response:\n Is afebrile. No complaints of painful urination. Very good urine\n output.\n Plan:\n Pt may be called back up to the floor.\n Hypotension (not Shock)\n Assessment:\n pt was hypotensive with systolic b/p 84\n Action:\n Pt received 500cc of ivf on previous shift.\n Response:\n Has not required any ivf or pressors this shift.\n Plan:\n Cont to assess b/p.\n Altered mental status (not Delirium)\n Assessment:\n Pt has remained alert and oriented x3 this entire shift with no\n confusion noted. Speaking in very pleasant conversation.\n Action:\n None required.\n Response:\n Pt is back to baseline mental status.\n Plan:\n Cont to observe for changes in mental status and infection.\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635995,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Altered mental status (not Delirium)\n Assessment:\n At start of shift pt A&O x 3. Appropriate with words and responses to\n questions. Followed all commands, PERRL.\n Action:\n Full neuro assessment performed. Head CT and MRI done yesterday on\n days. Reported results negative.\n Response:\n Around midnight MS started to change. Pt had expressive asphasia, was\n A&O x 2\n unaware of time as he thought it was ^th. No\n facial droop noted, followed commands and had equal strength in all\n four extremities. Team aware of MS change.\n Plan:\n Con\nt to monitor mental status and reorient pt as needed. Con\nt to\n monitor neuro status.\n Hypotension (not Shock)\n Assessment:\n SBP at start of shift up to 170\ns systolic. Team aware.\n Action:\n Started on 200mg PO Labetalol .\n Response:\n SBP down to 100\ns and pt\ns mental status started to deteriorate as he\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\n d/c\nd. BP has been normotensive throughout noc.\n Plan:\n Con\nt to monitor BP and treat as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636417,
"text": "85 yo male with multiple myeloma as well as autonomic dysfunction on\n florinef ? secondary to amyloid. He also has BPH and a recent history\n of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea. On vanco for RX\n of UTI ( staph).\n Pt discharged from after he had an episode of expressive\n aphasia, & SBP 90. Ct scan negative Responded to fld bolus. Aphasia\n resolved.\n Today pt found\nasleep\n When awakened oriented to person only. SP\n 84/60, RR 25, HR 75. Sats975 on RA. Given cefipime 2 gm & NS 500 cc\n with improvement in MS & BP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, OX3. Conversing on phone. MEA.\n Action:\n Ct scan done prior to ICU admission. Results pnd\n Response:\n Oriented\n Plan:\n Cont to assess MS, neuro status\n Hypotension (not Shock)\n Assessment:\n Bp 157/86, hr 80\nS. Receiving maint IVF at 100 c chr X 5 hrs.\n Action:\n Ongoing assessment\n Response:\n Normotensive at present\n Plan:\n Cont to asses BP\n Urinary tract infection (UTI)\n Assessment:\n Afeb, Received dose cefipime prior to ICU transfer. On vanco\n Action:\n Response:\n Afeb\n Plan:\n Cont to assess for S&Sx of infection, MS changes\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636570,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednision , s/p XRT\n for T11/sacral\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 636622,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n .\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n .H/O multiple myeloma (Cancer, Malignant Neoplasm)\n Assessment:\n Currently s/p chemotherapy velcade/mephalan/prednisione , s/p XRT\n for T11/sacral spine related to multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression. Pt had\n radiation today no c/o back pain no Oxycodone given\n Action:\n Radiation today. Pt on Lidocaine patch 5% for lower back.\n Response:\n Tolerated well\n Plan:\n Continue radiation Mon-Thursday of next week. Pt called out to\n Hem/Onc.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, no confusion noted. VSS bp stable\n 120/64 HR 70\ns SR no vea noted\n Action:\n None required\n Response:\n Pt back to baseline mental status\n Plan:\n Continue to observe for changes in mental status Florinef increased\n to .1 mg ?tilt table test to be done inpatient.\n Urinary tract infection (UTI)\n Assessment:\n Has hx of long term foley, pt has foley , draining clear yellow\n urine. Afebrile on Vanco for treatment of a staph UTI, blood\n cultures done x 2, urine cx sent\n Action:\n Vanco \n Response:\n Afebrile, no complaints, good urine output 30 cc/hr\n Plan:\n Continue with antibx, monitor urine output\n Demographics\n Attending MD:\n E.\n Admit diagnosis:\n WEAKNESS\n Code status:\n Full code\n Height:\n Admission weight:\n 65.5 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Multiple myeloma, BPH, dyslipidemia, \n orthostatic hypotension w/ autonomic dysfunction (reported normal echo,\n unremarkable holter per chart), IVCD/LBBB, LBP pathological\n compression fx T12/L1, s/p chole 10 yrs ago, lung nodule s/p resection\n many years ago reported benign.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:160\n D:84\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 72 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,185 mL\n 24h total out:\n 1,510 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:21 AM\n Potassium:\n 3.5 mEq/L\n 02:59 PM\n Chloride:\n 105 mEq/L\n 04:21 AM\n CO2:\n 25 mEq/L\n 04:21 AM\n BUN:\n 10 mg/dL\n 04:21 AM\n Creatinine:\n 0.6 mg/dL\n 04:21 AM\n Glucose:\n 98 mg/dL\n 04:21 AM\n Hematocrit:\n 29.2 %\n 04:21 AM\n Finger Stick Glucose:\n 109\n 10:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 7SOUTH\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 636413,
"text": "85 yo male with multiple myeloma as well as autonomic dysfunction on\n florinef ? secondary to amyloid. He also has BPH and a recent history\n of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea. On vanco for RX\n of UTI ( staph).\n Pt discharged from after he had an episode of expressive\n aphasia, & SBP 90. Ct scan negative Responded to fld bolus. Aphasia\n resolved.\n Today pt found\nasleep\n When awakened oriented to person only. SP\n 84/60, RR 25, HR 75. Sats975 on RA. Given cefipime 2 gm & NS 500 cc\n with improvement in MS & BP.\n"
},
{
"category": "Physician ",
"chartdate": "2123-10-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 635881,
"text": "Chief Complaint: hypotension\n HPI:\n 85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse . The patient generally\n feels fatigued but denies any specific symptoms. No SOB, no CP, no\n cough, no abdominal pain, no constipation or diarrhea.\n The a.m. of transfer to the he was standing participating in\n physical therapy when he was noted to have difficulty speaking, he\n demonstrated expressive aphasia. He was brought to bed and a supine\n blood pressure was systolic 90. He was given 500cc of NS and SBP\n improved to SBP 120 and his aphasia resolved. Again his SBP dropped to\n 110 and his aphasia returned. A code stroke was called and the patient\n was given an additional 500cc NS. Patient has a baseline SBP while\n supine of 170 and while standing drops to sbp 120. Per his daughter he\n has been more confused lately (difficulty writing checks, able to feed\n himself, but due to weakness lately difficulty bathing). His daughter\n states that his orthostatic hypotension has also been worsening lately\n and on Friday he had syncopized while in a chair. Also per the\n daughter has had delerium and difficulty speaking related to\n electrolyte abnormalities.\n The patient currently remains asymptomatic. He does not feel confused,\n felt lightheaded during the episodes but not currently. As above ROS\n is negative. No F/C.\n Patient admitted from: \n History obtained from Patient, Family / Friend\n Allergies:\n Sulfa (Sulfonamides)\n Hives; Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds:\n Atorvastatin 10 mg daily\n Docusate Sodium 100 mg \n Senna 8.6 mg Tablet prn\n Acetaminophen 325 mg Tablet 2 tabs q6h prn\n Latanoprost 0.005 % Drops Sig qhs\n Dorzolamide-Timolol 2-0.5 % Drops \n Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO HS\n Oxycodone 5 mg Tablet Sig: 0.5 Tablet q6h prn\n Sodium Chloride 1 gram Tablet tid\n Finasteride 5 mg daily\n Fludrocortisone 0.1 mg prn\n .\n Transfer Medications:\n Finasteride 5 mg daily\n Fludrocortisone 0.1 mg prn\n Oxycodone 5 mg Tablet q4prn\n Atorvastatin 10 mg daily\n Docusate Sodium 100 mg \n Senna 8.6 mg Tablet prn\n Acetaminophen 325 mg Tablet 2 tabs q6h prn\n Latanoprost 0.005 % Drops Sig qhs\n Dorzolamide-Timolol 2-0.5 % Drops \n Cipro 500mg po q12hrs\n (given cefepime / vanc on transfer)\n Past medical history:\n Family history:\n Social History:\n MM, diagnosed , followed by Heme, on Velcade/mephalan/prednisone\n for past month , c/b lytic lesions/compression fractures - recnet\n XRT to spine.\n BPH (meds were d/c'ed due to hypotension)\n dyslipidemia\n X2 : reported normal Echo, unremarkable holter per chart\n IVCD/LBBB-old\n LBP- pathological compression fx T12/L1 s/p choley 10years ago\n lung nodule s/p resection many years ago, reported benign\n Mother died uterine Ca, Father died PNA, has one brother/one sister who\n are alive and well at age 80s\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as job placement coordinator\n Lives with wife of 55+ years and disabled daughter (cerebral palsy). He\n is the primary caretaker of his daughter. Lives in single family home\n with approx three flights of stairs. Bedroom is on . wife,\n 2 daughters wife is HCP\n Quit tobacco > 20yrs ago, denies etoh\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Flowsheet Data as of 02:56 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36.4\nC (97.5\n HR: 92 (85 - 92) bpm\n BP: 147/81(97) {141/74(95) - 154/84(97)} mmHg\n RR: 20 (19 - 24) insp/min\n SpO2: 98%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Total In:\n 1,429 mL\n PO:\n TF:\n IVF:\n 1,429 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,129 mL\n Respiratory\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n T 95.8 HR 85 BP 158/74 O2 100% RA\n GEN: cachectic elderly male, AOx2 (date- , )\n HEENT: EOMI, PERRL, sclera anicteric, dry MM, OP Clear\n NECK: JVP 10cm, no bruits, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, soft heart sounds\n PULM: Lungs CTAB, no W/R/R\n ABD: Soft, NT, ND, +BS, no HSM, no masses, rectal soft brown stool,\n guiac negative\n EXT: No C/C/E, no palpable cords\n NEURO: alert, oriented to person, place, not to time. CN II\n XII\n grossly intact. 5/5 strength in UE deltoid, bicep, tricep, wrist flex /\n ext, normal grip stregnth. stregnth in lower ext- quad, hamstring,\n dorsiflexion / plantarflexion. Normal sensation to light touch bilat\n symmetrical. cerebellar testing is normal. Reflexes normal\n throughout. Babinski equivocal.\n Labs / Radiology\n 154 K/uL\n 7.0 g/dL\n 123 mg/dL\n 0.6 mg/dL\n 11 mg/dL\n 23 mEq/L\n 104 mEq/L\n 2.9 mEq/L\n 137 mEq/L\n 30.4 %\n 9.2 K/uL\n [image002.jpg]\n \n 2:33 A9/22/ 12:29 PM\n \n 10:20 P9/22/ 01:12 PM\n \n 1:20 P9/22/ 01:30 PM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.2\n Hct\n 20.6\n 30.4\n Plt\n 154\n Cr\n 0.6\n Glucose\n 123\n Other labs: Alk Phos / T Bili:/0.6, Differential-Neuts:90.3 %,\n Lymph:3.0 %, Mono:6.1 %, Eos:0.6 %, Lactic Acid:1.0 mmol/L, LDH:190\n IU/L\n Fluid analysis / Other labs: u/a: >50wbc, + nitrite, sm Leuk esterase.\n coag + staph aureus, 10,000-100,000.\n Imaging: CXR: minimal volume overload. minimal pleural effusion on R\n side.\n Microbiology: 6:48 pm URINE Source: Catheter.\n URINE CULTURE (Preliminary):\n STAPH AUREUS COAG +.\n 10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.\n ECG: EKG: sinus. rate 85. LBBB, no ST T wave changes when compared to\n previous.\n Assessment and Plan\n assessment and plan:\n 85 yo man with multiple myeloma as well as a history neurogenic\n presyncope secondary to autonomic dysfunction presenting initially with\n weakness and UTI, now with aphasia in the setting of hypotension, both\n have resolved with fluid repletion.\n .\n #) Hypotension: low reserve for hypotensive insult given baseline\n orthostatic hypotension.\n -likely infection related given + u/a with urine culture growing staph\n aureus, f/u sensitivities but currently will cover with vancomycin.\n Contact precautions for MRSA but no previous resistent bacteria on\n previous culture data.\n -vanc 1g IV q12hrs, cefepime 1g q 12 hrs\n -resend CBC / diff\n -send lactate\n -keep SBP > 110, has rec'd 2 liter bolus IVF, continue at rate of\n 250cc/hr\n -f/u CXR\n -resend U/a, ucx\n -send blood cultures and f/u previously send blood cx\n -if diarrhea will send C diff\n -given staph aureus obtain echo to r/o valvular / regurgitant lesions\n -continue florinef at home dose and salt tabs\n -rule out MI with 2 sets of enzymes 12 hours apart\n .\n #) Mental Status Changes: apparently these were expressive aphasia. He\n has no known cerebrovascular disease in the past but given the nature\n of these episodes he likley has some cerebrovascular stenosis which\n cause some reversible hypoperfusion during episodes of hypotension.\n -continue to bolus IVF for hypotension and mental status changes\n -when stable will send for CT head without contrast, then carotid\n ultrasound and MRA / MRI of the head (no contrast)\n -aspirin 325mg po daily\n #) chronic lower back pain:\n - due to malignant compression fractures multiple\n myeloma.\n continue oxycodone prn.\n .\n #) multiple myeloma:\n - currently s/p chemotherapy velcade/mephalan/prednisone , s/p XRT\n for T11/sacral spine related to Multiple myeloma, recent MRI for\n urinary retention negative for spinal cord compression\n -s/p bone marrow biopsy to evaluate for amyloid, will need to f/u these\n results\n .\n #) prophylaxis:\n - ppi and subcut heparin\n .\n #) full code.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635971,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Altered mental status (not Delirium)\n Assessment:\n At start of shift pt A&O x 3. Appropriate with words and responses to\n questions. Followed all commands, PERRL.\n Action:\n Full neuro assessment performed. Head CT and MRI done yesterday on\n days. Reported results negative.\n Response:\n Around midnight MS started to change. Pt had expressive asphasia, was\n A&O x 2\n unaware of time as he thought it was ^th. No\n facial droop noted, followed commands and had equal strength in all\n four extremities. Team aware of MS change.\n Plan:\n Con\nt to monitor mental status and reorient pt as needed. Con\nt to\n monitor neuro status.\n Hypotension (not Shock)\n Assessment:\n SBP at start of shift up to 170\ns systolic. Team aware.\n Action:\n Started on 200mg PO Labetalol .\n Response:\n SBP down to 100\ns and pt\ns mental status started to deteriorate as he\n became aphasic and was A&O x 2. 500ml NS bolus given x 1 and Labetalol\n d/c\nd. BP has been normotensive throughout noc.\n Plan:\n Con\nt to monitor BP and treat as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2123-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 635924,
"text": "85 yo male with multiple myeloma and as well as autonomic dysfunction\n on florinef ? secondary to amyloid. He also has BPH and a recent\n history of urinary obstruction requring long term foley presenting with\n weakness and per a visiting nurse .\n Urinary tract infection (UTI)\n Assessment:\n +staph in urine, wbc\ns 9.2, lactic acid 1.0\n Action:\n Contact precautions for possible MRSA, BC X2 sent, CXR; pt started on\n vanco/cefapime for ? urosepsis.\n Response:\n T 95-97; given Tylenol on 7F prior to coming to MICU.\n Plan:\n Continue antibiotics, follow cultures, wbc\n Hypotension (not Shock)\n Assessment:\n NBP 141-156/74-96 while in bed; HR 80-92, LBBB.\n Action:\n Pt received total of 2L of fluid since arrival to MICU. Receiving\n florinef.\n Response:\n BP stable.\n Plan:\n Monitor orthostatic BP, continue florinef, IV fluid boluses for\n hypotension.\n Altered mental status (not Delirium)\n Assessment:\n A&O X2, slow to respond but usually knows where he is and the date.\n Moves all extremities\n Action:\n Head CT and MRI done. Receiving ASA.\n Response:\n No acute bleed seen.\n Plan:\n Monitor neuro status, follow neuro recs, continue ASA\n .H/O electrolyte & fluid disorder, other\n Assessment:\n Na 137, K 2.9\n Action:\n Receiving sodium tabs and received 40meq KCL/1L at 250/hr.\n Response:\n Pending.\n Plan:\n Monitor lytes q 12hrs, replete per onc sliding scale.\n"
}
] |
51,834 | 148,768 | The patient was admitted to the hospital after bronchoscopy with BAL, which showed diffuse alveolar hemorrhage, for monitoring in the MICU. BAL fluid cultures for bacteria and fungi were sent and home medications were stopped. In the MICU simvastatin was restarted and a number of tests including antibody panels, viral cultures, and serologies were sent. His hematocrit dropped significantly from 27.9 to 22.5 and he was transfused with two units of packed red blood cells restoring it to 29.7. After this he remained stable and was transferred to the general medicine floor the next day. The most likely etiology of his DAH was thought to be from concurrent coumadin and aspirin treatment. Given his clinical stability and lack of other organ system involvement, other etiologies such as vasculitis were considered less likely although anti-GBM Ab, , ANCA, C2 were all sent. On the medicine floor, his INR declined from 2.5 on to 1.2 on off of coumadin. Given his history of sudden cardiac arrest and CAD, his aspirin was continued at 81 mg. His hematocrit was largely stable (27.4 at discharge). CBC, iron studies, and reticulocyte count (4.0, index 2.67 on ) indicated that his anemia was most consistent with acute blood loss. Overnight his O2 desaturated to 90%, requiring 2L O2, but recovering to 92% on RA by morning. A CXR and CT scan were ordered to rule out bleeding. The CXR showed no change from previously and the CT showed only a small amount of increased hemorrhage, and was reassuring overall. Echocardiogram showed a reduced ejection fraction of 30-35%, mild pulmonary hypertension, and some mitral regurgitation consistent patient's history of myocardial infarction. On , his oxygen saturation fell to 86% while climbing stairs and he continued in the hospital in order to assess his stability. On , his resting saturation increased to 100% RA, which was his highest since admission. Saturation during a six minute walk test remained above 90% and it stayed above 93% while climbing four flights of stairs and subsequently thereafter when ambulating. Pulmonary followed the patient throughout his hospital course and given his dramatic improvement, felt that he was safe to discharge home with close follow up the following week once the remainder of his test results became available. At the time of discharge, all cultures and serologies were negative except for the acid fast culture which showed no growth to date, but was not yet final. was negative, but ANCA and anti-GBM antibody and C2 studies were still pending. Based on persistently high fasting blood sugars, we ordered a hemoglobin A1c measurement and obtained previous records from . The A1c was 6.2, however, his historical fasting glucose measurements have remained above 130 since . Based on this, we made a diagnosis of Type II Diabetes Mellitus. We prescribed a glucometer and taught him and his wife how to use it instructing him to keep a diary of glucose levels to share with his PCP. also prescribed metformin to help improve his glucose control at home. His lisinopril was restarted at a reduced dose of 5mg prior to discharge. He was instructed not to restart warfarin without consulting with his cardiologist and pulmonologist as it was the most likely cause of his hemoptysis, though other etiologies may also have been involved. Given his CHADS2 score of 2, history of hypertension and new diagnosis of diabetes, he is considered at intermediate risk and aspirin only anticoagulation is acceptable. | Diffuse GGO/hazy opacities compatible with alveolar hemorrhage. The aortic root and ascending aorta are mildly dilated.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Mildlydilated ascending aorta. There is mildpulmonary artery systolic hypertension. The right ventricular cavity is mildly dilated with moderate globalfree wall hypokinesis. Mild to moderate [+] TR.Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Intra-atrial conduction delay.Consider prior inferior myocardial infarction, although it is non-diagnosticand may be within normal limits. No LVmass/thrombus.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo; basal inferior - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. There is moderate regional left ventricular systolicdysfunction with hypokinesis of the basal inferior wall and septum. Normal descending aorta diameter. Moderate global RV free wallhypokinesis.AORTA: Mildy dilated aortic root. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No 2D or Dopplerevidence of distal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Superimposed on these abnormalities, there is mild interlobar septal thickening with mild vascular congestion. There is no pericardial effusion.IMPRESSION: Normal left ventricular cavity size with regional systolicdysfunction c/w CAD. Mild mitral annularcalcification. Evaluate for valve diseaseHeight: (in) 67Weight (lb): 160BSA (m2): 1.84 m2BP (mm Hg): 116/62HR (bpm): 61Status: InpatientDate/Time: at 15:54Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Normal LV wall thickness and cavity size. A small hiatus hernia is seen. acute changes, fluid PFI REPORT No change in bilateral diffuse alveolar opacities. ST-T wave abnormalities are non-specific.Clinical correlation is suggested. The mitral valve leaflets are mildlythickened. Mild-moderate mitral regurgitation. Mild to moderate (+) mitral regurgitation is seen. There is hazy bilateral vasculature and some areas of patchy alveolar infiltrate. There are small mediastinal lymph nodes which do not meet CT size criteria for pathologic enlargement. Mild to moderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed without intravenous or oral contrast. Moderate regional LVsystolic dysfunction. Otherwise, non-contrast examination of the heart and great vessels are unremarkable. Calcification of the aortic annulus is also noted. acute changes, fluid PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj MON 2:03 PM No change in bilateral diffuse alveolar opacities. The airways are patent to a subsegmental level. Sinus rhythm with A-V conduction delay. IMPRESSION: No change in bilateral diffuse alveolar opacities. PATIENT/TEST INFORMATION:Indication: Murmur. Estimated cardiac index is normal (>=2.5L/min/m2). Vascular clips from prior CABG are seen. The estimated cardiacindex is normal (>=2.5L/min/m2). Dilated ascendingaorta. Focal calcifications in aortic root. (Over) 6:06 PM CT CHEST W/O CONTRAST Clip # Reason: ?change since prior scan Admitting Diagnosis: PULMONARY HEMORRHAGE FINAL REPORT (Cont) Otherwise, the visualized portions of the liver, spleen and kidneys are unremarkable in appearance. FINAL REPORT CHEST ON HISTORY: Diffuse alveolar hemorrhage. Calcification of the splenic artery is noted. FINDINGS: Diffuse bilateral alveolar infiltrates are not significantly changed since the prior study, no effusion or pneumothorax is present. IMPRESSION: Further interval progression of the diffuse bilateral ground-glass opacities with areas of frank consolidation seen in the apices bilaterally and superior segment of the right lower lobe. Pacemaker leads are seen in the expected positions overlying the right atrium and right ventricle. Severe coronary artery, splenic artery vascular calcs. The heart and mediastinal contours are normal. Left ventricular wall thicknesses andcavity size are normal. On review of the lung windows, there has been further progression of the diffuse bilateral ground-glass opacities with progression in some areas to frank consolidation. COMPARISON: Reference CT chest . There is a dual-lead pacemaker in situ. , R. MED CC7A 9:29 AM CHEST (PORTABLE AP) Clip # Reason: ? Appearances could be consistent with resorption of intra-alveolar hemorrhage; however, superimposed infection cannot be excluded and cryptogenic organizing pneumonia is also a possibility. FINDINGS: The visualized portions of the thyroid gland and supraclavicular regions are unremarkable in appearance. Sternotomy wires are intact. FINAL REPORT INDICATION: Diffuse alveolar hemorrhage, desaturation overnight. Pulmonary artery hypertension.CLINICAL IMPLICATIONS:The left ventricular ejection fraction is <40%, a threshold for which thepatient may benefit from a beta blocker and an ACE inhibitor or .Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Sternal wires and mediastinal clips are seen. This appearance may be the end point of resorption of hemorrhage; however, superimposed infection cannot be excluded and cryptogenic organizing pneumonia is also a possibility. No pericardial or pleural effusions. It is unclear if this is due to the known alveolar hemorrhage or if there is an overlying element of fluid overload or infection. | 6 | [
{
"category": "Radiology",
"chartdate": "2116-01-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176501,
"text": " 6:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: consolidation\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage s/p bronch.\n REASON FOR THIS EXAMINATION:\n consolidation\n ______________________________________________________________________________\n WET READ: ENYa FRI 8:30 PM\n No definite evidence of focal air-space consolidation. Diffuse GGO/hazy\n opacities compatible with alveolar hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Diffuse alveolar hemorrhage.\n\n FINDINGS:\n\n There are no old films available for comparison. A pacemaker is visualized\n with leads projecting over the expected locations of the heart. The heart is\n mildly enlarged. Sternal wires and mediastinal clips are seen. There is hazy\n bilateral vasculature and some areas of patchy alveolar infiltrate. It is\n unclear if this is due to the known alveolar hemorrhage or if there is an\n overlying element of fluid overload or infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176789,
"text": " 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute changes, fluid\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage and desaturation overnight\n REASON FOR THIS EXAMINATION:\n ? acute changes, fluid\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SJBj MON 2:03 PM\n No change in bilateral diffuse alveolar opacities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diffuse alveolar hemorrhage, desaturation overnight.\n\n COMPARISON: .\n\n FINDINGS: Diffuse bilateral alveolar infiltrates are not significantly\n changed since the prior study, no effusion or pneumothorax is present. The\n heart and mediastinal contours are normal. Sternotomy wires are intact.\n Vascular clips from prior CABG are seen. Pacemaker leads are seen in the\n expected positions overlying the right atrium and right ventricle.\n\n IMPRESSION: No change in bilateral diffuse alveolar opacities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176790,
"text": ", R. MED CC7A 9:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute changes, fluid\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage and desaturation overnight\n REASON FOR THIS EXAMINATION:\n ? acute changes, fluid\n ______________________________________________________________________________\n PFI REPORT\n No change in bilateral diffuse alveolar opacities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-01-20 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1176881,
"text": " 6:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?change since prior scan\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with diffuse alveolar hemorrhage of unknown etiology\n REASON FOR THIS EXAMINATION:\n ?change since prior scan\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JBRe MON 6:49 PM\n Only slight increase fof the diffuse pulmonary hemorrhage, predominantly in\n the basal segments of the left lower lobe and a more consolidated (rather than\n diffuse) appearance of the hemorrhage at the lung apices compared to prior CT\n (OSH CT). No pericardial or pleural effusions. Severe coronary artery,\n splenic artery vascular calcs.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with diffuse alveolar hemorrhage of unknown\n etiology, query change.\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n without intravenous or oral contrast. Images are presented for display in the\n axial plane at 1.25- and 5-mm collimation. A series of multiplanar\n reformations were also submitted for review.\n\n COMPARISON: Reference CT chest .\n\n FINDINGS: The visualized portions of the thyroid gland and supraclavicular\n regions are unremarkable in appearance. There are small mediastinal lymph\n nodes which do not meet CT size criteria for pathologic enlargement. The\n largest is an 8-mm pre-tracheal node (2:15). A small hiatus hernia is seen.\n The patient has had a previous coronary artery bypass graft and there are\n multiple surgical clips in the mediastinum as well as calcification of the\n coronary arteries. Calcification of the aortic annulus is also noted. There\n is a dual-lead pacemaker in situ. Otherwise, non-contrast examination of the\n heart and great vessels are unremarkable. No pleural effusion, no pericardial\n effusion.\n\n The airways are patent to a subsegmental level. On review of the lung\n windows, there has been further progression of the diffuse bilateral\n ground-glass opacities with progression in some areas to frank consolidation.\n This is most apparent in the superior segment of the right lower lobe (4:94),\n at the right apex (4:37) and left apex (4:45). This appearance may be the end\n point of resorption of hemorrhage; however, superimposed infection cannot be\n excluded and cryptogenic organizing pneumonia is also a possibility.\n Superimposed on these abnormalities, there is mild interlobar septal\n thickening with mild vascular congestion.\n\n This study is not tailored for evaluation of the subdiaphragmatic organs. The\n adrenal glands are unremarkable in appearance. Calcification of the splenic\n artery is noted. The spleen is borderline enlarged measuring 16 cm.\n (Over)\n\n 6:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?change since prior scan\n Admitting Diagnosis: PULMONARY HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Otherwise, the visualized portions of the liver, spleen and kidneys are\n unremarkable in appearance.\n\n BONY STRUCTURES: Degenerative changes noted in the left shoulder. No\n destructive lytic or sclerotic bony lesions are seen.\n\n IMPRESSION: Further interval progression of the diffuse bilateral\n ground-glass opacities with areas of frank consolidation seen in the apices\n bilaterally and superior segment of the right lower lobe. Appearances could\n be consistent with resorption of intra-alveolar hemorrhage; however,\n superimposed infection cannot be excluded and cryptogenic organizing pneumonia\n is also a possibility.\n\n"
},
{
"category": "Echo",
"chartdate": "2116-01-20 00:00:00.000",
"description": "Report",
"row_id": 92825,
"text": "PATIENT/TEST INFORMATION:\nIndication: Murmur. Evaluate for valve disease\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 116/62\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 15:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV\nsystolic dysfunction. Estimated cardiac index is normal (>=2.5L/min/m2). No LV\nmass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; basal inferior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Mildy dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta. Normal descending aorta diameter. No 2D or Doppler\nevidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction with hypokinesis of the basal inferior wall and septum. The\nremaining segments contract normally (LVEF = 30-35 %). The estimated cardiac\nindex is normal (>=2.5L/min/m2). No masses or thrombi are seen in the left\nventricle. The right ventricular cavity is mildly dilated with moderate global\nfree wall hypokinesis. The aortic root and ascending aorta are mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild to moderate (+) mitral regurgitation is seen. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size with regional systolic\ndysfunction c/w CAD. Mild-moderate mitral regurgitation. Dilated ascending\naorta. Pulmonary artery hypertension.\n\nCLINICAL IMPLICATIONS:\nThe left ventricular ejection fraction is <40%, a threshold for which the\npatient may benefit from a beta blocker and an ACE inhibitor or .\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2116-01-19 00:00:00.000",
"description": "Report",
"row_id": 256755,
"text": "Sinus rhythm with A-V conduction delay. Intra-atrial conduction delay.\nConsider prior inferior myocardial infarction, although it is non-diagnostic\nand may be within normal limits. ST-T wave abnormalities are non-specific.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\n\n"
}
] |
17,707 | 102,227 | The patient was admitted to the hospital on , after undergoing a right thoracotomy and a T11 vertebrectomy. She tolerated the procedure well with no apparent intraoperative complications. A chest tube was placed. Due to the extensive restrictive lung disease, she was subsequently monitored in the Post Anesthesia Care Unit in an intubated status pending planned posterior procedure three days later. The patient was able to be extubated prior to her second procedure. She was subsequently taken back to the operating room on , for attempted posterior spinal osteotomy with posterior spinal fusion and instrumentation for correction of her kyphoscoliosis. Intraoperatively, she was noted to have marked dural ectasia with subsequent durotomies times two with cerebrospinal fluid leak while attempting to place posterior spinal instrumentation. Given the marked atrophic nature of her dural tissue and significant difficulty in repairing the dural leaks, it was felt that it was inadvisable to proceed with attempted posterior osteotomy given that hardware placement would be significantly difficult and the risk of creating multiple additional durotomies with persistent cerebrospinal fluid leaks was likely. As such, the fusion mass was further explored and an in situ fusion was performed. The posterior most segmental hardware could not be removed due to the extensive amount of fusion mass which had embedded the hooks. Again, due to significant risks for further dural injury, the hardware was left. The patient was then transferred to the Surgical Intensive Care Unit for attempted extubation. The patient had an extensive Intensive Care Unit course lasting nearly two weeks with daily attempts at weaning off the ventilator. It was not until two weeks postoperatively that the patient was eventually extubated secondary to her significant restrictive lung disease and underlying CO2 retention. Following extubation, she was transferred to the Orthopedic floor in stable condition. Of note, the patient did have persistent intermittent drainage from her postoperative wound while in the Intensive Care Unit. She was treated with Ancef empirically during this period of drainage. Compressive and frequent dressing changes were applied in hopes that the drainage would stop. There was no evidence of wound infection at that time. After transfer to the Orthopedic floor, however, the patient was noted to have a significant increase in her postoperative wound drainage with signs of wound breakdown. She was subsequently taken back to the operating room on , and underwent irrigation and debridement of her postoperative wound. Intraoperatively, it was noted that there was a significant purulence present consistent with postoperative wound infection. There was additionally noted recurrence of the cerebrospinal fluid leak at the most distal durotomy site in the vicinity of L5. This cerebrospinal fluid leak was again repaired and a thorough irrigation and debridement was performed. Postoperative drains were placed and the patient had multiple intraoperative cultures obtained. Following the procedure, the patient was returned to the Orthopedic floor in extubated status. Intraoperative wound cultures eventually grew E. coli and bacteroides. The patient was seen by infectious disease and appropriate antibiotic regimens were instituted per their recommendations. The patient had been placed on Vancomycin empirically following her irrigation and debridement procedure followed by institution of Ceftazidime given initial gram stain results. Eventually the patient was placed on Ceftriaxone and Flagyl after cultures and sensitivities were obtained. A PICC line was placed for planned long term intravenous antibiotic therapy. The patient was maintained with postoperative drains for greater than one week until the drainage had dropped off significantly. The drains were subsequently removed and within two days the patient was again noted to have a significant accumulation of wound drainage with subsequent breakdown of her wound. The patient was taken back to the operating room on , and underwent repeat irrigation and debridement procedure. It was again noted that the previous durotomy site at L5 was again with evidence of recurrent cerebrospinal fluid leak. A third attempt at repair was performed utilizing suture, Duragen, to seal and following these procedures, a fascial fat graft was placed over the cerebrospinal fluid leak site. Cultures were again obtained intraoperatively and sent. The patient was subsequently transferred back to the Orthopedic floor, again in stable condition and again extubated. She was maintained in a supine position, flat bedrest for approximately one week in attempts to allow the cerebrospinal fluid leak to heal. Drains were maintained for nearly two weeks postoperatively until drainage was 30cc per shift prior to removal. Staples were allowed to remain in place to allow adequate healing of the wound. Following the second irrigation and debridement procedure, the wound remained clean, dry and intact and without any evidence of erythema or evidence of wound breakdown. Following removal of the drains, the wound continued to remain intact and she was felt to be stable for discharge home with close follow-up care. In addition, arrangements for VNA to observe the wound and assist with daily care was arranged. Plan will be to remain on Ceftriaxone and Flagyl intravenously for a period of eight weeks postoperatively. She should have a complete blood count with differential, ESR, CRP, and liver function tests obtained on a weekly basis and faxed to her primary care physician and the infectious disease clinic. The patient was seen by nutritionist during her hospitalization with subsequent calorie counts and supplementation as needed for postoperative nutrition. She otherwise remained medically stable throughout her hospitalization. She was felt to be medically stable for discharge home on . | There is again demonstrated a deformity with reduced size of the right hemithorax. Dural ectasia and leak x2 repaired intraop FINAL REPORT HISTORY: Scoliosis. CONCLUSION: Single rod placement related to the scoliosis as described. There has been interval placement of a nasogastric tube with the tip terminating in the distal esophagus. LUMBAR SPINE W/O CONTRAST: Post surgical changes and susceptibility artifact are present. Final chest image demonstrated appropriate position of the PICC tip in the distal superior vena cava. COMPARISON: Comparison made to prior study of , CHEST AP: There is again note of a marked kyphoscoliosis. Marked scoliotic deformity as before including orthopedic hardware for scoliosis support. lacking detail demonstrates a single rod stabilizing the scoliosis related to the anterior fusion. Bilateral small pleural effusions are again demonstrated. There marked thoracic scoliosis convex to right with rod fixation. IMPRESSION: 1) Bilateral effusions with right middle and lower lobe opacities. This is most consistent with a pseudomeningocele. There has been interval placement of an endotracheal tube which is grossly unremarkable. INDICATION: Scoliosis, status post right thoracotomy and chest tube placement. IMPRESSION: 1) Right PICC line likely terminates at the junction of superior vena cava and right atrium, although distal tip is difficult to definitively visualize. On the frontal radiograph, it is visualized to the level of the junction of the right subclavian and right brachiocephalic veins, and subsequently obscured by a fixation hardware device related to the spine. Probable right lower lobe atelectasis and effusion. IMPRESSION: 1) Interval placement of right-sided chest tube with no pneumothorax identified. 2) Limited examination secondary to baseline deformity and suboptimal view. Sinus rhythm.Septal and lateral ST-T changes are nonspecificLow QRS voltages in precordial leads Mild (1+) mitral regurgitation is seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Resp Care,Pt. ATTEMPT TO WEAN PS AGAIN THIS AM. CONT VENT WEAN AS . RESTART AS PT . PULM HYGIENE. RESTART ANTIHYPERTENSIVES. pt.on cpap+ps , bs coarse, sx for tan secretions, rsbi-64.3, abg alkalotic, will wean as . ASSESS FOR H/A. Resp. POST EXTUBATION ABG WNL. MONITOR RESP STATUS. FOLLOWS COMMANDS.CV-HRR. FIB IN PLACE. Effect (P).P: Monitor resp status. LS CTA briefly. SKIN W+D. VENT WEAN STARTED AGAIN. HR/BP STABLE, SEE FLOWSHEET FOR ALL VS. REATTEMPT IPS WEAN IN AM. FOCUS: STATUS UPDATEDATA:PT ALERT AND ORIENTED X3. LS OCCAS COARSE, REQUIRED MIN SUCTIONING. CONT PER CURRENT MGMT. CONT PER CURRENT MGMT. PBOOTS ON. MONITOR VS AND RESP STATUS. RSBI attempted this am, pt. ADAT. WEAN VENT AS ORDERED AS TOL. PERRL. LAST BM, COLACE GIVEN. Cont PSV wean as tolerated. See carevue for settings/ABG. SPONT/PURP MOVING UPPER EXTREMITIES, NEEDS MIN ASSISTANCE TO MOVE LOWER EXTREMETIES.CV: HR 78-94, NSR, NO ECTOPY. Assist with C&DB, repositioning. CONTINUES ON IV CEFAZOLIN, AFEBRILE. CONT PAIN MGMT. PAIN IMPROVED PER PT REPORT.RESP: LS CTA. PT USING PCA APPROPRIATELY. EASILY AWAKENED WHEN GTT D/C'D. RETURNED TO WITH IMPROVEMENT IN VS, REPEAT ABG PENDING.CV: TMAX 99. +PP. CONDITION UPDATEPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFCS.NEURO: ALERT. FEEDING TUBE THUS D/C'D. DULC SUPP GIVEN, EFFECT PENDING.GU: CLEAR YELLOW U/O VIA FOLEY.PLAN: RECHECK ABG. MD' AND LI PRESENT. CONT PER POST OP PROTOCOLS. ALINE D/C'D. CONTINUE WITH CURRENT MONITORING AND TREATMENT. PER DR. , PT GET OOB WITH PHYS THERAPY & ACTIVITY AS TOLERATED. pt.remains on mmv, see flowsheet for further info, sx for tan secretion, abg acidotic, will wean as tol., rsbi-41.7 LAST ABG IMPROVED-7.40/54/175/35/7/99.GI: ABD SOFTLY DISTENDED, +BS, TOLERATING TF IMPACT W/ FIBER AT GOAL AT 60CC/HR VIA POST PYLORIC DOBHOFF. Dr. to examine pt. DENIES CARDIAC COMPLAINTS.RESP-EXTUBATED THIS AM. lytes repleated. WILL MONITOR. PAIN WELL CONTROLLED WITH DILAUDID PCA. CONDITION UPDATEASSESSMENT:NEURO INTACT, COMMUNICATING BY MOUTHING WORDS & WRITING. +BS. + BS. CVP ~ 12.GI: NPO. RELIEVED WITH ZOFRAN. SBP 110-130's A-line slightly dampened. IVF KVO'D.GI: ABD SOFT. +diuresis.GI: +BS, abdomen softly distended. LG LIQUID BM THIS AM. normal affect.Good sensory respond from ext. TF'S HELD. Resp. Resp. Continues to use dilaudid PCA. RESTART TF'S SLOWLY WHEN PT ABLE TO . Tolerate t-piece for 1 hr - ABG - resp acidiotic (no sob). Plan to cont psv wean as tolerated. +flatus, pt. small drainage in proximal area of back - serosangious - DSD intact. c/o heartburn->zofran given w/ relief x1. CONT HOB FLAT. DRG CONTS, BUT IN DECREASED AMTS.RESP: LS CLEAR BUT DIM. MIN SECRETIONS. Clear upper lobes, dimish at bases. BP STABLE. MD INFORMED. LICSW # BS's ess clear. temp max 99.1. warm, dry, slight general edema.resp; clear in upper lobes. Wearing pboots.RESP: Lung sounds clear, coarse at times, dim to L. base. ATTEMPT VENT WEAN AS . ABG's with good oxygenation, slight resp acidosis. rectal bag replace. ABGs acceptable.Suctioned for white coarse secretions.CV: Afebrile. SIMV tolerated - ABG - better than prior, please see flow sheet.gu/gi; soft abd. PERRLA. Sxing small amts secretions from ETT. CONT PER CURRENT MGMT. Afebrile. Diamox x1 given. Cont. Cont. flowsheet. USING PCA MORE FREQUENTLY WITH STATED RELIEF. BS's clear. Extubate in AM? Lasix 20mg IV x1 w/excellent diuresis. soft abd, +BSX4. See flowsheet for pt data.Plan: Attempt weaning slowly. Good pain control with PCA.cv; NSR without ectopy. Et tube was rotated and retayped, SX mod amout thick white. extremities warm with palpable periferal pulses.RESP: lungs clear to dim at bases. heartburn X2 per pt - reglan given - good effect. alkalosis, resp. Sxing small amts thick white secretions from ETT. Neuro: Pt alert and oriented X3, mouthing words and able to write to make needs known.CV: Low grade temp 99.2, HR 60-80's NSR with no ectopy. to reflect met. RESPIRATORY CARE:Pt remains intubated, vent supported. Dobhoff - positive placement. Lytes replace.Plan; Continue to monitor. PERLA. PERLA. NSR. Care NotePt remains intubated and vented on settings as per resp. | 51 | [
{
"category": "Radiology",
"chartdate": "2154-02-05 00:00:00.000",
"description": "O LUMBAR SP,SINGLE FILM IN O.R.",
"row_id": 812411,
"text": " 10:11 AM\n LUMBAR SP,SINGLE FILM IN O.R. Clip # \n Reason: SCOLIOSIS,FUSION ANT. T-L SPINE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Back pain scoliosis effusion anterior T and L-spine\n\n Single portable film from the O.R. lacking detail demonstrates a single rod\n stabilizing the scoliosis related to the anterior fusion.\n\n CONCLUSION: Single rod placement related to the scoliosis as described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 814611,
"text": " 9:57 AM\n CHEST (PA & LAT) Clip # \n Reason: fever, eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with prolonged intubation in unit, recent extubation\n\n REASON FOR THIS EXAMINATION:\n fever, eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n PA & LATERAL RADIOGRAPHS:\n\n COMPARISON: and .\n\n FINDINGS: The patient is markedly scoliotic convex to the right, with a rod\n fixator. There is resultant asymmetry of the thorax. Allowing for this, the\n lungs appear clear with no effusions or focal consolidations. There is no\n CHF.\n\n IMPRESSION: No acute cardiopulmonary process. Thoracic deformity unchanged\n in appearance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812792,
"text": " 2:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess NGT position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n assess NGT position\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: S/P NG tube placement.\n\n COMPARISON: Comparison made to prior study of ,\n\n CHEST AP: There is again note of a marked kyphoscoliosis. There has been\n interval placement of a nasogastric tube with the tip terminating in the\n distal esophagus. The superior portion of the film suggests that there may be\n coiling of the tube within the pharynx. There is a right internal jugular\n catheter present with its tip projecting over the right lung apex. There is\n no evidence of pneumothorax. There is probable atelectasis at the right lung\n and associated effusion. There are surgical staples noted along the entire\n extent of the visualized spine.\n\n IMPRESSION:\n 1. Nasogastric tube present with the tip in the distal esophagus and possible\n coiling in the pharynx.\n 2. Probable right lower lobe atelectasis and effusion.\n 3. Marked deformity limiting evaluation of the chest.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812469,
"text": " 5:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate et tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis\n\n REASON FOR THIS EXAMINATION:\n evaluate et tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New tracheal tube placed. Check position. Patient is severely\n scoliotic.\n\n CHEST: The tip of the endotracheal tube lies 3.5 cm from the carina angle.\n Visualized portions of the left lung appear normal.\n\n IMPRESSION: Endotracheal tube in satisfactory position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812436,
"text": " 1:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p r thoracotomy ct placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis\n REASON FOR THIS EXAMINATION:\n s/p r thoracotomy ct placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY.\n\n INDICATION: Scoliosis, status post right thoracotomy and chest tube\n placement.\n\n Comparison is made to the prior chest x-ray on .\n\n AP OF THE CHEST: There is a known marked kyphoscoliosis convex to the right\n based on prior chest x-ray. The current study is extremely rotated. There\n has been interval placement of an endotracheal tube which is grossly\n unremarkable. There also appears to be a right internal jugular central\n venous catheter with its tip likely terminating in the distal SVC. There has\n been interval placement of a right-sided chest tube with its tip projecting\n over the right lung apex. There is no evidence of a pneumothorax. There is\n again demonstrated a deformity with reduced size of the right hemithorax.\n There is rod which projects over the right chest wall on this\n oblique view.\n\n IMPRESSION:\n\n 1) Interval placement of right-sided chest tube with no pneumothorax\n identified.\n\n 2) Limited examination secondary to baseline deformity and suboptimal view.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-12 00:00:00.000",
"description": "N-G TUBE PLACEMENT (W/ FLUORO)",
"row_id": 813249,
"text": " 3:54 PM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: please place postpyloric dobhoff\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with kyphoscoliosis s/p attempt at fusion with no success;\n now unable to wean off vent\n REASON FOR THIS EXAMINATION:\n please place postpyloric dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49 year old woman with kyphoscoliosis status post attempted\n fusion, unable to wean off ventilator.\n\n NG TUBE PLACEMENT:\n\n Under fluoroscopic guidance, an 8 FR - tube was advanced with\n its tip in the second portion of the duodenum. Position was confirmed with\n Conray contrast. There were no immediate post procedure complications.\n\n IMPRESSION: Successful placement of NG feeding tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815327,
"text": " 11:32 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: R picc placed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n R picc placed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old with scoliosis S/P right PICC placement.\n\n COMPARISON: .\n\n SINGLE PORTABLE CHEST: The tip of the PICC wire is seen to the right of mid-\n line. The course of the PICC catheter cannot be definitively determined\n because of an overlying catheter. It was recommended to the IV team to obtain\n additional views after the removal of the external catheter. There are new\n bilateral pleural effusions and there are increasing opacities in the right\n middle and lower lobe. These opacities could represent atelectasis however\n early pneumonia can't be excluded. There is significant scoliosis.\n\n IMPRESSION: 1) Bilateral effusions with right middle and lower lobe\n opacities. The latter may relate to atelectasis, but underlying infection is\n not excluded.\n\n 2) Additional views after the removal of external catheters is recommended to\n assess for the tip of the right PICC line.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 815403,
"text": " 7:01 PM\n CHEST (PA & LAT) Clip # \n Reason: R picc placed please page with \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with prolonged intubation in unit, recent extubation\n\n REASON FOR THIS EXAMINATION:\n R picc placed please page with \n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n CLINICAL INDICATION: PICC line placement.\n\n Comparison is made to previous portable chest radiograph of earlier the same\n date. A right PICC line is present. On the frontal radiograph, it is\n visualized to the level of the junction of the right subclavian and right\n brachiocephalic veins, and subsequently obscured by a fixation hardware device\n related to the spine. On the lateral view, the catheter is identified\n coursing to the region of the junction of the superior vena cava and right\n atrium although the distal tip is not definitively visualized.\n\n Cardiac and mediastinal contours are stable in the interval. There is\n improving aeration in the right middle and both lower lobes with residual\n patchy opacities remaining. Bilateral small pleural effusions are again\n demonstrated.\n\n IMPRESSION:\n 1) Right PICC line likely terminates at the junction of superior vena cava\n and right atrium, although distal tip is difficult to definitively visualize.\n 2) Improving aeration in the right middle and both lower lobes.\n 3) Persistent small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-05 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 815514,
"text": " 5:51 PM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n MR L SPINE SCAN\n Reason: recurrent wound drainage, previous csf leak (repaired)-- \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with recurrent wound drainage\n REASON FOR THIS EXAMINATION:\n recurrent wound drainage, previous csf leak (repaired)-- eval for csf leak\n ______________________________________________________________________________\n FINAL REPORT\n MR C, T, AND L SPINE .\n\n HISTORY: Recurrent wound drainage status post repair of CSF leak.\n\n Sagittal long TR, long TE, fast spin-echo and inversion recovery imaging was\n performed through the inferior spine. No contrast was administered.\n Comparisn to a study of .\n\n FINDINGS: The study is severely limited by the patient's severe scoliosis.\n This necessitated a suboptimally large field of view which limits the spatial\n resolution. On a number of the images, only a portion of the spine is\n included. The findings suggest an increase in the volume of fluid posterior\n to the spinal column. However, it is impossible to be certain that images of\n the same portions of the soft tissues posterior to the spine have been\n included in the current and the previous study. For this reason, even this\n finding is uncertain.\n\n CONCLUSION: Extremely limited study due to severe scoliosis and consequent\n technical limitation. Suggestion an increase in the volume of fluid in the\n tissues posterior to the spinal column. However, this is not a definite\n change since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-03-05 00:00:00.000",
"description": "REPOSITION CENTRAL VENOUS CATH W/FLUORO",
"row_id": 815493,
"text": " 3:55 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: current PICC in subclavian\n ********************************* CPT Codes ********************************\n * REPOSITION CENTRAL VENOUS CATH FLUORO 1 HR W/RADIOLOGIST *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with Post op wound infection, requires 6 weeks iv abx.\n Unsucessful PICC placement on floor\n REASON FOR THIS EXAMINATION:\n current PICC in subclavian\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 49-year-old woman with wound infection requiring IV antibiotics.\n She had a bedside PICC place with tip in the subclavian vein.\n\n PROCEDURE AND FINDINGS: The procedure was performed by Drs. and \n who was present and supervising. The patient's right arm was prepped and\n draped in standard sterile fashion. Under fluoroscopic guidance, an 018 glide\n wire was advanced through the PICC causing the tip to flip into the superior\n vena cava. The wire was removed. The line was flushed and hep-locked and\n secured with a Stat-lock. Final chest image demonstrated appropriate position\n of the PICC tip in the distal superior vena cava.\n\n IMPRESSION: Successful repositioning of single-lumen PICC with tip in the\n superior vena cava. The line is ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-26 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 814822,
"text": " 9:03 PM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n MR L SPINE SCAN; -52 REDUCED SERVICES\n Reason: eval for persistant csf leak/ pseudomeningoceal. Dural ecta\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with polio, wound drainage, HA postop\n REASON FOR THIS EXAMINATION:\n eval for persistant csf leak/ pseudomeningoceal. Dural ectasia and leak x2\n repaired intraop\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Scoliosis. Status post fusion.\n\n TECHNIQUE: Multiplanar MR images of the thoracolumbar spine were obtained.\n True cardinal planes were difficult to obtain due to the patient's severe\n scoliosis.\n\n FINDINGS:\n MR SPINE W/O CONTRAST: Evaluation is extremely limited secondary to large\n field of view, oblique imaging planes, and susceptibility artifact.\n\n There is diffuse edema involving the soft tissues of the neck. No CSF\n collection in the soft tissues surrounding the cervical spine is noted. High\n signal within the vertebral body of C3 on T1W images is a nonspecific finding\n and of uncertain significance. No definite evidence of a pseudomeningocele in\n the cervical region is appreciated.\n\n Limited views of the brain and nasopharynx are unremarkable.\n\n LUMBAR SPINE W/O CONTRAST: Post surgical changes and susceptibility artifact\n are present. There is an extensive fluid collection with an air-fluid level\n extending approximately 18 cm along the posterior thoracolumbar spine and\n surgical bed. This is most consistent with a pseudomeningocele. Follow-up is\n recommended to assess for interval change.\n\n Diffuse edema is present in the subcutaneous soft tissues overlying the\n thoracolumbar spine.\n\n IMPRESSION:\n\n Extremely limited examination.\n\n Pseudomeningocele. Followup is recommended to assess for interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 812674,
"text": " 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with scoliosis\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Female patient with scoliosis. Follow up of chest tube placement.\n\n FINDINGS: The AP single view is obtained with patient in supine position and\n analyzed in direct comparison with a similar film dated .\n Position of the ETT remains unchanged terminating approximately 3 cm above the\n carina. Marked scoliotic deformity as before including orthopedic hardware for\n scoliosis support. A right sided chest tube remains in place. No new\n parenchymal infiltrates can be identified on this single view examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-02-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 814245,
"text": " 10:52 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p extubation, cough\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with prolonged intubation in unit, recent extubation\n REASON FOR THIS EXAMINATION:\n s/p extubation, cough\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-extubation and cough\n\n AP and lateral views of the chest dated is compared with the\n prior PA and lateral radiograph dated .\n\n There marked thoracic scoliosis convex to right with rod fixation.\n Multiple staples overlie the soft tissues of the back. The left lung appears\n clear. The cardiac and mediastinal contours are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease. Chest deformity,\n unchanged.\n\n"
},
{
"category": "Echo",
"chartdate": "2154-03-11 00:00:00.000",
"description": "Report",
"row_id": 75618,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Endocarditis. Pericardial effusion.\nHeight: (in) 56\nWeight (lb): 150\nBSA (m2): 1.57 m2\nBP (mm Hg): 122/69\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 10:34\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na low risk (prophylaxis not recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets appear structurally normal with good leaflet excursion. No aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen.\nThere is an anterior space which most likely represents a fat pad.\n\nIMPRESSION: Mild mitral regurgitation with grossly normal morphology.\nPreserved global and regional biventricular systolic function.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2154-02-05 00:00:00.000",
"description": "Report",
"row_id": 181592,
"text": "Sinus rhythm.\nSeptal and lateral ST-T changes are nonspecific\nLow QRS voltages in precordial leads\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-07 00:00:00.000",
"description": "Report",
"row_id": 1494782,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nPT IS A 49 Y/O FEMALE S/P ANTERIOR THORACIC T3-PELVIS FUSION ON /O4. PT HAS BEEN IN PACU SINCE POST OP. PT EXTUBATED IN PACU THIS AM AND REINTUBATED A FEW HRS LATER. PT ADMITTED TO ICU AT 17:30 FOR MONITORING. PE AS FOLLOWS:\n\nNEURO-PT AWAKE, ALERT, MOUTHS WORDS, NODS APPROP. PT PARAPLEGIC AT BASELINE. FOLLOWS COMMANDS.\n\nCV-TEMP 101.4. PT PAN CX IN PACU. HR/BP STABLE. SKIN W+D. +PP. TEDS ON. AWAITING ARRIVAL OF PBOOT MACHINE.\n\nRESP-REMAINS VENTED ON CPAP. TOL WELL. WILL FOLLOW ABG. SXN FOR SM AMT THIN WHITE SPUTUM. PT ALSO WITH MOD AMT ORAL SECRETIONS. USING YANKEAR I. LS COARSE. CT TO SXN WITH SEROUSSANG DRG. NO LEAK NOTED.\n\nGI-ABD OBESE, SOFT, NT/ND. NPO.\n\nGU-VOIDING VIA FOLEY ADEQ AMT CL AMBER URINE.\n\nCOMFORT-USING DILAUDID PCA WITH EFFECT.\n\n-DSG INTACT.\n\nPLAN-CON'T WITH CURRENT PLAN. FOLLOW LABS. TO OR IN AM FOR POSTERIOR APPROACH.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-08 00:00:00.000",
"description": "Report",
"row_id": 1494783,
"text": "Resp Care Note, Decreased RR for ABG resp alk. Suctioned for sml amts thick white secretions. RSBI not done due to no spont resp.Getting pain med.Will cont to monitor resp status for further weaning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-11 00:00:00.000",
"description": "Report",
"row_id": 1494796,
"text": "CONDITION UPDATE:\nD/A: T MAX 100.5\n\nNEURO: UNCHANGED. PAIN WELL CONTROLLED WITH DILAUDID PCA. PER DR. , SLOWLY ELEVATE HOB OVERNIGHT. IF PT BEGINS TO GET A HEADACHE OR HAS A WORSENING HEADACHE, DO NOT ELEVATE HEAD ANY HIGHER. IF PT HAS ANY SIGNS OF CSF LEAK ON DRESSING, DO NOT ELEVATE HOB.\n\nRESP: LS COARSE, HOWEVER WITH AMBU, LAVAGE, SX MINIMAL SECRETIONS OBTAINED. VENT WEAN STARTED AGAIN. CURRENTLY ON CPAP, PS 50%, 5 PEEP 8 PS WITH LAST ABG: 7.28, 56, 174, -1, 98%.\n\nCV: HR 80'S-110, NSR ST. FLUID BOLUS 250 CC'S X1 FOR CONSISTENT BP ~ 88/50, HR > 100. SLIGHT + EFFECT. CVP ~ 12.\n\nGI: NPO. + BS. GLUCOSE LEVEL WNL'S. IVF INCREASED.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: MOTHER AND FRIEND VISITING MOST OF DAY.\n\nR: RESP ACIDOSIS, DIFFICULT VENT WEAN.\n\nP: CONTINUE ATTEMPTS TO WEAN. IF UNABLE TO EXTUBATE IN AM, REVISIT PLACING A NGT/PEDI TUBE FOR NUTRITION. PT AND FAMILY SUPPORT. CONTINUE WITH CURRENT CLOSE MONITORING AND MANAGEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-13 00:00:00.000",
"description": "Report",
"row_id": 1494797,
"text": "FOCUS: STATUS UPDATE\nDATA:\nPT ALERT AND ORIENTED X3. VERY PLEASANT AND COOPERATIVE. COMMUNICATES BY WRITING.\nLUNGS COARSE. CONTINUES VENTILATED, UNABLE TO WEAN OFF VENT D/T POOR ABG'S. ON MMV VENT MODE WITH IMPROVED ABG.\nTO FLUORO FOR POSTPYLORIC FT PLACEMENT.\n\nPLAN:\nSTART TF.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-13 00:00:00.000",
"description": "Report",
"row_id": 1494798,
"text": "CONDITION UPDATE\nASSESSMENT:\n PT SLEEPING ON/OFF, APPEARS ORIENTED X3. FOLLOWING ALL COMMANDS AND ABLE TO COMMUNICATE BY WRITING/MOUTHING WORDS.\nCV- HR/BP STABLE, SEE FLOWSHEET FOR VITALS AND DETAILS. CVP 12-18.\nRESP- LS OCCAS COARSE, SUCTIONED FOR THICK TAN SPUTUM. REMAINS ON MMV, NO VENT CHANGES MADE.\nGU- MAINTAINING ADEQ HRLY U/O, CLEAR YELLOW.\nGI- ABDOMEN SOFT, ? LAST BM, COLACE GIVEN. IMPACT WITH FIBER STARTED (POST-PYLORIC TUBE) @ 10CC/HR.\nINTEG- SKIN WARM & PINK. BACK DSG INTACT, NO DRAINAGE. RIGHT THORACOTOMY SIGHT WITH STERI-STRIPS, C/D/I. C/O BACK PAIN, INCREASES WITH MOVEMENT. PT USING PCA APPROPRIATELY. HOB < 30 DEGREES, BUT GRADUALLY INCREASING SINCE AM AND PT TOLERATING.\nPLAN:\nADVANCE TF TO GOAL RATE OF 65CC/HR AS TOLERATES. ATTEMPT TO WEAN PS AGAIN THIS AM. CONTINUE WITH CURRENT MONITORING AND TREATMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-13 00:00:00.000",
"description": "Report",
"row_id": 1494799,
"text": "pt.remains on mmv, see flowsheet for further info, sx for tan secretion, abg acidotic, will wean as tol., rsbi-41.7\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-13 00:00:00.000",
"description": "Report",
"row_id": 1494800,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFCS.\nNEURO: ALERT. ORIENTED X 3. COMMUNICATES VIA MOUTHING AND WRITING. HOB UP TO 30 DEGREES, C/O SL H/A, HOB DOWN TO 15 DEGREES WITH SOME RELIEF. HYDROMORPHONE PCA DOSE DECREASED TO .25MG Q6MIN WITH ADEQUATE PAIN CONTROL PER PT REPORT.\nRESP: LS CLEAR TO COARSE. SM AMTS THICK TAN SPUTUM. VENT WEAN ATTEMPTED, BUT PT RETAINING CO2 AND BECOMMING LETHARGIC WITH DECREASED IPS.\nCV: AFEBRILE. NSR. BP STABLE 90-130 SYS. NO FLUID BOLUSES THIS SHIFT. IVF CONTS AT 80CC/H.\nGI: ABD SOFT. TF'S SLOWLY ADVANCED TOWARD GOAL, BUT PT C/O NAUSEA WITH TF'S UP TO 40CC/H X ~3HOURS. RELIEVED WITH ZOFRAN. TF'S HELD FOR NOW.\nGU: CLEAR YELLOW U/O, INITIALLY > 20CC/HOUR, INCREASING TO >30CC/HOUR THIS EVE.\nSKIN: THORACOTOMY WOUND CLEAN AND DRY WITH STERISTRIPS INTACT. NO DRG NOTED FROM BACK INC, DSD CLEAN AND DRY.\nPLAN. REATTEMPT IPS WEAN IN AM. CONT PAIN MGMT. RESTART AS PT . MONITOR FOR SIGNS OF INFECTION. CONT PER CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-18 00:00:00.000",
"description": "Report",
"row_id": 1494815,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3. FOLLOWS COMMANDS.\n\nCV-HRR. SBP STABLE. ALINE D/C'D. SKIN W+D. +PP. PBOOTS ON. DENIES CARDIAC COMPLAINTS.\n\nRESP-EXTUBATED THIS AM. WELL THUS FAR. POST EXTUBATION ABG WNL. LS COARSE. PT WITH CONGESTED COUGH, USING YANKEAR I. O2 WEANED TO 2L NC. O2 SAT 99%.\n\nGI-ABD SOFT, NT/ND. +BS. CON'T WITH LIQ BROWN STOOL. FIB IN PLACE. PT REQUESTED TUBE D/C'D DESPITE INFORMATION FROM DR. AND THIS RN ABOUT IMPORTANCE OF KEEPING FEEDING TUBE AT THIS TIME. PT VERBALIZED AND STILL REQUESTED TUBE TO BE REMOVED. FEEDING TUBE THUS D/C'D. ABLE TO PILLS WITHOUT INCIDENT. ?ADAT.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CL YELLOW URINE.\n\nACT-REPOSITIONED FREQ.\n\nCOMFORT-REPORTS ADEQ PAIN RELIEF WITH VICODIN PRN. ALSO ON FENT PATCH.\n\nID-TMAX 100, NOW DOWN TO 98.6. CON'T ON KEFZOL.\n\n-RIGHT FLANK WITH STERISTRIPS C/D/I. BACK INCISION WITH STAPLES, PINK, WITH MOD AMT SEROUSSANG DRG. DSG CHANGED. DR. IN TO EVAL. WILL MONITOR.\n\n MOTHER AND SISTER IN TO VISIT FREQ. SW FOLLOWING.\n\nPLAN-CON'T WITH CURRENT PLAN. PULM HYGIENE. ASSESS PAIN. MONITOR FOR CHANGES. ? ADAT. SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-19 00:00:00.000",
"description": "Report",
"row_id": 1494816,
"text": "CONDITION UPDATE\nASSESSMENT:\nPT DOZING ON/OFF OVERNIGHT, NO ACUTE NEURO DEFICITS. BACK INCISION WITH STAPLES OOZING MOD AMTS BROWN/OLD SEROSANG DRAINAGE, DSD CHANGED. CONTINUES ON IV CEFAZOLIN, AFEBRILE. RIGHT THORACOTOMY INCISION WITH STERISTRIPS INTACT, NO DRAINAGE. HR/BP STABLE, SEE FLOWSHEET FOR ALL VS. BREATHING EVEN/UNLABORED @ REST, SP02 100% WITH NASAL CANNULA, LS CLEAR. GIVEN VICODIN FOR BACK PAIN; PT STATES SHE DOES NOT LIKE VICODIN (MAKES HER CONFUSED). PT GIVEN TYLENOL WITH ADEQ RELIEF OF PAIN; ALSO CONTS ON FENT PATCH. TOLERATING CLEAR LIQUIDS, IVF KVO.\nPLAN:\nADVANCE DIET TO REG. ? TRANSFER TO FLOOR TODAY. PULMONARY HYGEINE. PHYS THERAPY, INCREASE ACTIVITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-19 00:00:00.000",
"description": "Report",
"row_id": 1494817,
"text": "Addendum to Nursing Transfer Note A:\nD: O2sat 98-100%. HR 100's. BP stable. Weak cough. Coarse LS through out. Very weak cough.\nA: Gentle CPT provided. Per pt request hot tea provided. Declined NTsx. Gag reflex stimulated with yankeur with good effect. LS CTA briefly. Dr. to examine pt. Guaifenison 10cc provided. Effect (P).\nP: Monitor resp status. Assist with C&DB, repositioning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-08 00:00:00.000",
"description": "Report",
"row_id": 1494784,
"text": "Neuro: Alert and oriented. Able to follow directions. Having mod amount of pain at R CT insertion site. Using dilaudid PCA appropriately and requesting dilaudid coverage 0.5mg Q2hr with effect.\nCV: Temp 99.0, HR 80's NSR with no ectopy, SBP 90-120's. lytes repleated. Recieved 20mg lasix at 12am with good effect.\nRESP: lungs coarse through-out. requiring occasional suctioning of thick white sputum. O2 sats >98%. Vent setting changed this am. for Pco2 31. Resp rate decreased to 16.\nGI: NPO No stool tonight.\nGU:foley draining adequate amounts of clear yellow urine.\nEndocrine: blood sugars wnl no coverage required.\nPLAN: to OR this am for posterior approach of spinal fusion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-08 00:00:00.000",
"description": "Report",
"row_id": 1494785,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nPT TO OR AT APPROX 0730 THIS AM FOR T3 TO PELVIS FUSION. RETURNED APPROX 1200 S/P REMOVAL OF HARDWARE, REMOVAL OF CHEST TUBE, T3 TO L4 FUSION.\nNEURO: PT SEDATED ON PROPOFOL GTT ON ARRIVAL. EASILY AWAKENED WHEN GTT D/C'D. MOVES UPPER EXTREMTITES WELL. PERRL. MOUTHING WORDS APPROPRIATELY. C/O PAIN. MD' AND LI PRESENT. DILAUDID BOLUS GIVEN AND PCA DOSE INCREASED AS ORDERED. PAIN IMPROVED PER PT REPORT.\nRESP: LS CTA. ARRIVED INTUBATED ON IMV 16 X 400, IPS 10. ABG'S STABLE. ET SUCTIONED FOR SCANT AMTS BLOOD TINGED SPUTUM.\nGI: ABD SOFT. C/O NAUSEA ON ARRIVAL TO UNIT, RESOLVED WITHOUT INTERVENTION. NGT PLACEMENT ATTEMPTED, BUT UNABLE TO VISUALIZE TIP IN STOMACH ON CXR X2 (DESPITE FAR ADVANCEMENT), ? COILED IN PHARYNX. PLACEMENT BY MD , BUT UNSUCCESSFUL.\nGU: CLEAR, TINTED U/O VIA FOLEY. >30CC/HOUR.\nSKIN: R FLANK INCISION OTA WITH STERI-STRIPS INTACT. NO DRG. BACK ELASTOPLAST DSG CDI.\nPLAN: PAIN MGMT. REVERSE T- TO PREVENT RISK OF ASPIRATION AS TOLERATED. MED FOR NAUSEA. MONITOR VS AND RESP STATUS. WEAN VENT AS ORDERED AS TOL. CONT PER POST OP PROTOCOLS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-09 00:00:00.000",
"description": "Report",
"row_id": 1494786,
"text": "NEURO; ALERT X 1, WRITES NOTES TO COMMUNICATE, WIGGLES TOES BOTH FEET, AND MOVES THEM SLIGHTLY, USING DILAUDID PCA PUMP WITH ENCOURAGEMENT,\nPT MAINTAINED FLAT IN BED, LOG ROLLED PRN\n\nCARDIOVASCULAR; HR 90'S SR, SYS LOW 100'S, CVP 8-13, TEMP 100, EXTREMITIES EDEMATOUS, ESP EYELIDS,\n\nRESPIR; REMAINS ON CIMV, ABGS STABLE THIS AM, SUCTIONED FOR SMALL AMTS THIN WHITE SECRETIONS, FREQUENTLY USES YANKHAUER HERSELF AND SUCTIONS OCCAS THICK BLOODY MUCOUS\n\nWOUND; ACE DSG D/I TO THORACO-LUMBAR AREA, STERI-STRIPS INTACT FROM FORMER RT THORACOTOMY,\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-09 00:00:00.000",
"description": "Report",
"row_id": 1494787,
"text": "Resp Care,\nPt. remains intubated overnoc, no vent changes this shift. See carevue for settings/ABG. RSBI attempted this am, pt. had a prlonged period of apnea. Will try again later this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-09 00:00:00.000",
"description": "Report",
"row_id": 1494788,
"text": "Resp. Care Note\nPt received intubated and vented on settings SIMV 400x 16x 50% peep 5 psv 10. Pt changed over to PSV 15 peep 5 and 505 and has tolerated wean to PSV 12. Good ABG on current settings of PSV 12 peep 5 and 50%. Cont PSV wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-14 00:00:00.000",
"description": "Report",
"row_id": 1494801,
"text": "pt.on cpap+ps , bs coarse, sx for tan secretions, rsbi-64.3, abg alkalotic, will wean as .\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-14 00:00:00.000",
"description": "Report",
"row_id": 1494802,
"text": "CONDITION UPDATE\nASSESSMENT:\nNEURO INTACT, COMMUNICATING BY MOUTHING WORDS & WRITING. USING PCA APPROPRIATELY FOR BACK PAIN. PER DR. , PT GET OOB WITH PHYS THERAPY & ACTIVITY AS TOLERATED. BACK DSG INTACT, NO DRAINAGE. RIGHT THORACOTOMY INCISION WITH SS INTACT. NO VENT CHANGES MADE OVERNIGHT, FAILED SPONT BREATHING TRIAL IN AM. LS OCCAS COARSE, REQUIRED MIN SUCTIONING. IMPACT WITH FIBER ADVANCED OVERNIGHT, PT TOLERATING. ABDOMEN SOFTLY DISTENDED, DENIES NAUSEA. HEMODYNAMICS STABLE, SEE FLOWSHEET FOR VITALS AND FULL PHYS ASSESSMENT.\nPLAN:\nCONTINUE WITH CURRENT MONITORING AND TREATMENT. ? ATTEMPT TO WEAN PRESS SUPPORT TODAY. INCREASE & ASSIST WITH ACTIVITY AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-14 00:00:00.000",
"description": "Report",
"row_id": 1494803,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: ALERT AND ORIENTED X3. SLEEPY AT TIMES, BUT EASILY AWAKENS. PCA DOSE DECREASED, WITH ADEQUATE PAIN CONTROL. C/O PERSISTENT MILD H/A, UNCHANGED FROM PREVIOUS REPORT PER PT. C/ EARACHE, MD INFORMED AND TO EXAMINE WITH OTOSCOPE.\nRESP: LS CLEAR TO COARSE WHEN ET SUCTION NEEDED, SM AMT THICK WHITE TO TAN SPUTUM. VENT WEANED TO 10 PS, 5 PEEP. ABG SHOWS PCO2 UP TO 50S, BUT PT COMPENSATING WITH TCO2 UP TO 34, PH STABLE AT 7.39. WHEN WEAN TO ATTEMPTED, PT BECAME HYPERTENSIVE TO 190S SYS, TACHYCARDIC TO 110S, AND TACHYPNEIC WITH INCREASED WOB. RETURNED TO WITH IMPROVEMENT IN VS, REPEAT ABG PENDING.\nCV: TMAX 99. SBP 140S TO 150S. ? RESTART ANTIHYPERTENSIVES. ALINE RESITED TO L-RAD DUE TO MALFUNCTION. IVF CONTS AT 80CC/HOUR.\nGI: ABD SOFTLY DISTENDED. TF'S AT GOAL. C/O SL NAUSEA AND FULLNESS. DULC SUPP GIVEN, EFFECT PENDING.\nGU: CLEAR YELLOW U/O VIA FOLEY.\nPLAN: RECHECK ABG. MONITOR RESP STATUS. CONT VENT WEAN AS . PAIN MGMT. OOB TO CHAIR TOMORROW. ASSESS FOR H/A. CONT PER CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-15 00:00:00.000",
"description": "Report",
"row_id": 1494804,
"text": "NEURO: A&O X3, COMMUNICATES BY MOUTHING WORDS OR WRITING, APPROPRIATE. SPONT/PURP MOVING UPPER EXTREMITIES, NEEDS MIN ASSISTANCE TO MOVE LOWER EXTREMETIES.\n\nCV: HR 78-94, NSR, NO ECTOPY. SBP 121-151.\n\nRESP: VENT SETTINGS NOT TOLERATED ON CPAP+PS, MULT ABG'S DRAWN W/ INC PCO2 TO 64, DR. INFORMED. PT SWITCHED BACK TO SIMV 5 PEEP, 10 PS, TV 400'S, RR 14, FIO2 50%. LAST ABG IMPROVED-7.40/54/175/35/7/99.\n\nGI: ABD SOFTLY DISTENDED, +BS, TOLERATING TF IMPACT W/ FIBER AT GOAL AT 60CC/HR VIA POST PYLORIC DOBHOFF. HAD SMALL BM AFTER RECEIVING DULCOLAX SUPPOSITORY.\n\nGU: FOLEY DRAINING ADEQ U/O, CLEAR YELLOW URINE. PT IS CURRENTLY MENSTRUATING.\n\nID: TMAX 98.9\n\nPAIN: GOOD PAIN CONTROL ACHIVED W/ DILAUDID PCA.\n\nPLAN: MONITOR RESP STATUS, IF UNABLE TO WEAN VENT ?TRACH. MONITOR PAIN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-15 00:00:00.000",
"description": "Report",
"row_id": 1494805,
"text": "Respiratory Care\nPt remain intubated and on vent support, Paco2 issue that pressist and din not change alot despit the vent setting change Paco2 remain in the 50's. Et tube was rotated and retayped, SX mod amout thick white.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-10 00:00:00.000",
"description": "Report",
"row_id": 1494792,
"text": "Nursing note:\nNEURO: A/Ox3, writing on message board to make needs known. PERRLA 2-3mm and brisk bilat. Wiggles toes bilat , follows commands. C/O mild headache r/t dural tears per team. Using Dilaudid PCA w/fair relief of back pain and headache.\nCV: Afebrile. SR in 70s-80s, no ectopy. SBP 120-140s. Wearing pboots.\nRESP: Lung sounds clear, coarse at times, dim to L. base. Suctioned infrequently for thick white secretions. No vent changes today, ABGS cont. to reflect met. alkalosis, resp. acidosis. Diamox x1 given. +diuresis.\nGI: +BS, abdomen softly distended. -stool. +flatus, pt. c/o feeling bloated/constipated.\nGU: Foley patent for adequate amount amber urine. +diuresis.\nSOCIAL: Husband and mom @ bedside most of day.\n\nA/P: Stable s/p back/pelvic fusion surgery, now slow to wean off vent. Cont. gentle diuresis, follow ABGs, pain control, skin care and vent wean.To remain flat for more days. Cont. current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-10 00:00:00.000",
"description": "Report",
"row_id": 1494793,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as per resp. flowsheet. No vent changes made today, plan was to cont diuresis and Rx met. alkalosis with diamox. Assess weaning parameters in AM and cont with PSV wean with hopes to extubate tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-11 00:00:00.000",
"description": "Report",
"row_id": 1494794,
"text": "data/action: vss, using pca dilaudid w/ good relief of back pain.\nrr-16-20 on cpap w/ ips 12 o/n w/ morning abg's acidotic 7.22/pc02 64\nvent mode changed to simv12 w/ improvement in abg's 7.42/pc02 36.\nsx'd thin pale tan/white q3hr. bs 51 this am amp d50 iv given-bs pending. alert writing in notebook for needs. c/o heartburn->zofran given w/ relief x1.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-11 00:00:00.000",
"description": "Report",
"row_id": 1494795,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as charted on resp flowsheet. PSV level decreased today from 12-10-8. ABG's with good oxygenation, slight resp acidosis. Plan to cont psv wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-17 00:00:00.000",
"description": "Report",
"row_id": 1494811,
"text": "Neuro: Alert and oriented X3. Continues to use dilaudid PCA. attempting to wean off and use vicodin per dopoff. having some noted effect on pain with vicodin. back incision continues to drain small amounts of sero-sang drg from proximal end of incision.\nCV: afebrile, HR 80's NSR with no ectopy. SBP 100-120's A-line very dampended. extremities warm with palpable periferal pusles. repleated K+ X2.\nRESP: pt vent changed to CPAP 5&5 with acceptable ABG. Requiring occasional suctioning of thick white sputum. lungs clear to dim at bases.\nGI: tube feed with no cramping but some \"heartburn\" slightly improved with reglan, zofran and protonix.\nGU: foley draining adequate amounts of clear yellow urine.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-15 00:00:00.000",
"description": "Report",
"row_id": 1494806,
"text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: ALERT AND ORIENTED. USING PCA MORE FREQUENTLY WITH STATED RELIEF. LG AMT SEROSANG DRG FROM SPINAL INC. SICU TEAM INFORMED AND SHOWN. DSD CHANGED. PT DENIES H/A. HOB FLAT. DRG CONTS, BUT IN DECREASED AMTS.\nRESP: LS CLEAR BUT DIM. MIN SECRETIONS. NO VENT CHANGES TODAY.\nCV: TMAX 99.4. NSR. BP STABLE. 10MG IV LASIX GIVEN AS ORDERED WITH DIURESIS. PT STILL POS >1L SINCE MN. ADDITIONAL 20MG ORDERED AND GIVEN. PHOS REPLETED WITH NAPHOS AS ORDERED. IVF KVO'D.\nGI: ABD SOFT. LG LIQUID BM THIS AM. PT C/O INCREASING ABD FULLNESS AND NAUSEA. TF'S HELD. PT REFUSING RESTART. MD INFORMED. IVF INCREASED TO 60CC/HOUR UNTIL TF'S RESTARTED.\nGU: CLEAR YELLOW U/O.\nPLAN: CONT TO MONITOR. CONT HOB FLAT. MONITOR FOR DRG FROM SPINAL INCISION. RESTART TF'S SLOWLY WHEN PT ABLE TO . ATTEMPT VENT WEAN AS . CONT PER CURRENT MGMT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-16 00:00:00.000",
"description": "Report",
"row_id": 1494807,
"text": "Respiratory care\nPt remain intubated and on vent support no vent changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-16 00:00:00.000",
"description": "Report",
"row_id": 1494808,
"text": "Neuro: Pt alert and oriented X3, mouthing words and able to write to make needs known.\nCV: Low grade temp 99.2, HR 60-80's NSR with no ectopy. SBP 110-130's A-line slightly dampened. CVP>20. extremities warm with palpable periferal pulses.\nRESP: lungs clear to dim at bases. No vent changes. O2 sats 100%.\nGI: NPO per pt. request due to abd cramping from tube feeds. No stool today.\nGU: foley draining adequate amounts of clear yellow urine.\nendocrine: blood sugars wnl.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-17 00:00:00.000",
"description": "Report",
"row_id": 1494809,
"text": "7p-7a; Full assessment in flow sheet.\n\nneuro: A+OX3. Mouth and write words. MAE - stronger in upper than lower ext. Good gag and cough reflex. Follow commands. normal affect.\nGood sensory respond from ext. PERLA. Good pain control with PCA.\n\ncv; NSR without ectopy. VSS. temp max 99.1. warm, dry, slight general edema.\n\nresp; clear in upper lobes. dimish at bases. Strong - productive cough - white/thick sputum. SIMV tolerated - ABG - better than prior, please see flow sheet.\n\ngu/gi; soft abd. +BSX4. no flatus. no bm. heartburn X2 per pt - reglan given - good effect. restarted TF slowly - no pain cramp or nausea per pt. Dobhoff - positive placement. foley patent - clear yellow urine.\n\nSkin intact except for back dressing - serous/serousangious dressing in upper part of back - reinforce dressing.\n\nAM lab . Lytes replace.\n\nPlan; Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-17 00:00:00.000",
"description": "Report",
"row_id": 1494810,
"text": "RESPIRATORY CARE:\n\nPt remains ess unchanged, supported on SIMV thru noc. Sxing small amts thick white secretions from ETT. BS's ess clear. See flowsheet for pt data.\nPlan: Attempt weaning slowly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-09 00:00:00.000",
"description": "Report",
"row_id": 1494789,
"text": "Nursing note:\nNEURO: A/Ox3, communicating via gestures and writing on message board. PERRLA. Able to wiggle toes easily. Using Dilaudid PCA for adequate pain control.\nRESP: Lung sounds coarse, weaned to CPAP w/10 IPS. ABGs acceptable.\nSuctioned for white coarse secretions.\nCV: Afebrile. SBP 120s. SR in 80s, no ectopy. No cardiac issues. Lasix 20mg IV x1 w/excellent diuresis. K+ replaced w/60meq total IV.\nGI: +BS, abdomen soft, no stool or flatus. No n/v. Remains NPO.\nGU: Foley patent adequate amount amber urine.\nENDO: Glucose stable.\nWound: Ace dressing d/i to thoraco-lumbar area, steris intact from former R. thoracotomy.\nA/P: Stable s/p spinal /pelvic fusion, tolerating vent wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-10 00:00:00.000",
"description": "Report",
"row_id": 1494790,
"text": "NEURO; WRITES NOTES APPROPRIATELY, MOUTHES WORDS, USES DILAUDID PCA PUMP PRN,\nPT REMAINS FLAT IN BED\n\nCARDIOVASCULAR; HR 90'S SR, SYS BP 120-140'S, CVP 12-15, AFEBRILE, EDEMA OF ALL EXTREMITIES,\n\nRESPIR; SUCTIONED FOR SMALL AMTS THIN WHITE SECRETIONS, OCCAS BLOOD TINGED SECRETIONS ORALLY BUT HAS DECREASED SINCE YESTERDAY, ABGS REFLECT RESPIR ACIDOSIS\n\nRENAL; LASIX 20 IV ON EVES WITH FAIR DIURESIS,\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-10 00:00:00.000",
"description": "Report",
"row_id": 1494791,
"text": "RESPIRATORY CARE\nPt remain intubated no respiratory issue overnight Sx samll white thick ,Pt is aweak amd responsive , remain flat on her back.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-18 00:00:00.000",
"description": "Report",
"row_id": 1494812,
"text": "7p-7a; Full assessment in flow sheet.\n\nA+OX3. Mouth words and write need. Follow commands. MAE - stronger in upper than lower ext. PERLA. Good cough and gag reflex. Pain in back - relief with PCA - PCA d/ MD order - vicodin po started - not as effective per pt - also causes inc HR and feeling of being very warm per pt (no change in HR or temp per monitor). Slept on/off most of the night. VSS (except when increase with activities and t-piece trial). Afebrile. warm, dry, no edema. Clear upper lobes, dimish at bases. Tolerate t-piece for 1 hr - ABG - resp acidiotic (no sob). Return to CPAP 5/5 to rest for the night. soft abd, +BSX4. loose brown bm - negative guiac. rectal bag replace. skin intact. small drainage in proximal area of back - serosangious - DSD intact. AM lab done.\n\nPlan; Continue to monitor. Extubate in AM?\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-18 00:00:00.000",
"description": "Report",
"row_id": 1494813,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. Pt had trache mask trial x45mins overnoc, tired towards end. Sxing small amts secretions from ETT. BS's clear. RSBI=58.\nPlan: Extubate?\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-02-18 00:00:00.000",
"description": "Report",
"row_id": 1494814,
"text": "Social Work\nSpoke with pt's sister and mother at bedside to assist with handicapped accessible lodging and transport. Family has been dissatisfied with limited transport options avail to area hotels. However, family is pleased with pt's progress; pt is awake, alert, smiling, pleased with recent extubation and cont progress. SW will remain avail for cont support/resources assistance as needed.\n\n LICSW #\n"
}
] |
3,145 | 169,807 | 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from hospital with acute hepatic failure. She was admitted with acute alcoholic hepatitis and hypotension and had gradually worsening liver function with a rising bilirubin. She was also initially in renal failure but responded to albumin. Two days prior to expiring, she developed acutely worsening hypoxia with bilateral infiltrates and ARDS requiring intubation. She required high levels of peep and an esophogeal balloon was placed. She was also profoundly hypotensive, requiring four pressors. She had a rising lactate on broad spectrum antibiotics, and developed a profound lactic acidosis with a lactate peaking at 16. Her family was contact and her sons were able to see her before she expired at 5:30 p.m. on . They requested an autopsy. | Chronic IVDU & ETOH. Chronic IVDU & ETOH. Chronic IVDU & ETOH. Paracentesis in ED negative for SBP (Pt was given Ceftriaxone 1gm) Action: Lactulose given. Hypotension (not Shock) Assessment: Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60. Action: Pt on lactulose 60ml QID. Action: Pt on lactulose 60ml QID. Action: Pt on lactulose 60ml QID. Action: Pt on lactulose 60ml QID. Noaortic regurgitation is seen. Thiamine/Folate/MVI Hypotension (not Shock) Assessment: Recd pt from ED on Levophed @ 0.18mcg/kg/min. Thiamine/Folate/MVI Hypotension (not Shock) Assessment: Recd pt from ED on Levophed @ 0.18mcg/kg/min. Thiamine/Folate/MVI Hypotension (not Shock) Assessment: Recd pt from ED on Levophed @ 0.18mcg/kg/min. She was noted there to be hypotensive w/ SBP to the 80s, w/ an elevated bili and INR. She was noted there to be hypotensive w/ SBP to the 80s, w/ an elevated bili and INR. She was noted there to be hypotensive w/ SBP to the 80s, w/ an elevated bili and INR. CXR: (my read) hilar fullness w/ mild pulm vascular engorgement, infiltrates in the RML and RUL. - follow UOP and trend creatinine - renally dose meds # Anemia: bleeding likely into intraperitoneal space. Started levophed to limit fluid over-resusication - Rising lactate 4.4 > 5.5. Started levophed to limit fluid over-resusication - Rising lactate 4.4 > 5.5. - Hold diuresis for now while hypotensive - Keep PaO2 >60, try to increase PEEP if needed HYPOTENSION Worse post-intubation. - Hold diuresis for now while hypotensive - Keep PaO2 >60, try to increase PEEP if needed HYPOTENSION Worse post-intubation. Respiratory failure, acute (not ARDS/) Assessment: Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by 15 bpm, and most recent ABG 7.39/37/65. Respiratory failure, acute (not ARDS/) Assessment: Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by 15 bpm, and most recent ABG 7.39/37/65. Action: Pt with MAPs dropping to low 50s at beginning of shift requiring max dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and neo @ 0.5mcg/kg/min. CIRRHOSIS OF LIVER, ALCOHOLIC Stable Tbili, INR up somewhat - On rifaxamin, lactulose - Appreciate hepatology input - Will need FFP prior to procedures RENAL FAILURE Decreased UOP since midnight, with elevated Cr. Chief Complaint: 24 Hour Events: - MELD 27 - Liver consult: stop prednisone, albumin challenge, NGT with TFs, check AFP, GGT, IGG, , hep C viral load - CT chest: volume overload, intraperitoneal hemorrhage likely from paracentesis - Bladder pressure 17 - levophed weaned - had hct drop 35 -> 27.8 -> 26.5. Chief Complaint: 24 Hour Events: - MELD 27 - Liver consult: stop prednisone, albumin challenge, NGT with TFs, check AFP, GGT, IGG, , hep C viral load - CT chest: volume overload, intraperitoneal hemorrhage likely from paracentesis - Bladder pressure 17 - levophed weaned - had hct drop 35 -> 27.8 -> 26.5. Chief Complaint: 24 Hour Events: - MELD 27 - Liver consult: stop prednisone, albumin challenge, NGT with TFs, check AFP, GGT, IGG, , hep C viral load - CT chest: volume overload, intraperitoneal hemorrhage likely from paracentesis - Bladder pressure 17 - levophed weaned - had hct drop 35 -> 27.8 -> 26.5. # Acute hepatic failure: -f/u liver recs -steroids -AFP normal -lactulose and rifaximin # ARF: FeNa < 1%. Pt dysynchronous with vent at start of shift, vent changed to PCV briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06 mg/kg/hr, titrated per train of four for twitches. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. Response: Plan: Shock, other Assessment: Temp max 102.1 po. # DISPO: ICU ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 02:32 AM PICC Line - 12:40 PM Arterial Line - 06:29 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Limited ultrasound of the right upper quadrant with diffusely echogenic liver. FINDINGS: Right PICC is malpositioned, coursing cephalad in the right internal jugular vein with tip outside of the field of view. Splenomegaly (Over) 12:27 AM CT ABDOMEN W/CONTRAST Clip # Reason: eval for acute process, clot in portal system. WET READ: EAGg TUE 11:42 PM Very echogenic liver, limited assessment of gallbladder and portal vein. Unchanged markedly hypodense liver, consistent with fatty liver, presumably related to reported clinical history of liver failure. 12:27 AM CT ABDOMEN W/CONTRAST Clip # Reason: eval for acute process, clot in portal system. | 83 | [
{
"category": "Physician ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397775,
"text": "Chief Complaint: Acute on chronic hepatic failure\n HPI:\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\n w/respiratory failure and hypotension.\n 24 Hour Events:\n BLOOD CULTURED - At 09:18 AM\n blood cultures drawn from femoral CVL\n SPUTUM CULTURE - At 10:00 AM\n BLOOD CULTURED - At 10:00 AM\n blood cultures drawn from PICC\n URINE CULTURE - At 10:20 AM\n ESOPHOGEAL BALLOON - At 02:30 PM\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,580 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,980 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,040 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Bronchial: )\n Abdominal: Soft, Distended\n Skin: Not assessed, Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.5 g/dL\n 147 K/uL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOTENSION (NOT SHOCK)\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397781,
"text": "Chief Complaint: Acute on chronic hepatic failure\n HPI:\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\n w/respiratory failure and hypotension.\n 24 Hour Events:\n Pan cultured, started vanco/cefepime\n ESOPHOGEAL BALLOON\n PEEP uptitrated\nIncreasing pressor requirement\nStarted on stress dose hydrocortisone\nIncreasing hypoxia requiring paralysis\nVigileo monitor started\nIncreasing lactic acidosis, got 2 amps of bicarb\nRapid influenza negative\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives;\n Vasotec - hypertension;\n Last dose of Antibiotics:\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Levophed\n Propofol\n Cisatricurium\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Other medications:\n Lactulose, Rifaximin, Hydrocortisone\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,580 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,980 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,040 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, MMM\n Cardiovascular: RR, tachy, S1, S2, no RMG\n Extremities/Peripheral Vascular: Warm, palpable radial and DP pulses\n bilat\n Respiratory / Chest: Bronchial at bases bilat\n Abdominal: Soft, Distended, decreased BS\n Skin: NJaundice\n Neurologic: Sedated, paralysed, train of four\n \n Labs / Radiology\n 8.5 g/dL\n 147 K/uL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Cultures\n Blood, urine and sputum NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n Meets ARDS criteria. Etiology of\n infiltrates unclear, differential ARDS/PNA, DAH, cardiogenic edema.\n - Switch back to AC, 4-6cc/kg of IBW TV, will aim to keep PIPs~45\n pending new esophageal balloon numbers\n - Inhalers standing to minimize resistance\n - Consider bronchoscopy to r/o DAH, although tenuous respiratory status\n HYPOTENSION/SHOCK\n Per vigileo, minimal SVV, cardiac output ~,\n unclear if this is sufficient as improved with dopa. Lactate is\n worsening, as is LDH, will re-evaluate for intra-abdominal process.\n Had been favoring a septic/distributive process, although cannot\n exclude a cardiac component.\n - On Neo, vaso, levophed, dopa\n - Follow-up cultures, on broad spectrum abx\n - Consider Swann placement\n - TTE, cycle biomarkers\n - Increase thiamine dose\n - RUQ US w/dopplers\n - Cdiff\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Stable Tbili, INR up somewhat\n - On rifaxamin, lactulose\n - Appreciate hepatology input\n - Will need FFP prior to procedures\nRenal Failure\n Decreased UOP since midnight, with elevated Cr\n - Follow UOP with volume challenge\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin Sc\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Chlorhexidine, HOB to 30 degrees\n Comments:\n Communication: Attempting to contact family to update on her condition\n Code status: Full code\n Disposition : MICu for now\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397484,
"text": "Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension.\n HPI:\n 24 Hour Events:\n -received 7L crystalloid total and initiated on levophed for blood\n pressure support\n -seen by liver consult in ED\n -received po vitamin K\n -discriminate function was 71 so started on prednisone 40mg daily for\n alcoholic hepatitis\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone\n levaquin\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Protonix\n Folic acid and thiamine\n Lactulose 30mg QID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 97 (92 - 97) bpm\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\n RR: 19 (12 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,973 mL\n PO:\n 200 mL\n TF:\n IVF:\n 773 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,843 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular:RRR,PMI Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: crackles at both bases posteriorly\n Abdominal: Soft, Non-tender\n Extremities: no peripheral edema. Slightly cool to touch.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands. Alert and oriented x3.\n Labs / Radiology\n 11.1 g/dL\n 238 K/uL\n 176 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 99 mEq/L\n 129 mEq/L\n 35.2 %\n 17.7 K/uL\n [image002.jpg]\n From WBC 9.2\n From Cr 0.6 TB 16.3 to 19.8 AST/ALT 195/45 to 103/39\n FeNa 0.4%\n 06:01 AM\n WBC\n 17.7\n Hct\n 35.2\n Plt\n 238\n Cr\n 0.9\n Glucose\n 176\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL lactate 2.2 at midnight serum etoh: negative serum\n acetaminophen negative\n RUQ US: cirrhotic liver, difficult to assess portal vein, ascites noted\n CT abdomen with contrast: no portal vein thrombosis with hypodensities\n in the liver consistent with perfusion defect or mass effect\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n -only potential source at this point is pneumonia\n -titrating down on levophed\n -if off levophed by noon will hold on placing a-line\n -concern for septic shock but no clear source, no evidence of SBP\n -does not appear fluid responsive at this point. If we need to do\n further volume challenge would use 5% albumin\n -will check bladder pressure\n ACUTE LIVER FAILURE\n -will ask liver consult team to make some recommendations\n -followup AFP, lesions on liver can be concerning for hepatocellular\n carcinoma\n -continue prednisone for presumed alcoholic hepatitis\n -trend lactate\n -for elevated INR will continue oral vitamin K 10mg for total of 3 days\n -continue lactulose for encephalopathy\nacute renal failure with low FeNa\n -will ask renal consult to see given potential for hepatorenal syndrome\n vs contrast induced nephropathy\n -will likely need 5% albumin challenge to determine\nhypoxemia now resolved\n -will check CT chest without contrast to evaluate for ovine bronchus\n and possible obstruction\n ICU Care\n Nutrition: npo for now\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM femoral. If not off pressors within\n 24 hours will need to place IJ or subclavian TLC\n Prophylaxis:\n DVT: heparin SQ to be initiated\n Stress ulcer: IV pantoprazole\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code. Will need to clarify with her family.\n Disposition :\n Total time spent:\n"
},
{
"category": "Echo",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Report",
"row_id": 72279,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shock. Refractory hypotension. Shortness of breath.\nWeight (lb): 233\nBP (mm Hg): 97/61\nHR (bpm): 115\nStatus: Inpatient\nDate/Time: at 10:20\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT VENTRICLE: Small LV cavity. Suboptimal technical quality, a focal LV wall\nmotion abnormality cannot be fully excluded. Hyperdynamic LVEF >75%. Moderate\nresting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function.\nCannot assess regional RV systolic function.\n\nAORTIC VALVE: Aortic valve not well seen. No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator.\n\nConclusions:\nThe left ventricular cavity is unusually small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Left\nventricular systolic function is hyperdynamic (EF>75%). There is a moderate\nresting left ventricular outflow tract obstruction. The right ventricular\ncavity is probably dilated with borderline normal free wall function. The\naortic valve is not well seen. There is no valvular aortic stenosis. The\nincreased transaortic velocity is likely related to high cardiac output. No\naortic regurgitation is seen. The mitral valve leaflets are structurally\nnormal. Trivial mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is a trivial/physiologic pericardial effusion.\n\nCompared with the report of the prior study (images unavailable for review) of\n, left ventricular cavity size may be smaller and left ventricular\nfunction is now hyperdynamic with tachycardia. The right ventricle may not be\ndilated. No definite valvular lesions are identified in the current study but\nviews are suboptimal.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2114-12-25 00:00:00.000",
"description": "Report",
"row_id": 170804,
"text": "Sinus rhythm. Low precordial lead QRS voltage. Prolonged QTc interval.\nST-T wave abnormalities. Findings are non-specific but cannot exclude possible\ndrug/electrolyte/metabolic effect. Since the previous tracing of \nfurther ST-T wave changes are present.\n\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397754,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. CT chest : volume\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\n pressure ranging 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr\n for + gap and increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397755,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. CT chest : volume\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\n pressure ranging 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr\n for + gap and increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n ------ Protected Section ------\n ~ 0500 pt becoming more hypoxic on 100% 22 PEEP, with sats 87%, ABG\n 7.23/38/67. Pt placed on 25 PEEP, with sats increasing to 95%. BP\n dropped to 70s systolic, and pt was maxed out on vaso, levo, and neo.\n Dopamine gtt was initiated (see Metavision for specifics). Repeat ABG\n 7.14/39/140. 2 amps bicarb given. 500cc NS bolus given, albumin\n ordered- awaiting from pharmacy.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:13 ------\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397554,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Rec\nd on levo gtt to keep MAP > 55, UO 30 -60cc/hr, hr nsr 80\ns-90\n Hct 27 at change of shift.\n Action:\n Titrating Levophed gtt to maintain MAPs > 55, stable on 0.06 mcg/kg/min\n Levophed gtt. Repeat Hct sent.\n Response:\n UO improving, Hct stable 28, levophed gtt turned off at 0330.\n Plan:\n Cont. to monitor BP, MAP goal > 55. Currently off levophed gtt.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o abdominal pain,\n oriented x 2, mood labile- calm & cooperative to weepy and agitated.\n Bladder pressure 17 on .\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver team\n following, ivp morphine given frequently for a total of 10mg ivp this\n shift, Reoriented frequently. CIWA q4h, tolerating ice chips and\n popcicles.\n Response:\n no stool, abdominal pain down to 4-5 after narcotics, pt cont. to be\n confused as to time/place, oriented x2. CIWA < 10, no diazepam given\n this shift.\n Plan:\n Cont to monitor MS- cont po lactulose as ordered, reorient as needed,\n iv protonix/iv antibiotics as ordered, pain control. Bladder\n pressures daily. Liver team following.\n ? c/o this pm if stable off levophed gtt.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397649,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: Around 1500, pt c/o difficulty breathing. LS with crackles\n and wheezes and O2 sats decreasing into 80s. Pt given\n albuterol/atrovent nebs and chest xray taken which showed increased\n pulmonary edema. 20mg IV Lasix given for fluid overload with effect\n pending. Sats remaining high 80s/low 90s. BP stable post Lasix. Pt also\n started on PO cipro for UTI but refusing to take.\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs 90s. UOP 40s-50s per hour.\n Action:\n Pt cont OFF levo. Given 50g of 5% albumin today to improve\n intravascular volume and for albumin 2.6 this AM.\n Response:\n BPs remaining >90 with MAPs ranging 60s-70s, systolic pressures\n 90s-120s.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites and c/o \n abdominal pain. Pt alert and oriented x 3 at times but noted to be\n hallucinating at times as well.\n Action:\n Lactulose increased to 60ml PO QID and lactulose enema ordered and\n given. Albumin given for albumin 2.6 this am. Bladder pressure checked-\n 23 today.\n Response:\n Pt cont without stool despite increase in lactulose. Lactulose enema\n with minimal retention. Refused to take lactulose this pm. Pt refusing\n all meds this pm, likely becoming more encephalopathic.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure today. Also will likely\n need NGT if cont to refuse PO meds.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397472,
"text": "49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\n study.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\n historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\n Ceftriaxone 1gm) Constant moaning and c/o abd/back pain (although\n extremely inconsistent at times)\n Action:\n Lactulose given. Vitamin K 5mg PO x 1. Morphine 2mg IVP x 2. Frequent\n repositioning and reorientation. Pt extremely forgetful and repetitive.\n Response:\n Unchanged\n Plan:\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\n withdrawal. Thiamine/Folate/MVI\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\n Action:\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\n given. Urine lytes sent.\n Response:\n Awaiting AM lab results (sent @ 0600 post KCL repletion)\n Plan:\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\n cultures. Sputum culture needed if able.\n Full Code\n R femoral TLC\n Social: Would most likely benefit from SW cx. No contact\n with family O/N by this RN.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397463,
"text": "49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\n study.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\n historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\n Ceftriaxone 1gm)\n Action:\n Lactulose given. Vitamin K 5mg PO x 1.\n Response:\n Plan:\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\n withdrawal. Thiamine/Folate/MVI\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\n Action:\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\n given. Urine lytes sent.\n Response:\n Plan:\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\n cultures. Sputum culture needed when able.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397475,
"text": "49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF. Liver ultrasound with doppler was a difficult\n study.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Chronic IVDU & ETOH. Pt is a poor\n historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Received pt from ED extremely jaundiced. Minimal asterixis noted. MS\n waxing/. A&Ox2. Paracentesis in ED negative for SBP (Pt was given\n Ceftriaxone 1gm) Constant moaning and c/o abd/back pain (although\n extremely inconsistent at times)\n Action:\n Lactulose given. Vitamin K 5mg PO x 1. Morphine 2mg IVP x 2. Frequent\n repositioning and reorientation. Pt extremely forgetful and repetitive.\n Response:\n Unchanged\n Plan:\n Lactulose ATC. Hepatology to see this AM. Monitor for s&s of\n withdrawal. Thiamine/Folate/MVI\n Hypotension (not Shock)\n Assessment:\n Rec\nd pt from ED on Levophed @ 0.18mcg/kg/min. Pt did receive a total\n of 7L IVF. NS w/ 40 KCL infusing @ 100/hr X 1L for K of 2.8.\n Action:\n Levophed weaned to 0.10mcg/kg/min for a goal MAP >/= 55. KCL 40 mEq\n given. Urine lytes sent.\n Response:\n Awaiting AM lab results (sent @ 0600 post KCL repletion)\n Plan:\n Cont w/ Levaquin for possible UTI along with Ceftriaxone. F/U blood\n cultures. Sputum culture needed if able.\n Full Code\n R femoral TLC\n Social: Would most likely benefit from SW cx. No contact\n with family O/N by this RN.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397739,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. CT chest : volume\n overload, intraperitoneal hemorrhage likely from paracentesis. Bladder\n pressure ranging 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr\n for + gap and increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397704,
"text": "Chief Complaint: Liver failure\n HPI:\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\n failure.\n 24 Hour Events:\n PICC LINE placed\nAntibiotics stopped\n Intubated\n Hypotensive post intubation, increasing pressor requirement,\n increasing O2 requirements\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives\n Vasotec - hypertension\n Last dose of Antibiotics:\n Ciprofloxacin\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Potassium, MVI, folate, thiamine,\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Cool, anasarcic\n Respiratory / Chest: Coarse, bronchial anteriorally\n Abdominal: Soft, Bowel sounds present, slightly distended\n Skin: Icteric, no rashes\n Neurologic: Sedated\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\n Cultures\n Blood and peritoneal fluid NGTD\n CXR\nprogression of diffuse b/l fluffy ASD, no apparent effusions\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n ARDS (Unclear inciting factor\ninfection,\n no witnessed aspiration, no obvious acute pancreatitis) vs volume\n overload.. Plateaus elevated, bilateral infiltrates.\n - Hold diuresis for now while hypotensive\n - Keep PaO2 >60, try to increase PEEP if needed, consider esoph balloon\n placement to optimize given obese abd, wean fio2 as able\n Empiric broad antbx coverage, ruled out for flu. Pan cxs repeated,\n TTE to assess cardiac fx\n HYPOTENSION\n Worse post-intubation. Likely due to sedation and\n PEEP, but cannot exclude worsening infection/sepsis, although no fever\n or elevated WBC. Did have hemo-peritoneum, although Hct stable. Also\n had steroids stopped recently.\n - Broaden antibiotics, add vanco and cefepime\n - TTE, CvO2\n - Pan culture\n - Start stress dose hydrocortisone\n --trend lacate\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Tbili and INR stable\n - Add rifaxamin\n - Continue lactulose\n - stress dose hydrocortisone as above\nAnemia\n Stable yesterday, but given hypotension will trend q6h, space\n out if stable x2\n Renal Failure\n improved UOP, s/p two days of albumin, follow and\n hold on diuresis in light of pressor support\n ICU Care\n Nutrition: Start TFs\n Glycemic Control: RISS\n transition to IV insulin protocol given plan\n to start steroids\n Lines:\n Cleanly placed femoral TLC - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Hob elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU\n Critically ill,\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397479,
"text": "Chief Complaint: 49 yo woman with history of hepatitis C, active\n alcohol abuse, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension.\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 02:32 AM\n NASAL SWAB - At 03:00 AM\n MRSA swab\n URINE CULTURE - At 04:04 AM\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 97 (92 - 97) bpm\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\n RR: 19 (12 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,973 mL\n PO:\n 200 mL\n TF:\n IVF:\n 773 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,843 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.1 g/dL\n 238 K/uL\n 176 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 99 mEq/L\n 129 mEq/L\n 35.2 %\n 17.7 K/uL\n [image002.jpg]\n 06:01 AM\n WBC\n 17.7\n Hct\n 35.2\n Plt\n 238\n Cr\n 0.9\n Glucose\n 176\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397494,
"text": "Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension.\n HPI:\n 24 Hour Events:\n -received 7L crystalloid total and initiated on levophed for blood\n pressure support\n -seen by liver consult in ED\n -received po vitamin K\n -discriminate function was 71 so started on prednisone 40mg daily for\n alcoholic hepatitis\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone\n levaquin\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 06:00 AM\n Other medications:\n Protonix\n Folic acid and thiamine\n Lactulose 30mg QID\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 97 (92 - 97) bpm\n BP: 112/78(86) {90/52(62) - 115/78(86)} mmHg\n RR: 19 (12 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,973 mL\n PO:\n 200 mL\n TF:\n IVF:\n 773 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,843 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Cardiovascular:RRR,PMI Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: crackles at both bases posteriorly\n Abdominal: Soft, Non-tender\n Extremities: no peripheral edema. Slightly cool to touch.\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands. Alert and oriented x3.\n Labs / Radiology\n 11.1 g/dL\n 238 K/uL\n 176 mg/dL\n 0.9 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 5 mg/dL\n 99 mEq/L\n 129 mEq/L\n 35.2 %\n 17.7 K/uL\n [image002.jpg]\n From WBC 9.2\n From Cr 0.6 TB 16.3 to 19.8 AST/ALT 195/45 to 103/39\n FeNa 0.4%\n 06:01 AM\n WBC\n 17.7\n Hct\n 35.2\n Plt\n 238\n Cr\n 0.9\n Glucose\n 176\n Other labs: PT / PTT / INR:23.7/46.6/2.3, ALT / AST:39/103, Alk Phos /\n T Bili:113/19.8, Albumin:1.9 g/dL, Ca++:6.9 mg/dL, Mg++:1.6 mg/dL,\n PO4:3.6 mg/dL lactate 2.2 at midnight serum etoh: negative serum\n acetaminophen negative\n RUQ US: cirrhotic liver, difficult to assess portal vein, ascites noted\n CT abdomen with contrast: no portal vein thrombosis with hypodensities\n in the liver consistent with perfusion defect or mass effect\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n -only potential source at this point is pneumonia\n -titrating down on levophed\n -if off levophed by noon will hold on placing a-line\n -concern for septic shock but no clear source, no evidence of SBP\n -does not appear fluid responsive at this point. If we need to do\n further volume challenge would use 5% albumin\n -will check bladder pressure\n ACUTE LIVER FAILURE\n -will ask liver consult team to make some recommendations\n -followup AFP, lesions on liver can be concerning for hepatocellular\n carcinoma\n -continue prednisone for presumed alcoholic hepatitis\n -trend lactate\n -for elevated INR will continue oral vitamin K 10mg for total of 3 days\n -continue lactulose for encephalopathy\nacute renal failure with low FeNa\n -will ask renal consult to see given potential for hepatorenal syndrome\n vs contrast induced nephropathy\n -will likely need 5% albumin challenge to determine\nhypoxemia now resolved\n -will check CT chest without contrast to evaluate for ovine bronchus\n and possible obstruction\n ICU Care\n Nutrition: npo for now\n Glycemic Control: RISS\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM femoral. If not off pressors within\n 24 hours will need to place IJ or subclavian TLC\n Prophylaxis:\n DVT: heparin SQ to be initiated\n Stress ulcer: IV pantoprazole\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code. Will need to clarify with her family.\n Disposition : MICU\n Total time spent: 60 min\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397719,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\n 15 bpm, and most recent ABG 7.39/37/65.\n Action:\n Multiple vent changes today. Esophageal balloon placed with poor\n measurements pt\ns WOB but PEEP able to be increased to 22. Pt\n placed on triadyne bed.\n Response:\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\n 7.29/41/74\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\n neo @ 0.5mcg/kg/min.\n Response:\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\n Plan:\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\n Wean pressors as tol, would wean vaso off first.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today.\n Action:\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\n recs. Hydrocort added today for increasing bili and coags. Bladder\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\n Liver team following. Liver did not recommend para as they \nt feel\n she has a lg amt of ascites.\n Response:\n Large liquid yellow BM this AM so flexiseal inserted but pt without\n stool since that BM.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397720,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\n 15 bpm, and most recent ABG 7.39/37/65.\n Action:\n Multiple vent changes today. Esophageal balloon placed with poor\n measurements pt\ns WOB but PEEP able to be increased to 22. Pt\n placed on triadyne bed.\n Response:\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\n 7.29/45/74 and sats 88-92%.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\n neo @ 0.5mcg/kg/min. Pt also given 50g 25% albumin to improve\n intravascular volume status. Pt also started on IV Vanc/Cefepime for\n possible sepsis.\n Response:\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\n Plan:\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\n Wean pressors as tol, would wean vaso off first. attempt fluid\n challenge this pm and want vigileo set up.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today.\n Action:\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\n recs. Hydrocort added today for increasing bili and coags. Bladder\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\n Liver team following. Liver did not recommend para as they \nt feel\n she has a lg amt of ascites.\n Response:\n Large liquid yellow BM this AM so flexiseal inserted but pt without\n stool since that BM.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397721,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **EVENTS: Pt started on insulin gtt this AM for anion gap 18 up from\n 12 yesterday AM. Insulin gtt currently infusing @ 11 units/hr with last\n 2 BS 114, 105.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 100%/450/14/10 with sats low 90s, pt by\n 15 bpm, and most recent ABG 7.39/37/65.\n Action:\n Multiple vent changes today. Esophageal balloon placed with poor\n measurements pt\ns WOB but PEEP able to be increased to 22. Pt\n placed on triadyne bed. Suctioned for small amts dark yellow/green thin\n secretions.\n Response:\n Current vent settings now CMV 80%/400/26/22 with most recent ABG\n 7.29/45/74 and sats 88-92%.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mcg/kg/min with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ 0.4mcg/kg/min and addition of vasopressin @ 2.4units/hr and\n neo @ 0.5mcg/kg/min. Pt also given 50g 25% albumin to improve\n intravascular volume status. Pt also started on IV Vanc/Cefepime for\n possible sepsis, and blood cx x2 sent from PICC and CVL, urine cx sent,\n sputem cx sent.\n Response:\n BP maintained at goal MAP > 55. Able to wean neo off toward end of\n shift with MAPs remaining around 60, systolics high 80s to low 90s.\n Plan:\n Cont current pressors to maintain goal MAP > 55. Cont to monitor BPs.\n Wean pressors as tol, would wean vaso off first. attempt fluid\n challenge this pm and want vigileo set up. Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today.\n Action:\n Pt on lactulose 60ml QID. Rifaximin added today as well per liver\n recs. Hydrocort added today for increasing bili and coags. Bladder\n pressure checked Q6, measuring 14-15 today down from 23 yesterday.\n Liver team following. Liver did not recommend para as they \nt feel\n she has a lg amt of ascites.\n Response:\n Large liquid yellow BM this AM so flexiseal inserted but pt without\n stool since that BM.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397459,
"text": "49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Pt is a poor historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n 2)Hepatic Failure\nThis appears to be acute exacerbation in the setting\n of ongoing alcohol use and abuse. We do not see evidence of portal\n vein thrombosis or intra-peritoneal infection.\n -Steroids based upon discriminant function\n -Will need to send AFP given new densities on CT scan\n -Hepatology to see in the am\n -Lactulose\n 3)Coagulopathy-\n -Vitamin K given\n - be more likely related to poor hepatic function\n 4)EtOH Abuse-\n -Will monitor for withdrawl\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397714,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation. Sxned for bilious looking secretions.\n Response:\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\n vent settings 60% 450/14/5\nplaced on 100% FiO2 and Aline currently\n being placed for ABGs.\n Plan:\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\n ventilation.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mg/hr with SBPs 80s\n Action:\n Pt cont OFF levo for most of shift, then around 0400, pt becoming\n persistently hypotensive with systolics in the 80s, levophed gtt\n initiated, titrating to MAPs > 55.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\n tolerated by BP.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397716,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation. Sxned for bilious looking secretions.\n Response:\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\n vent settings 60% 450/14/5\nplaced on 100% FiO2 and Aline currently\n being placed for ABGs.\n Plan:\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\n ventilation.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.3mg/hr with SBPs 80s, MAPs 55-60.\n Action:\n Pt with MAPs dropping to low 50s at beginning of shift requiring max\n dose levo @ addition of vasopressin @ 2.4units/hr,\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\n tolerated by BP.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 397722,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (1500)\n Comments: Balloon placed measurements not taken Pt actively breathing.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397737,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt vented on CMV 80%/400/26/22, with esophageal balloon in\n place with sats low 90s, pt by 5-6 bpm, ABG at change of shift\n 7.29/45/74. Rec\nd on fentanyl and propofol gtts. On triadyne bed.\n Action:\n Pt maintaining sats > 86% for most of shift- tolerating turns, then ~\n 0200 after pt care, pt becoming hypoxic to 85%, dysyhnchronous with\n vent. Increased propofol to 30 mcg/kg/min, and fentanyl remained at\n 100 mcg/kg/min. ABG obtained with sats at 87% - 7.29/37/73. Suctioned\n for small amts dark yellow/green thin secretions.\n Response:\n Pt not over breathing vent, although sats remained 85%- so FiO2\n increased to 100%, pt now sating 91%. Rotation currently turned off on\n triadyne bed as pt is becoming hypoxic and hypotensive with turns.\n Plan:\n Cont current vent settings. Follow sats and ABGs. AM chest xray. Will\n tolerate PaO2s >65 and O2 sats >86%.\n Hypotension (not Shock)\n Assessment:\n Received pt on Levophed @ 0.4mcg/kg/min, vasopressin at 2.4 unit/hrs,\n and neosynephrine at 0.5 mcg/kg/min. Pan cultured on days. UO\n 5-15cc/hr.\n Action:\n Pt with MAPs dropping to low 50s ~ 0200 after pt care, increased\n neosynephrine to 2 mcg/kg/min, remains on max dose levophed, and\n vasopressin. Rec\nd a total of 2L NS and 25% albumin for low\n UO/hypotension/increased SVV. Placed on vigeleo. Pt remains on IV\n Vanc/Cefepime for possible sepsis. C. Diff spec sent.\n Response:\n Cont. on triple pressors to maintain MAPs > 55. Currently not\n tolerating turns as stated above. Lactate 5.7. CO ranging 4.8-5.5.\n SVV ranging .\n Plan:\n Titrate pressors to maintain goal MAP > 55. . Cont current IV abx for\n possible sepsis related hypotension. F/U culture results.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt extremely jaundiced, abdomen soft/distended with ascites, LFTs\n slightly elevated and tbili up to 27.7 today. Bladder pressure ranging\n 15-16 this shift. Rec\nd on insulin gtt at 11 units/hr for + gap and\n increasing FSBS.\n Action:\n Pt on lactulose 60ml QID. FSBS ranging 60-120- insulin gtt turned off\n low BS and thought gap r/t liver fail. And increasing lactate. On\n standing dose Rifaximin. On Hydrocort for increasing bili and coags.\n Bladder pressure checked Q6. Liver team following.\n Response:\n Pt stooling med-lg amounts of golden liquid stool. Bladder pressure\n 15-16. Cont. to monitor FSBS.\n Plan:\n Cont to monitor LFTs, tbili. Monitor Q6hr bladder pressures. Cont\n rifaximin/lactulose and hydrocort. F/U liver team recs.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397540,
"text": "Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Continues on levo gtt to keep MAP > 55, UO 30 -60cc/hr, hr nsr\n 80\ns-90\ns. Hct 27 at change of shift.\n Action:\n Titrating Levophed gtt to maintain MAPs > 55, stable on 0.06 mcg/kg/min\n Levophed gtt. Repeat Hct sent.\n Response:\n UO improving, Hct stable 28,\n Plan:\n Levo gtt as ordered to keep MAP > 55, ? a-line insertion this PM,\n frequent labs as ordered\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o # abdominal pain,\n oriented x , calm & cooperative, minimal uo, on levo gtt to maintain\n map > 55\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver consult\n placed, chest ct today, bladder pressure done, iv morphine given x 2 &\n po oxycodone x 1, npo except ice chips, iv albumin given\n Response:\n Bladder pressure 17, no stool, abdominal pain down to #1-2 after\n narcotics, not able to wean levo off, minimal response from iv albumin\n Plan:\n Continue to monitor for sepsis/pancreatitis/GI bleeding, po lactulose\n as ordered, wean levo as able, iv protonix/iv antibiotics as ordered,\n pain controll\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397625,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs 90s. UOP 40s-50s per hour.\n Action:\n Pt cont OFF levo. Given 50g of 5% albumin today to improve\n intravascular volume and for albumin 2.6 this AM.\n Response:\n BPs remaining >90 with MAPs ranging 60s-70s, systolic pressures\n 90s-120s.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites and c/o \n abdominal pain. Pt alert and oriented x 3 at times but noted to be\n hallucinating at times as well. Bladder pressure 23 today.\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver team\n following, ivp morphine given frequently for a total of 10mg ivp this\n shift, Reoriented frequently. CIWA q4h, tolerating ice chips and\n popcicles.\n Response:\n no stool, abdominal pain down to 4-5 after narcotics, pt cont. to be\n confused as to time/place, oriented x2. CIWA < 10, no diazepam given\n this shift.\n Plan:\n Cont to monitor MS- cont po lactulose as ordered, reorient as needed,\n iv protonix/iv antibiotics as ordered, pain control. Bladder\n pressures daily. Liver team following.\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397683,
"text": "Chief Complaint:\n 24 Hour Events:\n - D/cd Antibioitcs which were empiric for CAP, but afebrile with normal\n WBC\n - Receive IV Vitamin K x1\n - Started Cipro empirically per liver for mildly positive UA\n - Repeat Hct stable 26.3 < 24.2 < 25.6. Did not give FFP because Hct\n stable (which liver had advised earlier in the day)\n - Worsening hypoxemia around 1600. CXR appeared more volume overloaded.\n Received lasix 20 mg IV x3 with brisk response but continue to be more\n Hypoxic. Intubated around 10 pm with sats in 70s.\n - Hypotensive to SBP 70s-80s post intubation. Started levophed to limit\n fluid over-resusication\n - Rising lactate 4.4 > 5.5. Did not give fluids becuase appears\n overloaded and worsening oxygenation.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsLibrium (Oral) (Chlordiazepoxide\n Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.28 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 98 (94 - 111) bpm\n BP: 71/54(57) {71/40(44) - 141/87(94)} mmHg\n RR: 22 (22 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 327 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 327 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 545 mL\n Urine:\n 2,784 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 98%\n ABG: 7.39/37/65/20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 65\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 94 K/uL\n 8.7 g/dL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n WBC\n 10.6\n 11.0\n Hct\n 27.8\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Imaging: : AP single view of the chest obtained with patient in\n sitting\n semi-upright position is analyzed in direct comparison with the next\n preceding similar study obtained four hours earlier during the same\n day. No significant interval change can be identified. No pneumothorax\n has developed. The scattered bilateral patchy densities are still\n present and there is no evidence of gross pleural effusion as the\n lateral pleural sinuses remain free.\n Microbiology: BCx x 2 NGTD\n Pleural fluid culture NGTD\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG , + 1:20\n -HCV VL < 43\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\n despite BMs w/ lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n -vitamin k 10 mg IV x 1\n -if hct < 21 give FFP for elevated PTT and INR\n # ETOH abuse: thiamine, folate, MVI daily\n - No evidence of withdrawal, will stop CIWA\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n Plan to begin diuresing very gently if Cr stable by .\n -IS for atelectasis\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\n depletion.\n -improved\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397685,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PICC LINE - START 12:40 PM\n INVASIVE VENTILATION - START 10:18 PM\n ARTERIAL LINE - START 06:29 AM\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOTENSION (NOT SHOCK)\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397688,
"text": "Chief Complaint: Liver failure\n HPI:\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\n failure.\n 24 Hour Events:\n PICC LINE placed\nAntibiotics stopped\n Reintubated\n Hypotensive post intubation, increasing pressor requirement\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives\n Vasotec - hypertension\n Last dose of Antibiotics:\n Ciprofloxacin\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Potassium, MVI, folate, thiamine,\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Cool, anasarcic\n Respiratory / Chest: Coarse, bronchial anteriorally\n Abdominal: Soft, Bowel sounds present, slightly distended\n Skin: Icteric, no rashes\n Neurologic: Sedated\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\n Cultures\n Blood and peritoneal fluid NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n ARDS vs volume overload. Plateaus\n elevated, bilateral infiltrates.\n - Hold diuresis for now while hypotensive\n - Keep PaO2 >60, try to increase PEEP if needed\n HYPOTENSION\n Worse post-intubation. Likely due to sedation and\n PEEP, but cannot exclude worsening infection, although no fever or\n elevated WBC. Did have hemo-peritoneum, although Hct stable. Also had\n steroids stopped recently.\n - Broaden antibiotics, add vanco and cefepime\n - TTE, CvO2\n - Pan culture\n - Start stress dose hydrocortisone\n - q6h\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Tbili and INR stable\n - Add rifaxamin\n - Continue lactulose\n - stress dose hydrocortisone as above\nAnemia\n Stable yesterday, but given hypotension will trend q6h, space\n out if stable x2\n Renal Failure\n improved UOP, s/p two days of albumin\n ICU Care\n Nutrition: Start TFs\n Glycemic Control: RISS\n Lines:\n Cleanly placed femoral TLC - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Hob elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397689,
"text": "Chief Complaint:\n 24 Hour Events:\n - D/cd Antibioitcs which were empiric for CAP, but afebrile with normal\n WBC\n - Receive IV Vitamin K x1\n - Started Cipro empirically per liver for mildly positive UA\n - Repeat Hct stable 26.3 < 24.2 < 25.6. Did not give FFP because Hct\n stable (which liver had advised earlier in the day)\n - Worsening hypoxemia around 1600. CXR appeared more volume overloaded.\n Received lasix 20 mg IV x3 with brisk response but continue to be more\n Hypoxic. Intubated around 10 pm with sats in 70s.\n - Hypotensive to SBP 70s-80s post intubation. Started levophed to limit\n fluid over-resusication\n - Rising lactate 4.4 > 5.5. Did not give fluids becuase appears\n overloaded and worsening oxygenation.\n History obtained from Medical records\n Allergies:\n History obtained from Medical recordsLibrium (Oral) (Chlordiazepoxide\n Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.28 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 98 (94 - 111) bpm\n BP: 71/54(57) {71/40(44) - 141/87(94)} mmHg\n RR: 22 (22 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 327 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 327 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 545 mL\n Urine:\n 2,784 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 98%\n ABG: 7.39/37/65/20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 65\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 94 K/uL\n 8.7 g/dL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n WBC\n 10.6\n 11.0\n Hct\n 27.8\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Imaging: : AP single view of the chest obtained with patient in\n sitting\n semi-upright position is analyzed in direct comparison with the next\n preceding similar study obtained four hours earlier during the same\n day. No significant interval change can be identified. No pneumothorax\n has developed. The scattered bilateral patchy densities are still\n present and there is no evidence of gross pleural effusion as the\n lateral pleural sinuses remain free.\n Microbiology: BCx x 2 NGTD\n Pleural fluid culture NGTD\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Shock: at this point seems to be related to possible infectious\n cause, end stage liver disease, propofol. Would also consider adverse\n reaction to FFP or IV vitamin K. On levo, vaso.\n - MAP goal > 55\n - empiric vanc/zosyn/cipro\n - stress dose steroids\n - follow UOP, pulse pressure variation to assess intravascular volume\n - check ECHO\n - check TSH/FT4\n - wean propofol\n - check lytes, hct, ABG, lactate q6h\n # Respiratory failure/ARDS: Worsening hypoxia on and intubated\n in setting of receiving volume and severe liver disease. Differential\n includes volume overload versus infection versus pulm hemorrhage vs\n TROLI in setting of transfusion though unlikely. Would also consider\n PCP given IVDU history.\n - ARDSnet protocol with low tidal volumes\n - PaO2 > 60, SaO2 > 90\n - empiric antibx\n - r/o flu\n - may consider bronch\n - hold on diuresis for now but will consider pending creatinine trend,\n UOP\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n - restarted steroids with undetectable HCV viral load\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG , + 1:20\n -HCV VL < 43\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose and rifaxamin\n -will obtain OSH previous EGD / if any\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n - follow UOP and trend creatinine\n - renally dose meds\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\n and hct stable.\n -guaiac stools\n -active type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n # ETOH abuse: No evidence of withdrawal\n - thiamine, folate, MVI daily\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition: TF reccs\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397691,
"text": "Chief Complaint: Liver failure\n HPI:\n See H&P for full details. Briefly 49F w/acute on chronic hepatic\n failure.\n 24 Hour Events:\n PICC LINE placed\nAntibiotics stopped\n Reintubated\n Hypotensive post intubation, increasing pressor requirement\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives\n Vasotec - hypertension\n Last dose of Antibiotics:\n Ciprofloxacin\n Infusions:\n Fentanyl (Concentrate) - 100 mcg/hour\n Norepinephrine - 0.32 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 07:55 AM\n Lorazepam (Ativan) - 07:00 PM\n Morphine Sulfate - 08:15 PM\n Furosemide (Lasix) - 10:00 PM\n Other medications:\n Potassium, MVI, folate, thiamine,\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 92 (92 - 111) bpm\n BP: 80/47(55) {71/40(44) - 141/87(94)} mmHg\n RR: 29 (22 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 23 (23 - 23) mmHg\n Total In:\n 1,666 mL\n 365 mL\n PO:\n 240 mL\n TF:\n IVF:\n 426 mL\n 365 mL\n Blood products:\n 1,000 mL\n Total out:\n 2,784 mL\n 575 mL\n Urine:\n 2,784 mL\n 575 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,118 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 6,000 (6,000 - 6,000) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 100%\n RSBI Deferred: FiO2 > 60%\n PIP: 29 cmH2O\n Plateau: 28 cmH2O\n SpO2: 95%\n ABG: 7.41/35/98./20/-1\n Ve: 15.1 L/min\n PaO2 / FiO2: 98\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Cool, anasarcic\n Respiratory / Chest: Coarse, bronchial anteriorally\n Abdominal: Soft, Bowel sounds present, slightly distended\n Skin: Icteric, no rashes\n Neurologic: Sedated\n Labs / Radiology\n 8.7 g/dL\n 94 K/uL\n 156 mg/dL\n 1.0 mg/dL\n 20 mEq/L\n 2.6 mEq/L\n 7 mg/dL\n 101 mEq/L\n 139 mEq/L\n 26.0 %\n 11.0 K/uL\n [image002.jpg]\n 10:08 PM\n 02:21 AM\n 04:15 AM\n 12:54 PM\n 07:33 PM\n 08:25 PM\n 12:54 AM\n 03:57 AM\n 06:31 AM\n 07:26 AM\n WBC\n 10.6\n 11.0\n Hct\n 26.5\n 28.0\n 26.3\n 24.2\n 25.6\n 26.0\n Plt\n 127\n 94\n Cr\n 1.0\n 1.0\n TCO2\n 22\n 24\n 23\n 23\n Glucose\n 182\n 156\n Other labs: PT / PTT / INR:25.8/48.9/2.5, ALT / AST:25/75, Alk Phos / T\n Bili:66/27.7, Amylase / Lipase:14/26, Differential-Neuts:86.0 %,\n Band:1.0 %, Lymph:4.0 %, Mono:9.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:125 mg/dL, Lactic Acid:5.5 mmol/L, Albumin:2.8 g/dL, LDH:272\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.9 mg/dL\n Anti-smooth muscle ab 1:20, Hep C viral Load 43, AFP 1.7\n Cultures\n Blood and peritoneal fluid NGTD\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE\n ARDS vs volume overload. Plateaus\n elevated, bilateral infiltrates.\n - Hold diuresis for now while hypotensive\n - Keep PaO2 >60, try to increase PEEP if needed\n HYPOTENSION\n Worse post-intubation. Likely due to sedation and\n PEEP, but cannot exclude worsening infection, although no fever or\n elevated WBC. Did have hemo-peritoneum, although Hct stable. Also had\n steroids stopped recently.\n - Broaden antibiotics, add vanco and cefepime\n - TTE, CvO2\n - Pan culture\n - Start stress dose hydrocortisone\n - q6h\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Tbili and INR stable\n - Add rifaxamin\n - Continue lactulose\n - stress dose hydrocortisone as above\nAnemia\n Stable yesterday, but given hypotension will trend q6h, space\n out if stable x2\n Renal Failure\n improved UOP, s/p two days of albumin\n ICU Care\n Nutrition: Start TFs\n Glycemic Control: RISS\n transition to IV insulin protocol given plan\n to start steroids\n Lines:\n Cleanly placed femoral TLC - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Hob elevated, chlorhexidine\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : MICU\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 397453,
"text": "Chief Complaint: Weakness\n Jaundice\n Hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient to hospital with complaints of worsening weakness and\n change in urine color now admitted to with concern for evolving\n hepatic failure.\n In the ED here->\n -Pt with MSO4 for pain control\n -CTX given for possible SBP\n -Given hypotension femoral catheter placed and 7 liters fluid given\n -Levophed given for hypotension\n -Paracentesis perfored with 63 WBC seen\n Patient admitted to ICU for further care\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.14 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Cirrhosis-Hep C and EtOH\n EtOH abuse-h/o withdrawl seizures\n S/P CCY in past\n DM-II\n Non-contributory\n Occupation: Unk\n Drugs: None noted now\n Tobacco: Continued smoking\n Alcohol: Patient admits to some EtOH ingestion prior to onset of\n abdominal pain\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Genitourinary: Foley\n Psychiatric / Sleep: Daytime somnolence\n Signs or concerns for abuse : No\n Pain: Mild\n Flowsheet Data as of 04:32 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 92 (92 - 95) bpm\n BP: 90/52(62) {90/52(62) - 115/74(84)} mmHg\n RR: 21 (12 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,257 mL\n PO:\n TF:\n IVF:\n 257 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,167 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Abdominal: Soft, Bowel sounds present, Tender: Diffusely\n Musculoskeletal: Unable to stand\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\nPatient somnolent\n but arousable.\n Labs / Radiology\n 128\n 31\n 0.6\n 4\n 21\n 102\n 2.8\n 132\n 9\n [image002.jpg]\n Other labs: PT / PTT / INR:23.8/2.3, ALT / AST:45/195, Alk Phos / T\n Bili:91/16.3 (8.4-direct), Amylase / Lipase:/20, Differential-Neuts:78,\n Lactic Acid:3.1\n Fluid analysis / Other labs: TOx-Pos Benzos\n Serum-Negative to Tylenol and EtOH\n Imaging: CXR-Patient with what appears to be right middle lobe opacity.\n U/S--no Cholecystitis seen\n CT--no portal vein thrombosis noted. In segment II of the\n liver--multiple hypodensities noted which were felt to be non-specific\n findings\n Assessment and Plan\n 49 yo female with history of cirrhosis now admitted with worsening\n abdominal discomfort and hyper-bilirubinemia in the setting of recent\n EtOH ingestion. Initial tap of abdominal fluid did not reveal obvious\n SBP as source. This leaves, in the setting of significant hypotension,\n source of initial insult remains to be clearly defined.\n 1) Hypotension- be part of the hepatic failure picture present but\n alternative source of infection (possible urine) is possible with right\n middle lobe opacity but clinical history not suggestive.\n -Ceftriaxone/Levoflox in place\n -9 liters given and will use pressor for now\n -Follow up cultures\n 2)Hepatic Failure\nThis appears to be acute exacerbation in the setting\n of ongoing alcohol use and abuse. We do not see evidence of portal\n vein thrombosis or intra-peritoneal infection.\n -Steroids based upon discriminant function\n -Will need to send AFP given new densities on CT scan\n -Hepatology to see in the am\n -Lactulose\n 3)Coagulopathy-\n -Vitamin K given\n - be more likely related to poor hepatic function\n 4)EtOH Abuse-\n -Will monitor for withdrawl\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments: Discussed with patient but with signfiicant\n confusion\nwould be appropriate to discuss with a social support if\n available.\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 397455,
"text": "Chief Complaint: transfer from for liver failure\n HPI:\n 49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \n hospital after presenting with worsening jaundice and fatigue. She was\n noted there to be hypotensive to the low 80s systolic, noted to have an\n elevated bili and INR- she was given 4 Liters IVF and transferred to\n the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\n was given 4 L IVF in hospital, 3 L in the ER at .\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\n sat: 94% on 5L O2 NC.\n Currently the patient complains of generalized abdominal pain, moreso\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\n her abdominal pain beginning.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.16 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Other medications:\n (patient unsure of medications, none on list from hospital)\n patient states she takes insulin.\n Past medical history:\n Family history:\n Social History:\n 1. Hepatitis C.\n 2. Alcoholic hepatitis.\n 3. History of alcohol abuse with withdraw seizures and DTs in the\n past.\n 4. History of hypertension.\n 5. History of chronic pancreatitis.\n 6. Status post cesarean section and ectopic pregnancies in the past.\n 7. History of traumatic wrist laceration in the past status post\n surgical repair with blood transfusions in .\n 8. S/P ccy, s/p oophorectomy\n 9. DM II\n non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: 6 tabs of tylenol 3 days ago, 1 pint of hard liquor on \n however the patient's history is relatively unreliable given\n encephalopathy. She lives w/ friends, smokes and is a current\n abuser of ETOH (daily)- unable to quantify. H/o opiate abuse but no\n opiates x 1 year.\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 94 (94 - 95) bpm\n BP: 115/74(84) {115/74(84) - 115/74(84)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,172 mL\n PO:\n TF:\n IVF:\n 172 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,082 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: serum tylenol negative\n serum etoh negative\n serum opiates negative\n serum benzos +\n Imaging: RUQ ultrasound: (prelim) Very echogenic liver, limited\n assessment of gallbladder and portal vein. Ascites, predominantly in\n the RUQ, but not a good window to mark. Consider ultrasound guided\n paracentesis.\n CXR: (my read) hilar fullness w/ mild pulm vascular engorgement,\n infiltrates in the RML and RUL.\n CT abd / pelvis w/ contrast: . (prelim)\n liver w/ heterogeneous attenuation, shrunken nodular appearance.\n Several areas of hypodensities in segement 2 of the liver could\n represent perfusion defects, dilated bile ducts or could be related to\n underlying mass effect. Anasarca. No evidence of portal vein\n thrombosis. Bibasilar atelectasis.\n Microbiology: BCx x 2 P\n Peritoneal fluid cx P\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis given history and transaminase pattern.\n -paracentesis negative for sbp\n -liver consult\n -liver ultrasound with doppler was a difficult study,\n -discriminate function is 71. Will start steroids x 1 week then taper.\n -will give vitamin K to correct any portion of elevated INR that may be\n nutritional\n -thiamine, folate, MVI daily\n -lactulose- titrate to 3 BMs daily\n -send AFP given risk of HCC and finding on CT abd\n -Send Uhcg\n # Hypotension: no clear cause for hypotension with the exception of\n worsening liver function and possible infectious etiologies including\n pneumonia and possible urinary tract infection.\n -continue levofloxacin / ceftriaxone.\n -keep MAP > 55\n -has rec'd 7 liters IVF and likely fluid replete, appears euvolemic on\n exam\n # Hyponatremia: possibly related to volume overload / liver disease.\n -urine lytes\n # Hypoxia: appears to have R sided opacities which may be pneumonia.\n She has rec'd ceftriaxone. Will add levofloxacin in addition to CTX\n for severe CAP.\n -abx\n -f/u blood cultures\n -sputum culture\n -IS for atelectasis\n # ETOH abuse: h/o w/d seizures in the past.\n -CIWA scale w/ valium.\n # DM: Insulin sliding scale.\n # FEN: NPO for now until MS clears\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 397616,
"text": "Subjective\n \"Help me!\". Taking oxygen mask off.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 106 kg\n 36.5\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 61.2 kg\n 173%\n 72.4 kg\n Diagnosis: acute liver failure\n PMHx:\n 1. Hepatitis C.\n 2. Alcoholic hepatitis.\n 3. History of alcohol abuse with withdraw seizures and DTs in the\n past.\n 4. History of hypertension.\n 5. History of chronic pancreatitis.\n 6. Status post cesarean section and ectopic pregnancies in the past.\n 7. History of traumatic wrist laceration in the past status\n postsurgical repair with blood transfusions in .\n 8. S/P ccy, s/p oophorectomy\n 9. DM II\n Food allergies and intolerances: none\n Pertinent medications: Normal saline @ 10ml/hr, Albumin 5%,\n Pantoprazole, RISS, Multi-vitamin, Thiamine, Folic Acid, Lactulose\n Labs:\n Value\n Date\n Glucose\n 182 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 180\n 11:00 AM\n BUN\n 7 mg/dL\n 04:15 AM\n Creatinine\n 1.0 mg/dL\n 04:15 AM\n Sodium\n 134 mEq/L\n 04:15 AM\n Potassium\n 3.4 mEq/L\n 04:15 AM\n Chloride\n 101 mEq/L\n 04:15 AM\n TCO2\n 21 mEq/L\n 04:15 AM\n Albumin\n 2.6 g/dL\n 04:15 AM\n Calcium non-ionized\n 7.8 mg/dL\n 04:15 AM\n Phosphorus\n 3.2 mg/dL\n 04:15 AM\n Magnesium\n 2.6 mg/dL\n 04:15 AM\n ALT\n 34 IU/L\n 04:15 AM\n Alkaline Phosphate\n 82 IU/L\n 04:15 AM\n AST\n 83 IU/L\n 04:15 AM\n Amylase\n 14 IU/L\n 05:20 PM\n Total Bilirubin\n 27.5 mg/dL\n 04:15 AM\n WBC\n 10.6 K/uL\n 04:15 AM\n Hgb\n 8.7 g/dL\n 04:15 AM\n Hematocrit\n 24.2 %\n 12:54 PM\n Current diet order / nutrition support: Diet: regular\n GI: soft/distended, (+) bowel sounds, (+) flatus\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: decreased mental status, liver disease, etoh\n Estimated Nutritional Needs\n Calories: 1600-1810 (22-25 cal/kg)\n Protein: 87-109 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: likely inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 49 YO female presented with hypotension and worsening jaundice.\n Decreased po\ns and increased alcohol intake recently per chart.\n Consulted for tube feed recommendations and calorie counts. Diet\n advanced today to regular, only had water per co-worker, c/o abdominal\n pain. Would hold off on calorie counts at this time as patient not\n taking po\ns. Would provide temporary nutrition support with tube\n feeding until po\ns improve given likely poor nutritional status PTA.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropriate: Encourage\n po\ns as able\n o Will begin calorie counts when po\ns improve\n Multivitamin / Mineral supplement: continue current\n Tube feeding recommendations:\n o Place PPFT given ascites; check placement\n o Begin tube feed: Isosource 1.5 @ 20ml/hr, advance as\n tolerated to goal of 50ml/hr\n Add 15g Beneprotein for total of 1854 calories and 95g\n protein\n o No residual checks with PPFT, monitor abdominal exam, patient\n complaints\n Check chemistry 10 panel daily\n Will follow, page if questions *\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 397694,
"text": ":\n Recruitment Maneuvers Done\n CPAP pressure used: aprv cm H2O\n Duration: 30 sec\n Times per shift:\n Comments: 35/32\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397592,
"text": "Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\n lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Hallucinations: Visual hallucinations this morning. New since\n yesterday. ? Benzo related but also could be encephalopathy.\n - Increase lactulose\n - Hold Benzos for now and see if MS improves\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale but hold benzos for right now\n - D/c thiamine after today\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative.\n INR worsening so will check DIC labs\n -guaiac stools\n -type and screen.\n - IV Vitamin K since did not respond to po vitamin K\n -transfuse for hct < 21, and transfuse w/ Lasix when necessary\n -Q8. hct, DIC labs\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia: Imprved with volume so likely due to intravascular\n depletion prior to admission.\n -improved and will continue to trend lytes daily\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397593,
"text": "Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\n despite BMs w/ lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n -vitamin k 10 mg IV x 1\n -if hct < 25 give FFP for elevated PTT and INR\n # ETOH abuse: thiamine, folate, MVI daily\n - No evidence of withdrawal, will stop CIWA\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\n depletion.\n -improved\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition: calorie count today\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397594,
"text": "Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\n lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Hallucinations: Visual hallucinations this morning. New since\n yesterday. ? Benzo related but also could be encephalopathy.\n - Increase lactulose\n - Hold Benzos for now and see if MS improves\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale but hold benzos for right now\n - D/c thiamine after today\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative.\n INR worsening so will check DIC labs\n -guaiac stools\n -type and screen.\n - IV Vitamin K since did not respond to po vitamin K\n -transfuse for hct < 21, and transfuse w/ Lasix when necessary\n -Q8. hct, DIC labs\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia: Imprved with volume so likely due to intravascular\n depletion prior to admission.\n -improved and will continue to trend lytes daily\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397595,
"text": "Chief Complaint: Liver failure\n HPI:\n Please see admission note for full details. 49F w/HCV and cirrhosis\n admitted with worsening confusion and hepatic insufficiency.\n 24 Hour Events:\n - MELD 27\n - Stopped steroids\n - Chest CT obtained for evaluation of R-sided infiltrates\n - Concern for IP hemorrhage\n - Weaned off pressors\n Allergies:\n Librium - Confusion/Delir\n Erythromycin Base - Hives;\n Vasotec - HTN\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:50 AM\n Pantoprazole (Protonix) - 07:55 AM\n Other medications:\n MVI, folate, thiamine, lactulose, RISS\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 97 (90 - 101) bpm\n BP: 96/64(72) {82/15(40) - 107/69(78)} mmHg\n RR: 24 (15 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 8,915 mL\n 195 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 195 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 431 mL\n Urine:\n 409 mL\n 431 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -235 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Sallow, ill-appearing obese F, laying in bed\n Eyes / Conjunctiva: Scleral icterus\n Head, Ears, Nose, Throat: MMM, sublingual icterus, oropharynx clear\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Warm, diffusely edematous, palpable\n radial, DPs bilat\n Respiratory / Chest: bilateral crackles over the lower half of lung\n fields bilat\n Skin: Sallow, no rashes\n Neurologic: A&Ox2, repeatedly stating that her son is hiding in the\n room\n / Radiology\n 8.7 g/dL\n 127 K/uL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other : PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood cultures and peritoneal fluid cultures\n NGTD\n Chest CT\n Reviewed - Peribronchial edema, thickening, GGOs, trace\n bilateral effusions, ascites, pancreatic calcifiations\n Assessment and Plan\n CIRRHOSIS OF LIVER, ALCOHOLIC\n acutely decompensated\n - Increase lactulose as not stooling\n - Stopped steroids per hepatology\n - Will discuss prognosis given not a transplant candidate with son\n - On thiamine, folate, MVI for chronic EtOH\n HYPOTENSION - ?cirrhotic vs infectious\n - Weaned off pressors yesterday, follow\n - Goal MAP >55\n - Stop antibiotics\nHCT drop\n Appears to have been secondary to intraperitoneal bleed\n after paracentesis\n - Hct checks q8h\n - Transfusion goal >21 or if acute drop concerning for bleed\n - If need to transfuse, consider FFP if acute bleeding\n - IV vitamin K to try and improve coagulopathy\nEtOH Abuse\n - Monitor for withdrawal\nRenal Failure - Poor UOP yesterday with FENA <1, improving now, ATN\n vs hepatorenal vs contrast nephropathy\n - Getting albumin 50gm today\n - If worsens, consider midodrine and/or octreotide\nHypoxia, volume overload\n - On 4L NC\n - Consider gentle diuresis in the next 12-24 hrs pending UOP\n On RISS\n ICU Care\n Nutrition: PO diet\n Glycemic Control: RISS\n Lines: - Plan for PICC, d/c femoral line after\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Will discuss with son today\n status: Full code\n Disposition : MICU for now\n Total time spent: 30 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 397672,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing,\n Frequent desaturation episodes\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: may need to increase peep as O2 is decreased\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Pt was intubated for impending respiratory failure, hypoxia. New a line\n being placed, abg pending.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397673,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: At change of shift, pt agitated and in resp. distress,\n increased > Pt given ativan,lasix, with minimal effect, and placed\n on a NRB. Pt with sats 79-80% on NRB, ultimately intubated for resp.\n distress. SBP ranging 80s-90s, persistently hypotensive this AM, and\n levophed gtt initiated, and Aline placed. K 2.6- currently rec\n repletion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\n Action:\n Pt cont OFF levo.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397674,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: At change of shift, pt agitated and in resp. distress,\n increased > Pt given ativan,lasix, with minimal effect, and placed\n on a NRB. Pt with sats 79-80% on NRB, ultimately intubated for resp.\n distress. SBP ranging 80s-90s, persistently hypotensive this AM, and\n levophed gtt initiated, and Aline placed. K 2.6- currently rec\n repletion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually intubated, placed on propofol gtt for\n sedation. Sxned for bilious looking secretions.\n Response:\n Pt hypotensive on propofol gtt, sedation switched to fentanyl and\n versed see Metavision for details. Pt becoming hypoxic to 85% on AC\n vent settings 60% 450/14/5\nplaced on 100% FiO2 and Aline currently\n being placed for ABGs.\n Plan:\n Follow sats and ABGs. f/u on AM CXR. ? paracentesis to aide in\n ventilation.\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\n Action:\n Pt cont OFF levo for most of shift, then around 0400, pt becoming\n persistently hypotensive with systolics in the 80s, levophed gtt\n initiated, titrating to MAPs > 55.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55. Wean levophed gtt as\n tolerated by BP.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397600,
"text": "Chief Complaint: Liver failure\n HPI:\n Please see admission note for full details. 49F w/HCV and cirrhosis\n admitted with worsening confusion and hepatic insufficiency.\n 24 Hour Events:\n - MELD 27\n - Stopped steroids\n - Chest CT obtained for evaluation of R-sided infiltrates\n - Concern for IP hemorrhage\n - Weaned off pressors\n Allergies:\n Librium - Confusion/Delir\n Erythromycin Base - Hives;\n Vasotec - HTN\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 07:50 AM\n Pantoprazole (Protonix) - 07:55 AM\n Other medications:\n MVI, folate, thiamine, lactulose, RISS\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 97 (90 - 101) bpm\n BP: 96/64(72) {82/15(40) - 107/69(78)} mmHg\n RR: 24 (15 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 8,915 mL\n 195 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 195 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 431 mL\n Urine:\n 409 mL\n 431 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -235 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: Sallow, ill-appearing obese F, laying in bed\n Eyes / Conjunctiva: Scleral icterus\n Head, Ears, Nose, Throat: MMM, sublingual icterus, oropharynx clear\n Cardiovascular: RRR, S1, S2\n Extremities/Peripheral Vascular: Warm, diffusely edematous, palpable\n radial, DPs bilat\n Respiratory / Chest: bilateral crackles over the lower half of lung\n fields bilat\n Skin: Sallow, no rashes\n Neurologic: A&Ox2, repeatedly stating that her son is hiding in the\n room\n / Radiology\n 8.7 g/dL\n 127 K/uL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other : PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:272 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood cultures and peritoneal fluid cultures\n NGTD\n Chest CT\n Reviewed - Peribronchial edema, thickening, GGOs, trace\n bilateral effusions, ascites, pancreatic calcifiations\n Assessment and Plan\n CIRRHOSIS OF LIVER, ALCOHOLIC\n acutely decompensated\n - Increase lactulose as not stooling\n - Stopped steroids per hepatology\n - Will discuss prognosis given not a transplant candidate with son\n - On thiamine, folate, MVI for chronic EtOH\n HYPOTENSION - ?cirrhotic vs infectious\n - Weaned off pressors yesterday, follow\n - Goal MAP >55\n - Stop antibiotics\nHCT drop\n Appears to have been secondary to intraperitoneal bleed\n after paracentesis\n - Hct checks q8h\n - Transfusion goal >21 or if acute drop concerning for bleed\n - If need to transfuse, consider FFP if acute bleeding\n - IV vitamin K to try and improve coagulopathy\nEtOH Abuse\n - Monitor for withdrawal\nRenal Failure - Poor UOP yesterday with FENA <1, improving now, ATN\n vs hepatorenal vs contrast nephropathy\n - Getting albumin 50gm today\n - If worsens, consider midodrine and/or octreotide\nHypoxia, volume overload\n - On 4L NC\n - Consider gentle diuresis in the next 12-24 hrs pending UOP\n On RISS\n ICU Care\n Nutrition: PO diet\n Glycemic Control: RISS\n Lines: - Plan for PICC, d/c femoral line after\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: SCDs\n Stress ulcer: PPI\n VAP: N/A\n Comments:\n Communication: Will discuss with son today\n status: Full code\n Disposition : MICU for now\n Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397606,
"text": "Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and uptitrate lactulose, trial of dulcolax- if MS does not improve\n despite BMs w/ lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n -vitamin k 10 mg IV x 1\n -if hct < 21 give FFP for elevated PTT and INR\n # ETOH abuse: thiamine, folate, MVI daily\n - No evidence of withdrawal, will stop CIWA\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n Plan to begin diuresing very gently if Cr stable by .\n -IS for atelectasis\n # Hyponatremia: possibly related to cirrhosis and intravascular volume\n depletion.\n -improved\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition: calorie count today\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397668,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n **Events: Around 1500, pt c/o difficulty breathing. LS with crackles\n and wheezes and O2 sats decreasing into 80s. Pt given\n albuterol/atrovent nebs and chest xray taken which showed increased\n pulmonary edema. 20mg IV Lasix given for fluid overload with effect\n pending. Sats remaining high 80s/low 90s. BP stable post Lasix. Pt also\n started on PO cipro for UTI but refusing to take.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt agitated, yelling out, increased noted at change of shift, pt\n sating mid-80s on 5L nc. LS with crackles and ins/exp. wheeze heard\n t/o. RR 30s.\n Action:\n Given 20 mg ivp Lasix x2 with good UO, pt cont. in resp.\n distress/agitation. Given 4mg ivp morphine sulfate for pain and to\n aide in , Pt eventually\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Received pt OFF levo gtt. BPs ranging 80s-90s. UOP 40s-200s per hour.\n Action:\n Pt cont OFF levo.\n Response:\n BP maintained at goal MAP > 55.\n Plan:\n Cont to monitor BPs. Maintain goal MAP > 55.\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft/distended with ascites. Rec\nd pt agitated,\n yelling out, hallucinating, difficult to reorient. Oriented only to\n self. Pulling at lines and removing oxygen. Bladder pressure 23 on\n .\n Action:\n Pt placed in bilateral wrist restraints for safety. Ativan ivp given\n for agitation for a total of 2 mg ivp this shift. Cont. on standing\n dose lactulose.\n Response:\n Pt cont with only small smears of liquid stool despite increase in\n lactulose.\n Plan:\n Cont to monitor MS, LFTs. Liver team following. Pt will likely need\n therapeutic para for increased bladder pressure.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397802,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett.\n Action:\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. Hypotensive\n Action:\n Pan cx\nd this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397803,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C\n Action:\n Vent changed to PCV\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. Received on four pressors with MAPS ~60. C.O. \n with SVV\n Action:\n On IV Vanco. Pan cx\nd this shift. Started on Flagyl, Zosyn, Micafungin\n this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397804,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30 +25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. Received on four pressors with MAPS ~60. C.O. \n with SVV\n Action:\n On IV Vanco. Pan cx\nd this shift. Started on Flagyl, Zosyn, Micafungin\n this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 397830,
"text": "TITLE:\n Clinician: Resident\n Patient had progressively worsening shock, on four pressors, with\n severe ARDS requiring high PEEPs and profound lactic acidosis.\n Progressively became more hypotensive, spoke with family (sons)\n multiple times during day. They arrived here at 5 p.m. and she expired\n at 5:30 p.m. in the presence of nursing staff, myself, and a social\n worker. They were aware of the severity of their mother\ns illness and\n we provided support afterward. They also requested an autopsy.\n Total time spent: 15 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 397831,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 61.2 None\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Bronchial\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (1600)\n Comments:\n Pt expired plan for autopsy.\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 397833,
"text": "Chief Complaint: Acute respiratory failure\n HPI:\n See H&P for full details, in brief a 49F w/EtOH cirrhosis now\n w/respiratory failure and hypotension.\n 24 Hour Events:\n Remains intubated, mechanically ventilated.\n Oxygenation requirement remains high, requiring increased PEEP.\n Remains on multiple vaospressors to maintain adequate MAP.\n Worsening lactic acidosis.\n Rapid influenza negative\n Allergies:\n Librium - Confusion/Delir\n Erythromycin - Hives;\n Vasotec - hypertension;\n Last dose of Antibiotics:\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Levophed\n Propofol\n Cisatricurium\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Other medications:\n Lactulose, Rifaximin, Hydrocortisone\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,580 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,980 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,040 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: Overweight / Obese, intubated, sedated\n Eyes / Conjunctiva: PERRL, icteric sclera\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, MMM\n Cardiovascular: RR, tachy, S1, S2, no RMG\n Extremities/Peripheral Vascular: Warm, palpable radial and DP pulses\n bilat\n Respiratory / Chest: Bronchial at bases bilat\n Abdominal: Soft, Distended, decreased BS\n Skin: NJaundice\n Neurologic: Sedated, paralysed, train of four\n \n Labs / Radiology\n 8.5 g/dL\n 147 K/uL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Cultures\n Blood, urine and sputum NGTD\n Assessment and Plan\n Gravely ill, with persistent respiratory failure, persistent severe\n hypotension, progressive academia and metabolic acidosis.\n RESPIRATORY FAILURE, ACUTE\n Meets ARDS criteria. Etiology of\n infiltrates unclear, differential ARDS/PNA, DAH, cardiogenic edema.\n - Switch back to AC, 4-6cc/kg of IBW TV, will aim to keep PIPs~45\n pending new esophageal balloon numbers\n - Inhalers standing to minimize resistance\n - Consider bronchoscopy to r/o DAH, although tenuous respiratory status\n at this time.\n HYPOTENSION/SHOCK\n Per vigileo, minimal SVV, cardiac output ~,\n unclear if this is sufficient as improved with dopa. Lactate is\n worsening, as is LDH, will re-evaluate for intra-abdominal process.\n Had been favoring a septic/distributive process, although cannot\n exclude a cardiac component. Sepsis sources include SBP, bowel\n ischemia, urinary source, line-related infection, C. diff.\n - On Neo, vasopressin, levophed, dopa\n - Follow-up cultures, on broad spectrum abx\n - Consider Swan-Ganz placement\n - TTE, cycle biomarkers\n - Increase thiamine dose\n - RUQ US w/dopplers\n - Cdiff\n ACIDOSIS\n progressive, lactic acidosis. Concern for evolving sepsis,\n although at risk for bowel ischemia. Doubt thiamine deficiency (as\n received iv thiamine dose). Monitor ABG, lactic acid. HCO3 drip as\n needed to maintain pH >7.20.\n CIRRHOSIS OF LIVER, ALCOHOLIC\n Stable Tbili, INR up somewhat\n - On rifaxamin, lactulose\n - Appreciate hepatology input\n - Will need FFP prior to procedures\n RENAL FAILURE\n Decreased UOP since midnight, with elevated Cr. Poor\n dialysis candidate at this time.\n - Follow UOP with volume challenge\n ICU Care\n Nutrition: NPO\n Glycemic Control: Insulin Sc\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT: P-boots\n Stress ulcer: PPI\n VAP: Chlorhexidine, HOB to 30 degrees\n Comments:\n Communication: Attempting to contact family to update on her condition\n Code status: Full code\n Disposition : ICU\n Total time spent: 45 minutes\n"
},
{
"category": "General",
"chartdate": "2114-12-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 397827,
"text": "Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent at start of shift, vent changed to PCV\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\n mg/kg/hr, titrated per train of four for twitches. Temp max 102.1\n po, pan cx\nd this shift. Lactate on the rise throughout shift, multiple\n doses of sodium bicarb given and started on D5W with 3 amps bicarb @\n 150 cc/hr. BP labile throughout the shift with ^ing pressor\n requirements. Albumin given as ordered. Please see metavision for\n multiple abg\ns/vent changes.\n"
},
{
"category": "General",
"chartdate": "2114-12-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 397828,
"text": "Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent at start of shift, vent changed to PCV\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\n mg/kg/hr, titrated per train of four. Temp max 102.1 po, pan cx\nd this\n shift. Lactate on the rise throughout shift, multiple doses of sodium\n bicarb given and started on D5W with 3 amps bicarb @ 150 cc/hr. BP\n labile throughout the shift with ^ing pressor requirements. Albumin\n given as ordered. Please see metavision for multiple abg\ns/vent\n changes. Family in to visit in afternoon, emotional support proviced.\n S/W consulted. Pt became drop in HR,drop in BP with family at bedside.\n Dr. spoke with family and CPRNI.Pastor notified and in to pray\n with family at bedside. Fammily has requested an autopsy. Necklaace\n"
},
{
"category": "General",
"chartdate": "2114-12-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 397829,
"text": "Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent at start of shift, vent changed to PCV\n briefly received Cisastracurium 10 mg IVP and started on gtt @ 0.06\n mg/kg/hr, titrated per train of four. Temp max 102.1 po, pan cx\nd this\n shift. Lactate on the rise and more acidotic throughout shift, multiple\n doses of sodium bicarb given and started on D5W with 3 amps bicarb @\n 150 cc/hr. BP labile throughout the shift with Neo, Levo, &Vasopressin\n maxed, Dopa titrated to 10mcg/kg/min. Albumin given as ordered. Please\n see metavision for multiple abg\ns/vent changes. Sonsx2/girlfriendsx2 in\n to visit in afternoon, emotional support proviced. S/W consulted. Pt\n became hypotensive and bradycardic with family at bedside. Dr. \n spoke with family with plan for no further escalation of care.Pastor\n consulted->to bedside to pray with family. Family has requested an\n autopsy. Necklace with charm and watch sent home with son.\n"
},
{
"category": "General",
"chartdate": "2114-12-29 00:00:00.000",
"description": "ICU Event Note",
"row_id": 397836,
"text": "Clinician: Nurse\n 49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Pt dysynchronous with vent, started on parlytics this shift. Temp max\n 102.1, pan cx\nd this shift. Pt with worsening shock, severe ARDS\n requiring PEEP of 25 and profound lactic acidosis. Multiple doses of\n sodium bicarb given and started on D5W with 3 amps bicarb @ 150 cc/hr.\n Please see metavision for multiple abg\ns/vent changes. BP labile\n throughout the shift->Neo, Levo, & Vasopressin maxed, Dopa titrated to\n 10mcg/kg/min. Albumin given as ordered. Abx given as ordered.\n Sonsx2/girlfriendsx2 in to visit in afternoon, updated on status and\n plan of care, emotional support proviced. S/W consulted, at bedside. Pt\n became hypotensive and bradycardic with family at bedside. Dr. \n spoke with family, no further escalation of care, pronounced @ 1730.\n Pastor consulted->to bedside to pray with family. Family has requested\n an autopsy. Necklace with charm and watch sent home with family.\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397807,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Started on lacrilube paralytic.Multiple ABG\ns sent. Fentanyl and\n propofol gtts titrated. Desaturated to 84 after being placed on L side\n for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397808,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Started on lacrilube paralytic.Multiple ABG\ns sent. Fentanyl and\n propofol gtts titrated. Desaturated to 84 after being placed on L side\n for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. A-line dampened, tolerating MAPS >60 per\n NIBP (Dr. aware). C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397809,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Started on lacrilube paralytic.Multiple ABG\ns sent. Fentanyl and\n propofol gtts titrated. Desaturated to 84 after being placed on L side\n for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6 with am labs_. Now\n 12.2-13.7(on the rise). Received on four pressors with MAPS ~60. A-line\n dampened, tolerating MAPS >60 per NIBP (Dr. aware). C.O. \n with SVV\n Action:\n 50 gm Albumin given. NS 1L bolus given. Received total of 150 mEq Na\n bicarb IVP and started on D5W with 3 amps bicarb @ 150 cc/hr. On IV\n Vanco. Pan cx\nd this shift. Started on Flagyl, Zosyn, Micafungin this\n shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397805,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Multiple ABG\ns sent. Fentanyl and propofol gtts titrated. Desaturated\n to 84 after being placed on L side for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397806,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi throughout. Sxn for sm amts thick green secretions via\n ett. Accepted on A/C 85x400x30+25. Fentanyl gtt @ 150 mcg/hr and\n Propofol @ 70 mcg/kg/min. Dysnschronous with vent with RR in the 40\n Action:\n Vent changed to PCV, Nimbex 10 mg bolus given then started on gtt @\n 0.06 mcg/kg/min. Once paralyzed vent changed to A/C 85x400x36+25.\n Multiple ABG\ns sent. Fentanyl and propofol gtts titrated. Desaturated\n to 84 after being placed on L side for Abd U/S.\n Response:\n Plan:\n Shock, other\n Assessment:\n Temp max 102.1 po. WBC= 192. Lactate 9.6-\n(on the rise). Received on\n four pressors with MAPS ~60. C.O. with SVV\n Action:\n 50 gm Albumin given. On IV Vanco. Pan cx\nd this shift. Started on\n Flagyl, Zosyn, Micafungin this shift.\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n TF\ns off ^ residuals. Abd soft and distended, hypo BS noted.\n Flexiseal draining loose golden colored stool. ~500\ns residuals noted.\n Action:\n Held all po meds ^ residuals.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397577,
"text": "Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale\n # Anemia:\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia:\n -improved\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: NPO for now until MS clears\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397776,
"text": "TITLE:\n Chief Complaint: 49 yoF w/ a h/o hep C and ETOH related cirrhosis\n presents from hospital with acute hepatic failure.\n 24 Hour Events:\n BLOOD CULTURED - At 09:18 AM\n blood cultures drawn from femoral CVL\n SPUTUM CULTURE - At 10:00 AM\n BLOOD CULTURED - At 10:00 AM\n blood cultures drawn from PICC\n URINE CULTURE - At 10:20 AM\n ESOPHOGEAL BALLOON - At 02:30 PM\n -patient hypotensive requiring max dose levophed and vasopressin, as\n well as intermittent neosynephrine\n -hydrocortisone 50mg IV q6hrs started (serving dual purpose for alcohol\n hepatitis and as stress dose steroids)\n -given hypotension patient pan-cultured and started on broad spectrum\n antibiotics\n -respiratory viral screen negative\n -50g albumin given\n -CVO2 75%\n -Rifaximin started\n -lactulose uptitrated - pt had 1 BM, started dulcolax and senna\n -Esophageal balloon placed, PEEP uptitrated to 22\n -hct relatively stable\n -insulin drip initiated\n -Vigileo initiated, Stroke volume variation 13- 1L fluid challenege, no\n change in BP, over course of night SVV increased to 19. Gave 1L IVF\n and 25g of albumin in 500cc.\n -attempted calling son x 2 overnight given worsening clinical status\n -Additional 500cc bolus NS given and 50g IV albumin ordered\n -ABG 7.14 / 39 / 140 on AC 400 x 30- breathing at a rate of 35 and w/\n tidal volumes of 500. RR increased to 36, and pt breathing at 40 after\n this. PaO2 140, PEEP 25, FiO2 100%. 2 amps of bicarb given.\n -patient dysynchronous w/ the ventilator despite 70 of propofol and\n 150mcg of fentanyl. Unresponsive. Peak pressures increasing to low\n 40s (previously mid / low 30s) and unable to control PCO2 / normalize\n pH- decision made to paralyze.\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Cisatracurium - 07:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,588 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,988 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,051 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 147 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Shock: at this point seems to be related to possible infectious\n cause, end stage liver disease, propofol. Would also consider adverse\n reaction to FFP or IV vitamin K. On levo, vaso.\n - MAP goal > 55\n - empiric vanc/zosyn/cipro\n - stress dose steroids\n - follow UOP, pulse pressure variation to assess intravascular volume\n - check ECHO\n - check TSH/FT4\n - wean propofol\n - check lytes, hct, ABG, lactate q6h\n # Respiratory failure/ARDS: Worsening hypoxia on and intubated\n in setting of receiving volume and severe liver disease. Differential\n includes volume overload versus infection versus pulm hemorrhage vs\n TROLI in setting of transfusion though unlikely. Would also consider\n PCP given IVDU history.\n - ARDSnet protocol with low tidal volumes\n - PaO2 > 60, SaO2 > 90\n - empiric antibx\n - r/o flu\n - may consider bronch\n - hold on diuresis for now but will consider pending creatinine trend,\n UOP\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis. New hallucinations this morning.\n - restarted steroids with undetectable HCV viral load\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG , + 1:20\n -HCV VL < 43\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose and rifaxamin\n -will obtain OSH previous EGD / if any\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n - follow UOP and trend creatinine\n - renally dose meds\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\n and hct stable.\n -guaiac stools\n -active type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n # ETOH abuse: No evidence of withdrawal\n - thiamine, folate, MVI daily\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397780,
"text": "TITLE:\n Chief Complaint: 49 yoF w/ a h/o hep C and ETOH related cirrhosis\n presents from hospital with acute hepatic failure.\n 24 Hour Events:\n BLOOD CULTURED - At 09:18 AM\n blood cultures drawn from femoral CVL\n SPUTUM CULTURE - At 10:00 AM\n BLOOD CULTURED - At 10:00 AM\n blood cultures drawn from PICC\n URINE CULTURE - At 10:20 AM\n ESOPHOGEAL BALLOON - At 02:30 PM\n -patient hypotensive requiring max dose levophed and vasopressin, as\n well as intermittent neosynephrine\n -hydrocortisone 50mg IV q6hrs started (serving dual purpose for alcohol\n hepatitis and as stress dose steroids)\n -given hypotension patient pan-cultured and started on broad spectrum\n antibiotics\n -respiratory viral screen negative\n -50g albumin given\n -CVO2 75%\n -Rifaximin started\n -lactulose uptitrated - pt had 1 BM, started dulcolax and senna\n -Esophageal balloon placed, PEEP uptitrated to 22\n -hct relatively stable\n -insulin drip initiated\n -Vigileo initiated, Stroke volume variation 13- 1L fluid challenege, no\n change in BP, over course of night SVV increased to 19. Gave 1L IVF\n and 25g of albumin in 500cc.\n -attempted calling son x 2 overnight given worsening clinical status\n -Additional 500cc bolus NS given and 50g IV albumin ordered\n -ABG 7.14 / 39 / 140 on AC 400 x 30- breathing at a rate of 35 and w/\n tidal volumes of 500. RR increased to 36, and pt breathing at 40 after\n this. PaO2 140, PEEP 25, FiO2 100%. 2 amps of bicarb given.\n -patient dysynchronous w/ the ventilator despite 70 of propofol and\n 150mcg of fentanyl. Unresponsive. Peak pressures increasing to low\n 40s (previously mid / low 30s) and unable to control PCO2 / normalize\n pH- decision made to paralyze.\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Levofloxacin - 10:00 AM\n Piperacillin/Tazobactam (Zosyn) - 10:15 AM\n Cefipime - 01:15 PM\n Vancomycin - 10:53 PM\n Infusions:\n Vasopressin - 2.4 units/hour\n Fentanyl (Concentrate) - 150 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Phenylephrine - 4 mcg/Kg/min\n Cisatracurium - 0.1 mg/Kg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Sodium Bicarbonate 8.4% (Amp) - 05:47 AM\n Cisatracurium - 07:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.7\nC (99.8\n HR: 122 (85 - 126) bpm\n BP: 90/54(68) {86/45(57) - 105/64(79)} mmHg\n RR: 48 (20 - 48) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 67 Inch\n Bladder pressure: 15 (14 - 16) mmHg\n Mixed Venous O2% Sat: 75 - 75\n Total In:\n 4,777 mL\n 3,588 mL\n PO:\n TF:\n IVF:\n 4,117 mL\n 2,988 mL\n Blood products:\n 200 mL\n 500 mL\n Total out:\n 1,058 mL\n 540 mL\n Urine:\n 818 mL\n 20 mL\n NG:\n 240 mL\n 120 mL\n Stool:\n 400 mL\n Drains:\n Balance:\n 3,719 mL\n 3,051 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PCV+\n Vt (Set): 420 (400 - 420) mL\n Vt (Spontaneous): 350 (330 - 350) mL\n PS : 10 cmH2O\n RR (Set): 36\n RR (Spontaneous): 7\n PEEP: 25 cmH2O\n FiO2: 85%\n RSBI Deferred: PEEP > 10\n PIP: 43 cmH2O\n Plateau: 40 cmH2O\n SpO2: 96%\n ABG: 7.18/42/153/15/-12\n Ve: 12.4 L/min\n PaO2 / FiO2: 180\n Physical Examination\n GEN: intubated sedated., unresponsive\n HEENT: PERRL, minimally reactive\n CARD: RRR, HSM at the LLSB\n PULM: CTAB ant\n ABD: soft, obese, NT\n EXT: WWP, no c/c/e\n NEURO: sedated, unresponsive, paralyzed, pupils minimally reactive to\n light. Train of 4: .\n Labs / Radiology\n 147 K/uL\n 8.5 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 8 mg/dL\n 100 mEq/L\n 135 mEq/L\n 26.1 %\n 19.2 K/uL\n [image002.jpg]\n 11:15 AM\n 01:26 PM\n 03:18 PM\n 05:33 PM\n 05:41 PM\n 01:50 AM\n 03:57 AM\n 04:07 AM\n 05:30 AM\n 06:35 AM\n WBC\n 19.2\n Hct\n 25.6\n 26.1\n Plt\n 147\n Cr\n 0.9\n TCO2\n 21\n 21\n 21\n 23\n 19\n 17\n 14\n 16\n Glucose\n 102\n Other labs: PT / PTT / INR:33.9/66.9/3.4, ALT / AST:22/78, Alk Phos / T\n Bili:55/30.9, Amylase / Lipase:14/9, Differential-Neuts:85.0 %,\n Band:3.0 %, Lymph:5.0 %, Mono:7.0 %, Eos:0.0 %, D-dimer:2144 ng/mL,\n Fibrinogen:127 mg/dL, Lactic Acid:9.6 mmol/L, Albumin:2.8 g/dL, LDH:395\n IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Shock: sepsis versus hepatic failure.\n - MAP goal > 55\n - empiric vanc/zosyn/cipro\n - stress dose steroids\n - follow UOP, pulse pressure variation to assess intravascular volume\n - possible swan ganz catheter plcmt today to further evaluate\n hemodynamics, especially given good BP and Cardiac index response to\n dopamine\n - check ECHO\n - wean fentanyl\n - q6hrs lactate\n -send c diff\n # Respiratory failure/ARDS: intubated related to ARDS.\n -ECHO\n -possible swan plcmt\n -ARDSnet ventilation\n -attempt to wean FiO2\n .\n # Acute hepatic failure:\n -f/u liver recs\n -steroids\n -AFP normal\n -lactulose and rifaximin\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, hepatorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n - follow UOP and trend creatinine\n - renally dose meds\n # Anemia: bleeding likely into intraperitoneal space. Guaiac negative\n and hct stable.\n -guaiac stools\n -active type and screen\n -transfuse for hct < 21 or active bleeding, transfuse w/ Lasix when\n necessary\n -p.m. hct\n # ETOH abuse: No evidence of withdrawal\n - thiamine, folate, MVI daily\n # DM: Insulin sliding scale.\n # FEN: when GI output decreasing can start tube feeds.\n # PPX: PPI, INR elevated- hct stable so will restart sc heparin\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 02:32 AM\n PICC Line - 12:40 PM\n Arterial Line - 06:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397800,
"text": "49 yo woman with history of hepatitis C complicated by cirrhosis,\n active alcohol abuse with history of alcohol withdrawal seizures,\n chronic pancreatitis transferred from Hospital with\n hepatic failure and hypotension.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2114-12-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 397748,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 61.2\n Ideal tidal volume: 244.8 / 367.2 / 489.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 19 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff pressure: 30 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Green / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C 400x30/+25/1.0\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\n efforts, High flow demand\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: appears dysynchronous\n Comments: Pt overbreathing vent with high flow demand, rate increased\n in an effort to match; desat necessitating increased Fi02/peep up to\n 25; unable to tol recruitment d/t dysynchrony\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: Unable to measure esophageal pressures d/t\n dysynchrony; RSBI held d/t peep/Fi02\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 397448,
"text": "Chief Complaint: transfer from for liver failure\n HPI:\n 49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \n hospital after presenting with worsening jaundice and fatigue. She was\n noted there to be hypotensive to the low 80s systolic, noted to have an\n elevated bili and INR- she was given 4 Liters IVF and transferred to\n the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\n was given 4 L IVF in hospital, 3 L in the ER at .\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\n sat: 94% on 5L O2 NC.\n Currently the patient complains of generalized abdominal pain, moreso\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\n her abdominal pain beginning.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.16 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Other medications:\n (patient unsure of medications, none on list from hospital)\n patient states she takes insulin.\n Past medical history:\n Family history:\n Social History:\n 1. Hepatitis C.\n 2. Alcoholic hepatitis.\n 3. History of alcohol abuse with withdraw seizures and DTs in the\n past.\n 4. History of hypertension.\n 5. History of chronic pancreatitis.\n 6. Status post cesarean section and ectopic pregnancies in the past.\n 7. History of traumatic wrist laceration in the past status post\n surgical repair with blood transfusions in .\n 8. S/P ccy, s/p oophorectomy\n 9. DM II\n non contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: 6 tabs of tylenol 3 days ago, 1 pint of hard liquor on \n however the patient's history is relatively unreliable given\n encephalopathy. She lives w/ friends, smokes and is a current\n abuser of ETOH (daily)- unable to quantify. H/o opiate abuse but no\n opiates x 1 year.\n Review of systems:\n Flowsheet Data as of 03:54 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 94 (94 - 95) bpm\n BP: 115/74(84) {115/74(84) - 115/74(84)} mmHg\n RR: 22 (12 - 22) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Total In:\n 6,172 mL\n PO:\n TF:\n IVF:\n 172 mL\n Blood products:\n Total out:\n 0 mL\n 90 mL\n Urine:\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,082 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n Vitals - T: BP: HR: RR: 02 sat:\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: serum tylenol negative\n serum etoh negative\n serum opiates negative\n serum benzos +\n Imaging: RUQ ultrasound: (prelim) Very echogenic liver, limited\n assessment of gallbladder and portal vein. Ascites, predominantly in\n the RUQ, but not a good window to mark. Consider ultrasound guided\n paracentesis.\n CXR: (my read) hilar fullness w/ mild pulm vascular engorgement,\n infiltrates in the RML and RUL.\n CT abd / pelvis w/ contrast: . (prelim)\n liver w/ heterogeneous attenuation, shrunken nodular appearance.\n Several areas of hypodensities in segement 2 of the liver could\n represent perfusion defects, dilated bile ducts or could be related to\n underlying mass effect. Anasarca. No evidence of portal vein\n thrombosis. Bibasilar atelectasis.\n Microbiology: BCx x 2 P\n Peritoneal fluid cx P\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis given history and transaminase pattern.\n -paracentesis negative for sbp\n -liver consult\n -liver ultrasound with doppler was a difficult study,\n -discriminate function is 172. Will start steroids x 1 week then\n taper.\n -will give vitamin K to correct any portion of elevated INR that may be\n nutritional\n -thiamine, folate, MVI daily\n -lactulose- titrate to 3 BMs daily\n -send AFP given risk of HCC and finding on CT abd\n -Send Uhcg\n # Hypotension: no clear cause for hypotension with the exception of\n worsening liver function and possible infectious etiologies including\n pneumonia and possible urinary tract infection.\n -continue levofloxacin / ceftriaxone.\n -keep MAP > 55\n -has rec'd 7 liters IVF and likely fluid replete, appears euvolemic on\n exam\n # Hyponatremia: possibly related to volume overload / liver disease.\n -urine lytes\n # Hypoxia: appears to have R sided opacities which may be pneumonia.\n She has rec'd ceftriaxone. Will add levofloxacin in addition to CTX\n for severe CAP.\n -abx\n -f/u blood cultures\n -sputum culture\n -IS for atelectasis\n # ETOH abuse: h/o w/d seizures in the past.\n -CIWA scale w/ valium.\n # DM: Insulin sliding scale.\n # FEN: NPO for now until MS clears\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT:\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397449,
"text": "49 yoF w/ a h/o ETOH and hep C cirrhosis presents from \n hospital after presenting with worsening jaundice and fatigue. She was\n noted there to be hypotensive to the low 80s systolic, noted to have an\n elevated bili and INR- she was given 4 Liters IVF and transferred to\n the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n In the ER she rec'd morphine 2mg IV x 4 doses for pain and ceftriaxone\n 1g IV x 1. A right femoral line was placed. On levophed on 0.15. She\n was given 4 L IVF in hospital, 3 L in the ER at .\n Prior to transport from the ER she was afebrile, HR 93 BP 108/71 O2\n sat: 94% on 5L O2 NC.\n Currently the patient complains of generalized abdominal pain, moreso\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days prior to 1 pint of vodka the night prior to\n her abdominal pain beginning.\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397445,
"text": "Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Hepatic encephalopathy\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397450,
"text": "49 yo F w/ h/o ETOH and Hep C cirrhosis who presents from \n Hospital after worsening abd pain, jaundice and fatigue. She was noted\n there to be hypotensive w/ SBP to the 80\ns, w/ an elevated bili and\n INR. She was given 4L IVF and transferred to the ER.\n In the ED, initial VS: T 97.2 HR 94 BP 81/53 RR 16 O2 sat: 99%.\n She rec'd morphine 2mg IV x 4 doses for pain and Ceftriaxone 1g IV x 1\n (for concern of SBP) A right femoral line was placed. Pt placed on\n Levophed & given 3L IVF.\n Currently the patient complains of generalized abdominal pain, more so\n of the lower abdomen. No SOB, no Chest pain. She denies any other\n symptoms. She has given conflicting reports regarding ETOH intake,\n ranging from 6 beers 4 days ago to 1 pint of vodka the night prior to\n her abdominal pain beginning. Pt is a poor historian overall.\n Cirrhosis of liver, alcoholic\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2114-12-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 397517,
"text": "Chief Complaint: 49 yo woman with history of hepatitis C complicated by\n cirrhosis, active alcohol abuse with history of alcohol withdrawal\n seizures, chronic pancreatitis transferred from Hospital\n with hepatic failure and hypotension\n Hypotension (not Shock)\n Assessment:\n Continues on levo gtt to keep MAP > 55, low uo < 30 cc/hr, hr nsr\n 80\ns-90\n Action:\n Levo gtt weaned down to 0.03 mic/kg/min but not able to keep map> 55 on\n that dose so gtt titrated back up, 5% albumim 500 cc\n x 2 today, labs\n sent as ordered\n Response:\n Not able to wean levo off, minimal improvement in uo & bp after albumin\n Plan:\n Levo gtt as ordered to keep MAP > 55, ? a-line insertion this PM,\n frequent labs as ordered\n Cirrhosis of liver, alcoholic\n Assessment:\n Pt jaundiced, abdomen soft, c/o mild nausea, c/o # abdominal pain,\n oriented x , calm & cooperative, minimal uo, on levo gtt to maintain\n map > 55\n Action:\n Frequent labs sent as ordered, po lactulose as ordered, liver consult\n placed, chest ct today, bladder pressure done, iv morphine given x 2 &\n po oxycodone x 1, npo except ice chips, iv albumin given\n Response:\n Bladder pressure 17, no stool, abdominal pain down to #1-2 after\n narcotics, not able to wean levo off, minimal response from iv albumin\n Plan:\n Continue to monitor for sepsis/pancreatitis/GI bleeding, po lactulose\n as ordered, wean levo as able, iv protonix/iv antibiotics as ordered,\n pain controll\n"
},
{
"category": "Physician ",
"chartdate": "2114-12-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 397582,
"text": "Chief Complaint:\n 24 Hour Events:\n - MELD 27\n - Liver consult: stop prednisone, albumin challenge, NGT with TFs,\n check AFP, GGT, IGG, , hep C viral load\n - CT chest: volume overload, intraperitoneal hemorrhage likely from\n paracentesis\n - Bladder pressure 17\n - levophed weaned\n - had hct drop 35 -> 27.8 -> 26.5. Got 5mg vit K.\n - Son takes care of for the past 6 months or so\n given worsening mental status. He noticed that she was drinking 1\n liter of vodka per day. He forced her to stop and then after that she\n was drinking 3-4 beers per day. She had a male friend that would\n provide her with klonopin 2mg pills (5 pills at a time). She was only\n drinking beer and taking klonopin but not eating any other food or\n leaving her bed. The son then left for two days after getting into a\n fight with his mother's male friend for one day and then his mother's\n friend stated that she was becoming more jaundice and was brought to\n the hospital.\n -per son the only medication is metformin\n -per son she is currently full code but will come in for a meeting w/\n the medical team tomorrow . He also requests if she improves that\n she has a prolonged 3 month inpt stay somewhere to prevent her from\n drinking ETOH.\n -SW consult ordered- son would like to talk to SW when he comes in\n tomorrow.\n - friend is \"\" and we should not provide him w/ any medical\n information. If comes to see him we should have security search\n him for substances prior to his visit.\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Librium (Oral) (Chlordiazepoxide Hcl)\n Confusion/Delir\n Erythromycin Base\n Hives;\n Vasotec (Oral) (Enalapril Maleate)\n hypertension;\n Last dose of Antibiotics:\n Ceftriaxone - 12:05 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 93 (90 - 101) bpm\n BP: 97/58(68) {82/15(40) - 112/76(85)} mmHg\n RR: 21 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 67 Inch\n Bladder pressure: 17 (17 - 17) mmHg\n Total In:\n 8,915 mL\n 165 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,715 mL\n 165 mL\n Blood products:\n 1,000 mL\n Total out:\n 439 mL\n 330 mL\n Urine:\n 409 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8,476 mL\n -165 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n GENERAL: NAD, AOx2\n HEENT: MM slightly dry, JVP 9cm\n CARDIAC: RRR, SEM at the USB\n LUNG: ronchi of R lower and middle lung fields\n ABDOMEN: soft, obese, NT, ND, no masses, ascites\n EXT: WWP, no c/c/e\n NEURO: asterixis, mild confusion and somnolence\n DERM: jaundice, icterus\n Labs / Radiology\n 127 K/uL\n 8.7 g/dL\n 182 mg/dL\n 1.0 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 101 mEq/L\n 134 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 06:01 AM\n 05:20 PM\n 10:08 PM\n 02:21 AM\n 04:15 AM\n WBC\n 17.7\n 10.6\n Hct\n 35.2\n 27.8\n 26.5\n 28.0\n 26.3\n Plt\n 238\n 127\n Cr\n 0.9\n 1.0\n 1.0\n Glucose\n 176\n 182\n Other labs: PT / PTT / INR:28.0/51.1/2.7, ALT / AST:34/83, Alk Phos / T\n Bili:82/27.5, Amylase / Lipase:14/26, Lactic Acid:2.6 mmol/L,\n Albumin:2.6 g/dL, LDH:231 IU/L, Ca++:7.8 mg/dL, Mg++:2.6 mg/dL, PO4:3.2\n mg/dL\n Blood culture x 2 Pending\n Peritoneal fluid pending (GS negative)\n HCV viral load pending\n Assessment and Plan\n 49 yoF w/ a h/o hep C and ETOH related cirrhosis presents from \n hospital with acute hepatic failure.\n # Acute hepatic failure: the patient has a history of cirrhosis (ETOH\n and hep C) and has had an acute decompensation. Likely related to\n alcoholic hepatitis.\n -per liver consult have sent hep C viral load and have stopped steroids\n -paracentesis negative for SBP\n -AFP normal, GGT 83, IgG, P\n -trend LFTs- bili and INR increasing\n -d/w family (Son today at 1 p.m. w/ social work\n -lactulose- titrate to 3 BMs daily, no BMs- will start lactulose enema\n and give 10mg PO dulcolax- if MS does not improve despite BMs w/\n lactulose will start rifaximin\n -will obtain OSH previous EGD / if any\n # ETOH abuse: thiamine, folate, MVI daily\n -CIWA scale\n # Anemia: bleeding likely into intraperitoneal space. Guaiac\n negative.\n -guaiac stools\n -type and screen.\n -transfuse for hct < 25, transfuse w/ Lasix when necessary\n -p.m. hct\n -if hct < 25 give FFP for elevated PTT and INR\n # Hypotension: at this point seems to be related to possible infectious\n cause but more likely to significant end stage liver disease. Off\n pressors since 3:30 a.m. .\n -MAP goal > 55\n -were treating pneumonia mainly on the basis of radiographic findings,\n but given new CT findings w/o any infiltrate and only volume overload\n can stop antibiotics at this point. WBC normal, patient is afebrile\n and without cough.\n # ARF: FeNa < 1%. Cr has stabilized, ddx includes pre-renal azotemia\n that has now started to improve, heptorenal (although Cr not above 1.5\n and pt does have other reason to have renal failure such as shock, also\n has seemed to respond to albumin challenge). Contrast nepropathy\n (although worsening renal function occurred too early for this) or ATN\n as pts w/ hepatic disease can have FeNa < 1%. At this point will avoid\n further volume depletion, monitor urine output.\n -given additional 50g of albumin this a.m.\n -avoid volume depletion\n -d/w hepatology any further treatment such as octreotide/midodrine, at\n this point may not be useful given stabilization of cr\n # Hyponatremia:\n -improved\n # Hypoxia: 92% on 4L NC, likely related to volume overload. At this\n point will tolerate hypoxia related to volume overload, will be able to\n diurese when creatinine has fully stabilized. When diuresing will\n likely need to use albumin to help avoid further renal hypoperfusion.\n -IS for atelectasis\n # DM: Insulin sliding scale.\n # FEN: calorie counts, allow pt to have regular diet, nutrition consult\n as pt likely will need dobhoff for feeding\n # PPX: PPI, INR elevated, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: (son) (this\n is younger brother, if patient dies do not call the younger\n brother, would like to be notified first so he can tell his\n younger brother).\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:00 AM\n Multi Lumen - 02:32 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1114503,
"text": " 11:23 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Plesea read for right basilic PICC, 46cm. Thanks! #\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with need for PICC line for access.\n REASON FOR THIS EXAMINATION:\n Plesea read for right basilic PICC, 46cm. Thanks! #\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: Radiograph .\n\n INDICATION: PICC placement.\n\n FINDINGS: Right PICC is malpositioned, coursing cephalad in the right\n internal jugular vein with tip outside of the field of view. This finding was\n communicated by phone with the IV nurse, .\n\n Cardiac silhouette is mildly enlarged and there is persistent widening of the\n right mediastinal contour, corresponding to prominent mediastinal fat and\n vascular distention on the recent CT of one day earlier.\n\n Interstitial edema has worsened in the interval, and there are also increasing\n scattered patchy opacities in the right mid and lower lung. These are\n nonspecific but could potentially represent an early developing\n bronchopneumonia in the appropriate clinical setting. Opacities in the left\n base have improved and a small left effusion has decreased in size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-26 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1114296,
"text": " 10:33 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for pna\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with liver failure, ?pna.\n REASON FOR THIS EXAMINATION:\n assess for pna\n CONTRAINDICATIONS for IV CONTRAST:\n arf\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST WITHOUT CONTRAST, \n\n INDICATION: Liver failure, and concern for pneumonia.\n\n COMPARISON: Abdominal CT, , 00:27 hours.\n\n TECHNIQUE: Volumetric CT of the chest was performed without contrast per\n departmental protocol, including multiplanar reformatted images.\n\n CT CHEST: Heart size is upper limits of normal. There are three-vessel\n coronary artery calcifications. There is no pericardial effusion. Thoracic\n aorta is normal in caliber and contour throughout. There are mild\n atherosclerotic calcifications in the arch and descending thoracic aorta.\n\n Central airways are patent to the subsegmental level. There are scattered\n mediastinal small lymph nodes, none meeting specific CT criteria for\n pathologic enlargement. Thyroid gland is normal.\n\n Evaluation of the lung parenchyma shows no focal airspace consolidation.\n However, there is mild diffuse thickening of the interlobular septa, and\n irregular areas of linear airspace opacity in the bilateral lower lobes.\n There are small bilateral pleural effusions, and mild dependent bibasilar\n atelectasis. Note is also made of mild biapical pleural/parenchymal scarring.\n\n This study is not specifically tailored for subdiaphragmatic evaluation.\n Within the visualized upper abdomen, note is made of moderate ascites around\n the liver and spleen. However, in contrast to recent abdominal CT of less\n than 12 hours prior, the ascitic fluid is now high in density, worrisome for\n development of intraperitoneal hemorrhage. Diffusely hypodense liver, most\n consistent with fatty liver or changes related to clinically reported liver\n failure, is unchanged. Geographic areas of slightly different hepatic density\n probably reflect differing degrees of steatosis.\n\n Calcifications within the pancreas consistent with chronic pancreatitis, and\n cholecystectomy clips are unchanged.\n\n OSSEOUS STRUCTURES: There is no osseous lesion suspicious for malignancy.\n\n IMPRESSION:\n\n (Over)\n\n 10:33 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess for pna\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. No evidence of lobar/bacterial pneumonia. Findings most consistent with\n volume overload, probably with superimposed areas of linear and dependent\n atelectasis. A concurrent atypical pneumonia is difficult to exclude.\n\n 2. Slight increase in ascites, which is now hyperdense, most consistent with\n hemorrhage. Findings are very concerning for new intraperitoneal hemorrhage,\n particularly if there has been a recent procedure such as paracentesis.\n\n 3. Unchanged markedly hypodense liver, consistent with fatty liver,\n presumably related to reported clinical history of liver failure.\n\n Findings discussed via telephone with Dr. at 11:30 on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-27 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1114551,
"text": " 4:54 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: SOB\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with liver cirrhosis\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 49-year-old female patient with liver cirrhosis, shortness of\n breath. Followup examination.\n\n FINDINGS: AP single view of the chest obtained with patient in sitting\n semi-upright position is analyzed in direct comparison with the next preceding\n similar study obtained four hours earlier during the same day. No significant\n interval change can be identified. No pneumothorax has developed. The\n scattered bilateral patchy densities are still present and there is no\n evidence of gross pleural effusion as the lateral pleural sinuses remain free.\n\n IMPRESSION: No significant interval change during last four hours examination\n interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114713,
"text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 49-year-old woman with respiratory failure and tube placement.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The tip of the endotracheal tube is 8 cm above the carina, could be advanced 1\n to 2 cm for optimal placement. The ETT tube has been pulled back since the\n previous study. The nasogastric tube and side port are well below the\n gastroesophageal junction. There has been mild improvement of the airspace\n opacities since the previous study. However, they remain diffuse. There is a\n right-sided PICC line with the distal lead tip at the distal SVC.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114598,
"text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alcohol/hep c cirrhosis s/p intubation\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post intubation, cirrhosis, evaluate for change.\n\n CHEST:The bilateral densities are now somewhat more confluent than on the\n prior film of six hours ago and is noticeably worse than the prior film of ten\n hours before.\n\n The position of the various lines and tubes is satisfactory. A nasogastric\n tube has been placed and the tip lies within the stomach.\n\n IMPRESSION: Worsening lung densities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114578,
"text": " 10:09 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: intubated\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with intubated\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Liver cirrhosis, SOB.\n\n CHEST: An endotracheal tube has been placed with the tip at the thoracic\n inlet. There has been a subtle increase in the bilateral densities since\n prior scan of four hours previous.\n\n IMPRESSION: Endotracheal tube placed. Slight increase in density.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1114516,
"text": " 12:20 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: pic repositioned. check tip now\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with new picc\n REASON FOR THIS EXAMINATION:\n pic repositioned. check tip now\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST, \n\n INDICATION: New PICC.\n\n FINDINGS: Comparison is made to 11:42 hours. Since\n previous exam, right PICC has been repositioned, now with tip pointing\n inferiorly, at roughly the position of the superior cavoatrial junction. Lung\n volumes are extremely low, limiting evaluation of cardiomediastinal contours,\n which are probably unchanged. Interstitial pulmonary edema appears slightly\n worse.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114242,
"text": " 12:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with acute liver failure. Evaluate for acute\n process.\n\n COMPARISON: CT and chest radiograph of .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Evaluation is limited by low lung volumes.\n Within this limitation, there is right retrocardiac and peripheral mid-lung\n opacity that may represent atelectasis, but underlying infection is not\n excluded. There is no pneumothorax. The heart size is normal. Widened\n mediastinum is most likely a combination of tortuous aorta, low lung volumes\n and mild overload. Pulmonary vasculature is slightly engorged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-26 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1114244,
"text": " 12:27 AM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: eval for acute process, clot in portal system. Please do CT\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with abd pain, acute liver failure\n REASON FOR THIS EXAMINATION:\n eval for acute process, clot in portal system. Please do CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EAGg WED 1:53 AM\n Portal vein patent. Cirrhotic liver with moderate ascites. Atelectatis at b/l\n lung bases, underlying infection not excluded. Wedge deformity of an upper\n lumbar vertebra (??L2), new since , but uncertain chronicity.\n WET READ VERSION #1 EAGg WED 1:48 AM\n Portal vein patent. Cirrhotic liver with moderate ascites.\n WET READ VERSION #2 EAGg WED 1:51 AM\n Portal vein patent. Cirrhotic liver with moderate ascites. Wedge deformity of\n an upper lumbar vertebra (??L2), new since , but uncertain chronicity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with abdominal pain and acute liver failure.\n Evaluate portal vein.\n\n COMPARISON: CT abdomen and CT chest .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen after\n administration of 130 cc IV Optiray contrast. Coronal and sagittal reformats\n were displayed.\n\n CT ABDOMEN WITH IV CONTRAST: There is extensive bibasilar atelectasis in the\n lungs with trace pleural effusion bilaterally. Underlying infection is not\n excluded. Coronary artery calcifications are noted, but the heart is\n otherwise unremarkable.\n\n The liver demonstrates low and heterogeneous attenuation with shrunken nodular\n contour. Several areas of hypodensity are noted within segment II of the\n liver and may represent perfusion abnormality, focal hepatitis, or dilated\n bile ducts, but underlying mass lesion is not excluded in context of\n cirrhosis. There is enlargement of the caudate lobe with exaggerated\n hypoattenuation consistent with severe fatty infiltration, particularly at the\n inferior of the caudate. There is a 4-mm newly apparent round hypodensity in\n segment VII of the liver (2:27), which is incompletely evaluated but may\n represent a cyst. There is no extrahepatic biliary ductal dilatation.\n\n The main portal vein and major branches are patent without filling defect.\n Gastric and splenic varices are noted.\n\n There is moderate diffuse ascites and anasarca.\n\n The patient is status post cholecystectomy. The pancreas demonstrates diffuse\n calcification, as before, consistent with chronic pancreatitis. Splenomegaly\n (Over)\n\n 12:27 AM\n CT ABDOMEN W/CONTRAST Clip # \n Reason: eval for acute process, clot in portal system. Please do CT\n Field of view: 50 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is less apparent than on concurrent ultrasound, measuring up to 12 cm. The\n bilateral adrenal glands are unremarkable. The kidneys enhance and excrete\n contrast symmetrically, without evidence of hydronephrosis or hydroureter.\n There are small nonspecific portacaval and periaortic lymph nodes not meeting\n CT criteria for pathologic enlargement. No mesenteric lymphadenopathy meeting\n CT criteria for pathologic enlargement is noted. The stomach and\n intra-abdominal loops of bowel are unremarkable. There is an\n ascites-containing ventral abdominal wall hernia. There is no free air in the\n abdomen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is identified.\n There is a wedge deformity of the L2 vertebral body, likely chronic in nature\n but new since . There is atherosclerotic calcification of the abdominal\n aorta.\n\n IMPRESSION:\n\n 1. No evidence of portal vein thrombosis.\n\n 2. Cirrhotic liver with stigmata of liver disease. New segmental regions of\n hypodensity in segment II of the liver which may represent perfusion\n abnormality, focal hepatitis or dilated intrahepatic ducts, but underlying\n mass lesion is not excluded. Further assessment could be performed by MRI once\n the patient is able to cooperate with breathhold instructions.\n\n 3. Moderate ascites and anasarca.\n\n 4. Bibasilar atelectasis, underlying infection is not excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-25 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1114235,
"text": " 10:25 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for acute process/thrombus. Also please mark for parac\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with acute liver failure\n REASON FOR THIS EXAMINATION:\n eval for acute process/thrombus. Also please mark for paracentesis.\n ______________________________________________________________________________\n WET READ: EAGg TUE 11:42 PM\n Very echogenic liver, limited assessment of gallbladder and portal vein.\n Ascites, predominantly in the RUQ, but not a good window to mark. Consider\n ultrasound guided paracentesis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old female with acute liver failure. Evaluate for acute\n process or thrombus. Mark for paracentesis.\n\n COMPARISON: Ultrasound of and CT, .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely echogenic and\n shrunken. No focal hepatic lesion is identified on this limited exam. The\n gallbladder is not identified. The main portal vein could not be assessed.\n Visualized portion of the pancreas is unremarkable. The spleen appears mildly\n enlarged measuring approximately 13 cm. There is a small-to-moderate amount of\n ascites, predominantly in the right upper quadrant but there is no suitable\n site to mark for paracentesis.\n\n IMPRESSION:\n\n 1. Limited ultrasound of the right upper quadrant with diffusely echogenic\n liver. Slightly shrunken morphology suggests more advanced forms of liver\n disease such as fibrosis or cirrhosis.\n\n 2. Gallbladder and main portal vein not visualized.\n\n 3. Small-to-moderate amount of ascites, predominantly in the right upper\n quadrant but there is no suitable window to mark.\n\n 4. Splenomegaly.\n\n Findings were discussed with Dr. at 11:40 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-29 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1114758,
"text": " 11:21 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate for portal vein thrombosis or budd chiari w/\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alk hep now w/ worsening pressor requirement and rising\n lactate\n REASON FOR THIS EXAMINATION:\n please evaluate for portal vein thrombosis or budd chiari w/ doppler\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SAT 2:55 PM\n Non-diagnostic study due to technical limitations. Hepatic steatosis is\n _____.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rising lactate, evaluate for portal vein thrombosis or Budd-Chiari\n syndrome.\n\n COMPARISON: .\n\n FINDINGS: This is a non-diagnostic study. Due to the patient's body habitus\n and intubated state, diagnostic Doppler studies could not be obtained. Fatty\n infiltration of the liver is again noted in visualized regions of the liver\n parenchyma.\n\n IMPRESSION: Non-diagnostic study due to technical limitations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-12-29 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1114759,
"text": ", D. MED MICU-7 11:21 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate for portal vein thrombosis or budd chiari w/\n Admitting Diagnosis: ACUTE LIVER FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with alk hep now w/ worsening pressor requirement and rising\n lactate\n REASON FOR THIS EXAMINATION:\n please evaluate for portal vein thrombosis or budd chiari w/ doppler\n ______________________________________________________________________________\n PFI REPORT\n Non-diagnostic study due to technical limitations. Hepatic steatosis is\n _____.\n\n"
}
] |
48,368 | 109,685 | He arrived via med flight to ED awake and alert. In ED noted to have expanding hematoma tracking up arm from fistula into the chest wall with a very large amt of blood in the chest wall. A CT torso at was negative for aortic abnormality or retroperitoneal bleed. Three liters of fluid and 2 units of PRBC were given at then he received aother unit of PRBC here at as well as 2 units of FFP and a six pack of platelets. A small needle hole was noted in AVF. A single stitch was placed with hemostasis. HCT slowly trended down each day to 23.4 on . Epogen was given at dialysis. He was admitted to the SICU for monitoring with serial hematocrits drawn. An U/S was done to assess for active bleeding. This was a limited study due to extensive hematoma. No pseudoaneurysm was visualized. His arm was kept elevated. Tylenol was given for comfort. On , Hct decreased to 23. He was transfused with 2 units of PRBC while in hemodialsyis. Hemodialsyis was done via the R tunnelled HD line. Upon admission, cardiac enzymes were cycled for previously noted T wave changes. These were negative for MI. He was dialyzed via the tunnelled HD line on for 1.5 liters and again on . Vital signs remained stable. The LUE arm circumference measured 12 inches with extensive bruising. Sensation was intact. Diet was advanced and tolerated. Ileo conduit was draining well. PT and OT evaluated him given that his wife reported that he had fallen at home and that she was not strong enough to assist him to get up. PT recommended rehab. He will be discharged to at , . | Non-specific inferolateral T waveflattening. Left axisdeviation. Consider left anterior fascicular block. Cannot exclude ischemia. Prolonged Q-T interval. Probable sinus rhythm with premature atrial beats, although baseline artifactmakes P wave morphology difficult. T wave inversion inleads V1-V4. | 1 | [
{
"category": "ECG",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Report",
"row_id": 265068,
"text": "Probable sinus rhythm with premature atrial beats, although baseline artifact\nmakes P wave morphology difficult. Prolonged Q-T interval. Left axis\ndeviation. Consider left anterior fascicular block. T wave inversion in\nleads V1-V4. Cannot exclude ischemia. Non-specific inferolateral T wave\nflattening. No previous tracing available for comparison.\n\n"
}
] |
10,212 | 157,506 | The patient was initially admitted to the Endoscopic retrograde cholangiopancreatography Service and status post performance of her endoscopic retrograde cholangiopancreatography, she was transferred to the Intensive Care Unit and later to the regular medical floor. The patient's vital signs remained stable. Her abdominal pain improved. She was initially NPO and was advanced to clear liquids. However, she had some vomiting which was responsive to Compazine and Droperidol. She was later changed back to NPO for this and her diet was subsequently advanced to the point where she was tolerating solids on the day of discharge. The patient was also started on Protonix, Ciprofloxacin and Flagyl during this admission for treatment of potential biliary infection and gastrointestinal prophylaxis. The patient has been doing well since transfer to the medical floor. She is being discharged home on . | S/P cholecystectomy with intact cystic duct remnant. Mild pancreatic ductal dilatation is associated with this finding. IMPRESSION: Multiple calculi and slightly dilated common bile duct. #20 ANGIO LEFT ANTECUBITAL IV ACCESS.GI: PT IS NPO. 2) Right cardiophrenic angle opacity, probably due to a prominent pericardial fat pad. FINDINGS: Transabdominal images reveal post cholecystectomy changes including common bile duct dilatation. There is dilatation of the common bile duct with multiple filling defects consistent with calculi. Increased amylase/lipase, increasaed lfts/wbc and dilated CBD with ? S/P biliary sphincterotomy and extraction of multiple calculi. IMPRESSION: 1) Findings suggest obstructing common bile duct stone, causing common bile duct dilatation and mild pancreatic duct dilatation. At this level, intraluminal fluid surrounds a hyperechoic structure which casts an acoustic shadow and lies approximately at the head of the pancreas. Left ventricular hypertrophy.Anterolateral ST-T wave abnormalities may be due to ischemia.TRACING #1 There is contrast filling of the common bile duct, common hepatic duct, right and left hepatic ducts and multiple intrahepatic biliary divisions. However, the distal portion of the duct appears dramatically dilated, measuring as great as 1.8 cm. ALT IN COMFORT: PT C/O HEADACHE AT545 AM, GIVEN TYLENOL AS ORDERED. IV D51/2NS INFUSING, CHANGED TO IV NS AT 150CC/H. thanx FINAL REPORT ABDOMINAL ULTRASOUND, : CLINICAL: 63 y/o/f with abdominal pain and findings of acute pancreatitis. TMAX=101.5 BLOOD CULTS WERE DONE. PMH: CHOLECYSTECTOMY,APPY 84, PANCREATITIS 84. filling defect at distal end. DURING ERCP PT : DROPERIDOL 5MG, FENTANYL 350MG, VERSED 7.5 MG, AND GLUCAGON 0.2MG. Assess for free intraperitoneal air. MANY STONES WERE EXTRACTED FROM THE COMMON BILE DUCT WHICH WERE CAUSING OBSTRUCTION OF BILIARY TREE.IN ER SHE RECEIVED: MSO4 4MG IV,ASA 325 MG, LOPRESSOR 5MG IV,ZANTAC 50MG IV, FLAGYL 500MG IV,CIPRO 400MG IV, AND TYLENOL. Sinus rhythm. Sinus rhythm. ALLERGY: PCN. SHE HAD ABDOMENAL CT THEN WAS SENT TO FOR A ERCP. SUPINE ABDOMEN: Gas and feces can be seen throughout the large bowel. The lungs reveal apparent focal area of increased opacity in the right cardiophrenic angle region, possibly due to a prominent pericardial fat pad. REASON FOR THIS EXAMINATION: R/O CBD stone FINAL REPORT ERCP. HISTORY: Acute pancreatitis with increasing LFT's, and dilated common bile duct on son with possible stone in distal duct. NO N&V CURRENTLY, +BS.GU: FOLEY CATH IN PLACE, CLEAR YELLOW URINE, LARGE AMTS.SKIN: NO RED OR OPEN AREAS NOTED.RESP: LUNG SOUNDS CLEAR, O2 2L NC, SATS 97-99%SOCIAL: DAUGHTER VISITED PT AND SPOKE WITH RESIDENT AFTER ARRIVAL HERE.PLAN: IV ANTIBIOTICS, IV FLUIDS. please page with prelim report. IV NS AT 150CC/H SHE CAME TO THE ER 10/25AM AFTER 12HOURS OF ABDOMENAL PAIN, CHEST PAIN, SOB, FEVER,CHILLS AND N&V-CLEAR FLUID. Dedicated PA and lateral chest radiograph may be helpful for more complete assessment of this region, when the patient's condition permits. HR NSR NO ECTOPY 80'S. Abnormal left axis deviation. S/P biliary sphincterotomy and extraction of multiple calculi with aid of balloon and basket. NO WEAKNESSES JUST VERY SLEEPY.CARDIOVASCULAR: AFEBRILE. ALL PERIPHERAL PULSES PALPABLE. There is also filling of the cystic duct remnant. 5:21 AM PORTABLE ABDOMEN Clip # Reason: rule out free air, abnormal bowel loops MEDICAL CONDITION: 63 year old woman with abdominal pain REASON FOR THIS EXAMINATION: rule out free air, abnormal bowel loops FINAL REPORT INDICATION: Abdominal pain. IMPRESSION: 1) No radiographic evidence of free intraperitoneal air. There is a dextroconcave curvature to the lower lumbar spine. PUPILS =+. The pancreatic tail is not visualized. Five fluoroscopic spot films are provided. The aorta is slightly unfolded. The exam also demonstrates a normal-appearing spleen, a 10.6 cm normal- appearing left kidney, and a normal-appearing 10.5 cm right kidney. 7:49 AM ABDOMEN U.S. (COMPLETE STUDY) Clip # Reason: 64 yo female with acute pancreatitis s/p ccy in1984, please MEDICAL CONDITION: 63 year old woman with see above REASON FOR THIS EXAMINATION: 64 yo female with acute pancreatitis s/p ccy in1984, please evaluate for intraductal dilation and /or other findings sig for pancreatitis. RECOGNIZES FAMILY, DOES NOT SPEAK MUCH ENGLISH.NEURO: NO DEFICITS NOTED. 5:21 AM CHEST (PORTABLE AP) Clip # Reason: rule out free air MEDICAL CONDITION: 63 year old woman with abdominal pain REASON FOR THIS EXAMINATION: rule out free air FINAL REPORT PORTABLE CHEST, : CLINICAL INDICATION: Abdominal pain. | 8 | [
{
"category": "ECG",
"chartdate": "2164-11-15 00:00:00.000",
"description": "Report",
"row_id": 112262,
"text": "Sinus rhythm. No change since earlier this date.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2164-11-15 00:00:00.000",
"description": "Report",
"row_id": 112263,
"text": "Sinus rhythm. Abnormal left axis deviation. Left ventricular hypertrophy.\nAnterolateral ST-T wave abnormalities may be due to ischemia.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-11-16 00:00:00.000",
"description": "Report",
"row_id": 1397237,
"text": "ALT IN COMFORT: PT C/O HEADACHE AT545 AM, GIVEN TYLENOL AS ORDERED. ALERT AND ORIENTED,NEUROS INTACT. VSS. IV NS AT 150CC/H\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 745225,
"text": " 5:21 AM\n PORTABLE ABDOMEN Clip # \n Reason: rule out free air, abnormal bowel loops\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n rule out free air, abnormal bowel loops\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain.\n\n SUPINE ABDOMEN: Gas and feces can be seen throughout the large bowel. No\n abnormal small bowel loops are seen. There is a dextroconcave curvature to\n the lower lumbar spine.\n\n IMPRESSION: No evidence of ileus or obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 745224,
"text": " 5:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with abdominal pain\n REASON FOR THIS EXAMINATION:\n rule out free air\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST, :\n\n CLINICAL INDICATION: Abdominal pain. Assess for free intraperitoneal air.\n\n No prior films are available for comparison.\n\n The heart size is normal. The aorta is slightly unfolded. The lungs reveal\n apparent focal area of increased opacity in the right cardiophrenic angle\n region, possibly due to a prominent pericardial fat pad. No free\n intraperitoneal air is identified, and no pleural effusions or pneumothoraces\n are detected.\n\n IMPRESSION: 1) No radiographic evidence of free intraperitoneal air.\n 2) Right cardiophrenic angle opacity, probably due to a prominent pericardial\n fat pad. Dedicated PA and lateral chest radiograph may be helpful for more\n complete assessment of this region, when the patient's condition permits.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-15 00:00:00.000",
"description": "ERCP S&I (74330)",
"row_id": 745297,
"text": " 9:42 AM\n ERCP S&I () Clip # \n Reason: R/O CBD stone\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with acute onset abd pain. Increased amylase/lipase,\n increasaed lfts/wbc and dilated CBD with ? filling defect at distal end.\n REASON FOR THIS EXAMINATION:\n R/O CBD stone\n ______________________________________________________________________________\n FINAL REPORT\n ERCP.\n\n HISTORY: Acute pancreatitis with increasing LFT's, and dilated common bile\n duct on son with possible stone in distal duct.\n\n Five fluoroscopic spot films are provided.\n There is contrast filling of the common bile duct, common hepatic duct, right\n and left hepatic ducts and multiple intrahepatic biliary divisions. There is\n also filling of the cystic duct remnant. There is dilatation of the common\n bile duct with multiple filling defects consistent with calculi. S/P biliary\n sphincterotomy and extraction of multiple calculi with aid of balloon and\n basket.\n\n IMPRESSION: Multiple calculi and slightly dilated common bile duct. S/P\n cholecystectomy with intact cystic duct remnant. S/P biliary sphincterotomy\n and extraction of multiple calculi.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-11-15 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 745230,
"text": " 7:49 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: 64 yo female with acute pancreatitis s/p ccy in1984, please\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with see above\n REASON FOR THIS EXAMINATION:\n 64 yo female with acute pancreatitis s/p ccy in1984, please evaluate for\n intraductal dilation and /or other findings sig for pancreatitis.\n please page with prelim report.\n thanx\n \n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND, :\n\n CLINICAL: 63 y/o/f with abdominal pain and findings of acute pancreatitis.\n\n FINDINGS: Transabdominal images reveal post cholecystectomy changes including\n common bile duct dilatation. Proximally, the duct measures approximately 9\n mm. However, the distal portion of the duct appears dramatically dilated,\n measuring as great as 1.8 cm. At this level, intraluminal fluid surrounds a\n hyperechoic structure which casts an acoustic shadow and lies approximately at\n the head of the pancreas. Mild pancreatic ductal dilatation is associated\n with this finding. No ascites, intrahepatic ductal dilatation, or clearly\n visualized additional common bile duct stone is present.\n\n The exam also demonstrates a normal-appearing spleen, a 10.6 cm normal-\n appearing left kidney, and a normal-appearing 10.5 cm right kidney.\n\n No peripancreatic fluid collections are identified. The pancreatic tail is\n not visualized.\n\n IMPRESSION:\n 1) Findings suggest obstructing common bile duct stone, causing common bile\n duct dilatation and mild pancreatic duct dilatation.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-11-15 00:00:00.000",
"description": "Report",
"row_id": 1397236,
"text": "ADMISSION NOTE: PTISA 64 YEAR OLD RUSSIAN SPEAKING WOMAN. SHE CAME TO THE ER 10/25AM AFTER 12HOURS OF ABDOMENAL PAIN, CHEST PAIN, SOB, FEVER,CHILLS AND N&V-CLEAR FLUID. PMH: CHOLECYSTECTOMY,APPY 84, PANCREATITIS 84. ALLERGY: PCN. SHE HAD ABDOMENAL CT THEN WAS SENT TO FOR A ERCP. MANY STONES WERE EXTRACTED FROM THE COMMON BILE DUCT WHICH WERE CAUSING OBSTRUCTION OF BILIARY TREE.\nIN ER SHE RECEIVED: MSO4 4MG IV,ASA 325 MG, LOPRESSOR 5MG IV,ZANTAC 50MG IV, FLAGYL 500MG IV,CIPRO 400MG IV, AND TYLENOL. TMAX=101.5 BLOOD CULTS WERE DONE. DURING ERCP PT : DROPERIDOL 5MG, FENTANYL 350MG, VERSED 7.5 MG, AND GLUCAGON 0.2MG. SHE WAS SUPPOSED TO BE ADMITTED TO MICU BUT NO BED WAS AVAILABLE.\n\nSHE ARRIVED AT 9PM BY AMBULANCE IN MICU WITH NO REPORT CALLED TO US.\nMENTAL STATUS: PT IS VERY LETHARGIC BUT AROUSABLE. MOVES ALL EXTREMITIES,OPENS EYES AND FOLLOWS COMMANDS. RECOGNIZES FAMILY, DOES NOT SPEAK MUCH ENGLISH.\nNEURO: NO DEFICITS NOTED. PUPILS =+. NO WEAKNESSES JUST VERY SLEEPY.\nCARDIOVASCULAR: AFEBRILE. HR NSR NO ECTOPY 80'S. SBP 130-140. SKIN IS WARM AND DRY. IV D51/2NS INFUSING, CHANGED TO IV NS AT 150CC/H. ALL PERIPHERAL PULSES PALPABLE. #20 ANGIO LEFT ANTECUBITAL IV ACCESS.\nGI: PT IS NPO. NO N&V CURRENTLY, +BS.\nGU: FOLEY CATH IN PLACE, CLEAR YELLOW URINE, LARGE AMTS.\nSKIN: NO RED OR OPEN AREAS NOTED.\nRESP: LUNG SOUNDS CLEAR, O2 2L NC, SATS 97-99%\nSOCIAL: DAUGHTER VISITED PT AND SPOKE WITH RESIDENT AFTER ARRIVAL HERE.\nPLAN: IV ANTIBIOTICS, IV FLUIDS. MONITOR OVERNIGHT THEN TRANSFER TO FLOOR.\n"
}
] |
29,703 | 128,711 | A/P: Pt is a 19 yo male with an extensive psychiatric history as well as a history of poly-substance abuse in the past who presents with fever, sore throat and respiratory distress. . # Multifocal pneumonia: Initially, due to concern for respiratory distress and fever, Pt was assessed by CT scan for pharyngeal abscess, which was negative. His initial CXR, however, showed a multifocal pneumonia by CXR. Pt received Azithromycin, Ceftriaxone, and Vancomycin in the ED as well as solumedrol and stablized from a respiratory standpoint. He was admitted to the ICU because of the extent of his initial respiratory distress, but was saturating at or near 100% on RA at that point. Upon transfer to the floor pt remained febrile, but was saturating in the mid 90s on room air. Vancomycin was discontinued in the setting of 72 hours of negative blood cultures. . With continued fevers, Clindamycin was added given concern for the possibility of aspiration pneumonia. This concern was raised in the setting of a multilobular process combined with the fact that Pt has been taking multiple sedating medications at relatively large doses. Pt defervesced following the addition of clindamycin with decreased cough and improved SaO2, including the maintanence of SaO2 in the 90's during ambulation on . . Given risk factors of IVDU and unprotected sex Pt was tested for HIV and both Antibody and viral load were negative. Influenza a/b DFA was negative. GAHS throat swab was negative as was urine legionella, GC, and Chlamydia. . Pt was discharged in stable condition and was instructed to complete a 14 day course of levofloxacin and clindamycin for likely community acquired pneumonia. . # OCD/MDD: Pt did not manifest any signs or symptoms of active OCD or depression during this admission. He was made aware of the fact that there was concern for the possibility of an aspiration event secondary to over-sedation, but deferred psychiatric consultation on numerous occasions as he prefers to have his medications managed by his outside psychiatrist. A detailed message regarding Pt's clinical course and concern for the possibility of overmedication was left with Pt's psychiatrist on the day of discharge. Pt was otherwise maintained on his home doses of psychiatric medications during this hospitalization. | LP done, ruled out for meningitis. Droplet precautions D/C'd, flu ruled out. Non pathologically enlarged lymph nodes in mediastinum, most likely reactive. Nursing Progress Note MICU 7Admx Date: Allergies: NKDAAccess: 1 PIVNeuro: Pt. Question of abscess or effusion/empyema formation. ruled out for flu. CXR showed multilobar PNA. Concern for lung abscesses/epmpyema. Slightly prominent lymph nodes are seen within the jugular chain at the level of the mandible (measuring 11 mm in short axis), likely reactive. Resolution of consolidation FINAL REPORT CHEST RADIOGRAPHS INDICATION: Follow up. Tylenol given.GI/GU: Pt. BP 90's to 110's systolic. There are at least two mediastinal lymph nodes measuring 9.9 mm and 3.9 mm along with axillary lymphadenopathy, likely reactive to the underlying pneumonic consolidation. WAS BETWEEN 110-120'S, NOW SR 80'S AND B/P DROPPED TO 91/47. He was given PCN for possible strep throat/tonsillar or retropharygneal abscess. He was given azithromycin IV. 9:34 AM CHEST (PA & LAT) Clip # Reason: Progression vs. Lung sounds coarse at beginning of shift, now decreased.ID: ID following patient. Concern for lung abscesses or empyema. Labs showed leukocytosis and bandemia. INDICATION: Multilobar pneumonia. PMH OCD, h/o IVDU, depression. Incidentally noted is excretion of contrast into bilateral renal collecting systems (from recent CECT neck); there may be UPJ obstruction on the right. CT of neck neg for abscess, cxr showed multilobar pna. The lung volumes remain low and (allowing for technical differences) the patchy airspace process involving the right mid lung and both lung bases has become slightly more confluent. Modest inferior ST-T wave changes which are non-specific.Findings are within normal limits. on Ceftriaxone and Azithromycin. Sinus rhythm. Afebrile.a. Small left pleural effusion with apparent loculation is also demonstrated, new in the interval. pt has some course breath sounds with expiratory wheezing given Alb tx two doses tol well, will continue to monitor. Pt arrived MICU 7 0100am on 100% Nonrebreather o2 sat 100% lungs coarse with faint expiratory wheezing. FINDINGS: In comparison to the previous radiograph from , there is further progression of bilateral parenchymal consolidations. PA AND LATERAL VIEWS OF THE CHEST: Two foci of consolidation are seen; in the lingula and the right upper lobe. Desats to mid 80's when oxygen is off. Additionally, new patchy ill-defined areas of consolidation have developed within the upper lungs, right greater than left. Prevertebral soft tissues appear unremarkable. He was given levofloxacin 750mg iv x1. RECEIVED 1 LITER FOR THIS. (Over) 11:11 AM CT CHEST W/CONTRAST Clip # Reason: Pt with multifocal pneumonia, excessive sputum production. Widespread, multifocal areas of consolidation have progressed in the interval, particularly in the mid and lower lungs bilaterally. DR. Strep swab sent this shift pending. fevers leukocytosis cxr pna has h/o IVDU and unprotected sex r/o HIV pcpOCD, depression. 11:11 AM CT CHEST W/CONTRAST Clip # Reason: Pt with multifocal pneumonia, excessive sputum production. and (ED). Thinner slice 5 mm and 1.25 mm were reconstructed in the axial plane. REASON FOR THIS EXAMINATION: Progression vs. Below the diaphragm, the abdominal structures are unremarkable. PT'S HR. Sating mid 90's on 3 liters. Receiving IVF at 200cc/hr.Resp: Pt. Q Admitting Diagnosis: PNEUMONIA FINAL REPORT (Cont) Continue abx. pt. Pt. Pt. Pt. Pt. PT. PT. PT. PT. IMPRESSION: Worsening widespread multifocal pneumonia with new small partially loculated left pleural effusion. Benzo with drawal. Labs showing positive leukocytosis and bandemia. restarted on home dose of Xanax. IMPRESSION: 1. IMPRESSION: 1. o2 was turned down to 60% he maintained o2 sat of >98%. IMPRESSION: Rapidly progressing right lung and slower but also progressing left lower lobe consolidations. The piriform sinuses contain small foci of air with a normal appearance. NKDA. The epiglottis is normal. No contraindications for IV contrast FINAL REPORT CHEST CT WITHOUT CONTRAST ON TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the subdiaphragmatic area without IV contrast. Does have a smoking hx, has not had a drink since .O. in sinus tach HR 100's up to 120's at end of shift. T max today 100.1 axillary. UA/cx pending. TECHNIQUE: MDCT-acquired axial images were obtained through the neck after the administration of intravenous contrast material. IMPRESSION: Bilateral airspace consolidation in the lingula and right upper lobe, consistent with pneumonia. Urine specs sent including tox screen which is pending.Plan: Pt. BLOOD CULTURES X4 AND SPUTUM CULTURE SENT. not feeling well at time. REMAINS A CALL OUT TO THE FLOOR. The upper lungs are unremarkable. | 12 | [
{
"category": "Radiology",
"chartdate": "2201-01-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 998959,
"text": " 9:34 AM\n CHEST (PA & LAT) Clip # \n Reason: Progression vs. Resolution of consolidation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with fever, SOB, productive cough, and multifocal opacification\n on previous CXR.\n REASON FOR THIS EXAMINATION:\n Progression vs. Resolution of consolidation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPHS\n\n INDICATION: Follow up.\n\n FINDINGS: In comparison to the previous radiograph from ,\n there is further progression of bilateral parenchymal consolidations.\n Otherwise, the radiograph is unchanged. The size of the cardiac silhouette is\n normal, no evidence of pleural effusions.\n\n IMPRESSION: In comparison to , bilateral opacities have\n further increased. Otherwise unchanged.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2200-12-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 998475,
"text": " 2:20 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with cough and fever\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n WET READ: CXWc MON 3:23 PM\n Bilateral airspace consolidations in the lingula and RUL, concerning for PNA.-\n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man with cough and fever.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: Two foci of consolidation are seen; in the\n lingula and the right upper lobe. There is no pleural effusion. There is no\n pneumothorax. The cardiomediastinal silhouette is normal. Soft tissues and\n osseous structures are unremarkable.\n\n IMPRESSION: Bilateral airspace consolidation in the lingula and right upper\n lobe, consistent with pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-12-31 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 998794,
"text": " 10:58 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multilobar PNA\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, \n\n COMPARISON: and radiographs.\n\n INDICATION: Multilobar pneumonia.\n\n Widespread, multifocal areas of consolidation have progressed in the interval,\n particularly in the mid and lower lungs bilaterally. Additionally, new patchy\n ill-defined areas of consolidation have developed within the upper lungs,\n right greater than left. Small left pleural effusion with apparent loculation\n is also demonstrated, new in the interval.\n\n IMPRESSION: Worsening widespread multifocal pneumonia with new small\n partially loculated left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998522,
"text": " 5:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with acute onset hypoxia\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST, DATED \n\n HISTORY: 19-year-old man with acute-onset hypoxia; rule out pneumothorax.\n\n FINDINGS: Single bedside AP examination labeled \"upright with grid\" is\n compared with the study obtained some two hours earlier. The lung volumes\n remain low and (allowing for technical differences) the patchy airspace\n process involving the right mid lung and both lung bases has become slightly\n more confluent. There is no pneumothorax or pleural effusion and the\n cardiomediastinal silhouette and pulmonary vessels are unchanged, with no\n evidence of hilar adenopathy. Incidentally noted is excretion of contrast into\n bilateral renal collecting systems (from recent CECT neck); there may be UPJ\n obstruction on the right. Large-bore tubing overlies the upper abdomen.\n\n COMMENT: Findings reviewed with Drs. and (ED).\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-01-01 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 998984,
"text": " 11:11 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Pt with multifocal pneumonia, excessive sputum production. Q\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with h/o IVDU, fever, productive cough, s/p ICU stay, now\n sating 90% on RA with continued sputum production. Concern for lung\n abscesses/epmpyema.\n REASON FOR THIS EXAMINATION:\n Pt with multifocal pneumonia, excessive sputum production. Question of abscess\n or effusion/empyema formation.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT WITHOUT CONTRAST ON \n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the subdiaphragmatic area without IV contrast. Thinner slice 5 mm and 1.25 mm\n were reconstructed in the axial plane. Sagittal/coronal reformatted images\n were also obtained.\n\n COMPARISON: None similar. Multiple previous chest radiographs and a CT of\n the neck.\n\n HISTORY: 19-year-old man with a history of IVDU, fever, productive cough,\n status post ICU stay, now saturating at 90% on room air with continued sputum\n production. Concern for lung abscesses or empyema.\n\n FINDINGS: There is extensive multifocal pneumonic consolidation seen in all\n lung segments but mainly be localized in the mid and lower zones. In\n addition, there are bilateral small pleural effusions. There are at least two\n mediastinal lymph nodes measuring 9.9 mm and 3.9 mm along with axillary\n lymphadenopathy, likely reactive to the underlying pneumonic consolidation.\n These consolidations have been rapidly progressing over the period of last 4\n days according to chest radiographs.\n\n The heart is not enlarged. There is no pericardial effusion. The osseous\n structures do not show any lesion suspicious for infectious process or\n malignancy. Below the diaphragm, the abdominal structures are unremarkable.\n\n IMPRESSION:\n 1. Multifocal pneumonia characterized by the presence of consolidation in all\n lung segments along with some reactive lymphadenopathy and accompaning\n pleural fluid bilaterally.\n 2. Non pathologically enlarged lymph nodes in mediastinum, most likely\n reactive.\n\n (Over)\n\n 11:11 AM\n CT CHEST W/CONTRAST Clip # \n Reason: Pt with multifocal pneumonia, excessive sputum production. Q\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-12-29 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 998459,
"text": " 1:25 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: eval for epiglottitis, retropharyngeal abscess\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with fever, sore throat, difficulty swallowing and decreased O2\n sats. Throat exam not impressive\n REASON FOR THIS EXAMINATION:\n eval for epiglottitis, retropharyngeal abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc MON 3:22 PM\n No tonsillar, retropharyngeal or parapharyngeal abscess. Mild uniform\n thickening of prevert soft tissues without loss of fat planes. -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 19-year-old man with fever, sore throat, difficulty swallowing,\n and decreased oxygen saturation.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the neck after\n the administration of intravenous contrast material. Multiplanar reformatted\n images were also obtained.\n\n FINDINGS: No focal collections suspicious for abscess are seen. No abnormal\n foci of gas within the soft tissues are identified. The piriform sinuses\n contain small foci of air with a normal appearance. The epiglottis is normal.\n Prevertebral soft tissues appear unremarkable.\n\n Slightly prominent lymph nodes are seen within the jugular chain at the level\n of the mandible (measuring 11 mm in short axis), likely reactive. The lingual\n tonsils and adenoids are not significantly enlarged given the patient's age.\n\n Evaluation of the lung apices is limited due to respiratory motion, however,\n no large foci of consolidation are identified in the included upper lobes.\n\n Osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. No acute abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-12-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 998554,
"text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Re-assess pna\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 19 year old man with multilobar pna, hypoxia\n REASON FOR THIS EXAMINATION:\n Re-assess pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia in a patient with multifocal pneumonia.\n\n COMPARISON: Two chest radiographs from , dating 12:52 and\n 5:47 p.m.\n\n A rapid progression in the right lung consolidation is demonstrated with\n currently widespread right lower lobe and anterior segment of right upper lobe\n consolidations demonstrated. The left lower lobe consolidation has also\n progressed in the interim, although less compared to the right lung. There is\n no appreciable pleural effusion, although small amount of right pleural fluid\n cannot be excluded. The upper lungs are unremarkable. The cardiomediastinal\n silhouette is stable.\n\n IMPRESSION:\n\n Rapidly progressing right lung and slower but also progressing left lower lobe\n consolidations. Differential diagnosis in an appropriate clinical setting\n would include rapidly progressing pneumonia. Aspiration or acute drug\n toxicity associated with recreational drug use should be considered, although\n less likely.\n\n\n Findings discussed with Dr at the time of dictation over a phone bbu dr\n \n\n DL\n\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2200-12-30 00:00:00.000",
"description": "Report",
"row_id": 1646334,
"text": "Nursing Progress Note MICU 7\nAdmx Date: \nAllergies: NKDA\nAccess: 1 PIV\n\nNeuro: Pt. lethargic, sleeping most of shift, but easily arousable. Pleasant and cooperative. Answers questions appropriately.\n\nCV: Pt. in sinus tach HR 100's up to 120's at end of shift. ? Benzo with drawal. Pt. restarted on home dose of Xanax. BP 90's to 110's systolic. Receiving IVF at 200cc/hr.\n\nResp: Pt. weaned from high flow face mask to 3 liters nasal cannula. Sating mid 90's on 3 liters. Desats to mid 80's when oxygen is off. CXR showed multilobar PNA. Droplet precautions D/C'd, flu ruled out. Lung sounds coarse at beginning of shift, now decreased.\n\nID: ID following patient. Multiple cultures pending. UA/cx pending. Sputum cultures, blood cultures, HIV/viral load all pending. Pt. ruled out for flu. LP done, ruled out for meningitis. Strep swab sent this shift pending. Labs showing positive leukocytosis and bandemia. Pt. on Ceftriaxone and Azithromycin. T max today 100.1 axillary. Tylenol given.\n\nGI/GU: Pt. tolerating regular diet. Voiding in urinal. Urine specs sent including tox screen which is pending.\n\nPlan: Pt. is a call out. Await cultures. Continue abx. mother is contact person. Pt. to have social work consult. Social work came by today, will come back to see pt. pt. not feeling well at time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-12-31 00:00:00.000",
"description": "Report",
"row_id": 1646335,
"text": "PT. REMAINS A CALL OUT TO THE FLOOR. REFER TO TRANSFER NOTE. PT. REMAINED IN ICU OVERNIGHT DUE TO INCREASE IN O2 DEMAND WHEN O2 SATS DROPPED TO 87% AND PT. REQUIRED 5L/MIN VIA N/C. PT'S HR. WAS BETWEEN 110-120'S, NOW SR 80'S AND B/P DROPPED TO 91/47. PT. RECEIVED 1 LITER FOR THIS. TEMP HAD BEEN 98.3 AT , THEN 101.2 AT 2300. BLOOD CULTURES X4 AND SPUTUM CULTURE SENT. OTHERWISE, PT'S DENIED PAIN OR DISCOMFORT, PT. REMAINS SLIGHTLY ANXIOUS REGARDING HIV TEST RESULTS. PT. CONTINUES TO VOID LARGE AMT'S OF CLEAR YELLOW URINE. PLAN REMAINS TO TRANSFER TO FLOOR, TRANSFER NOTED WRITTEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-12-30 00:00:00.000",
"description": "Report",
"row_id": 1646332,
"text": "19 yo male with past h/o IVDA (according to patient he has not done IV drugs or cocaine for yrs) had three days of sore throat, cough, sob, ha, decrease po intake, fever, dizziness. He went to ED via ambulance In ED temp 101.2 tachycardiac o2 sats 94% on room air. Labs showed leukocytosis and bandemia. He was given PCN for possible strep throat/tonsillar or retropharygneal abscess. CT of neck neg for abscess, cxr showed multilobar pna. He was given levofloxacin 750mg iv x1. Patient became hypoxic in ED to 80% on nasal canula and he was given methlprednisolone 125mg x1, vanco, ceftriaxone along with 3500cc of NS. LP was also done in ED because of decreased mental status and fever to r/o meningitis. PMH OCD, h/o IVDU, depression. NKDA. Social lives in at where he is a freshman he has a h/o IVDU unclear exactly when he stopped. He had unprotected sex 5 days ago. He is from his mother is his next of phone number , he stated that he did not have a father. Does have a smoking hx, has not had a drink since .\nO. Pt arrived MICU 7 0100am on 100% Nonrebreather o2 sat 100% lungs coarse with faint expiratory wheezing. Resp rate 16 he was placed on a high flow face mask and given neb tx. o2 was turned down to 60% he maintained o2 sat of >98%. Patient rested comfortably for the rest of the night resp rate <18 VSS. IVF NS at 200cc q hr. He was given azithromycin IV. Afebrile.\na. fevers leukocytosis cxr pna has h/o IVDU and unprotected sex r/o HIV pcp\nOCD, depression\n. follow cultures obtain blood cultures this am, antibiotics as ordered, sputum induction for gram stain, cx and pcp, HIV and viral load, nebs prn, wean o2 as tolerated, send DFA for flu droplet precautions until flu r/o, continue home psych meds, SW consult\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-12-30 00:00:00.000",
"description": "Report",
"row_id": 1646333,
"text": "Respiratory\nPt changed from a NRM to a high flow on 95% seem to tol well, weaned down to 60% maintains sats 98% slept most of the am, plan to get a nasal aspirate and a sputum indution this am. pt has some course breath sounds with expiratory wheezing given Alb tx two doses tol well, will continue to monitor.\n"
},
{
"category": "ECG",
"chartdate": "2201-01-02 00:00:00.000",
"description": "Report",
"row_id": 214279,
"text": "Sinus rhythm. Modest inferior ST-T wave changes which are non-specific.\nFindings are within normal limits. No previous tracing available\nfor comparison.\n\n"
}
] |
98,024 | 126,482 | 1. Coronary artery disease - The patient's CKs were cycled during hospital course. The patient had a peak CK MB of 157 with an index of 10 at 10:00 p.m. on . The patient's troponin was measured to be greater than 50. The patient was treated with Aspirin, Plavix, Lopressor, Captopril, bedrest, ReoPro drip for twelve hours and then discontinued. Nitroglycerin drip was titrated and discontinued. The patient was maintained on telemetry. The patient had episodes of nonsustained supraventricular tachycardia on telemetry as well as bradycardia after Lopressor treatment began. LDL was checked which was 120. The patient was started on Lipitor 10 milligrams p.o. q.d. During the hospital course, the patient was adequately beta blocked to a heart rate of 80 with a systolic blood pressure of 100 to 120 on 50 milligrams b.i.d. Lopressor. The patient was also treated with Captopril 12.5 milligrams p.o. t.i.d. His blood pressure tolerated this treatment. The patient was provided nutritional counseling for cardiac diet. The patient's urine output was within normal limits during hospital course. After contrast during cardiac catheterization, blood urea nitrogen and creatinine were within normal limits. After ReoPro drip and Heparin treatment, the patient's platelets were within normal limits. During hospital course, the patient complained of chest pain within the hour after arrival to the CCU. Serial electrocardiograms were obtained showing no electrocardiographic changes and no evidence of in stent restenosis. Stat transthoracic echocardiogram was obtained which showed normal left atrium, mild symmetric left ventricular hypertrophy, mild regional left ventricular systolic dysfunction with hypokinesis of the posterior wall and basal inferior wall. Aortic leaflets appeared within normal limits. Mitral leaflets were structurally normal. No mitral valve prolapse and 1+ mitral regurgitation was noted. No pericardial effusion. For further workup of the patient's predisposition for myocardial infarction, lipid protein A and homocystine laboratories were sent which are pending at the time of discharge. The patient complained of gastric upset. He was treated with Prilosec 20 milligrams p.o. q.d. as well as Maalox p.r.n. The patient was noted to have an elevated white count which decreased consistent with myocardial infarction. The patient was noted to have a low grade temperature to 101 which abated which was consistent with recent myocardial infarction. Amylase and lipase were sent when the patient complained of epigastric pain with back pain. Amylase and lipase were both noted to be within normal limits. The patient was discharged on , with the following medications: 1. Atenolol 50 milligrams p.o. q.d. 2. Zestril 2.5 milligrams p.o. q.d. 3. Nitroglycerin 0.4 milligrams sublingual q5minutes p.r.n. chest pain. 4. Prilosec 20 milligrams p.o. q.d. 5. Lipitor 10 milligrams p.o. q.d. 6. Aspirin 325 milligrams p.o. q.d. 7. Plavix 75 milligrams p.o. q.d. times twenty-eight days. | Mild (1+) mitral regurgitation is seen. Mild tricuspid [1+]regurgitation is seen. There is mild symmetric left ventricularhypertrophy. There is nomitral valve prolapse. There is nomitral valve prolapse. The right ventricleis not well seen.The aortic leaflets (3) appear structurally normal with goodleaflet excursion. Noaortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild regional left ventricularsystolic dysfunction.RIGHT VENTRICLE: The right ventricle is not well seen.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. There is systolic motion of the mitral chordae (normalvariant), but no resting outflow tract gradient. There is mild regional left ventricular systolic dysfunction withhypokinesis of the posterior wall and basal inferior wall. The pulmonary artery systolic pressure could not bedetermined.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation. There is nopericardial effusion. Lateral ST-T wave flattening persists.TRACING #2 There is nopulmonic valve stenosis.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: The patient is bradycardic (HR<60bpm).Conclusions:The left atrium is normal in size. Sinus rhythm with a single late cycle ventricular premature beat. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Compared to the previous tracing of ST segmentelevations, consistent with acute infero-posterolateral myocardial infarction,have resolved. The leftventricular cavity size is normal. T wave inversions in leads III, aVF and V5-V6 consistent withevolution of the infero-posterolateral myocardial infarction. Since the previous tracing of ST-T wave changes inevolution persist.TRACING #1 Acute myocardial infarction.Height: (in) 71Weight (lb): 170BSA (m2): 1.97 m2Status: InpatientDate/Time: at 14:30Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Subcostal views are limited.LEFT ATRIUM: The left atrium is normal in size.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Since the previous tracing of T wave abnormalities areless marked.TRACING #2 Low limb lead voltage. The mitral leaflets are structurally normal. Compared to theprevious tracing of T wave inversions are new. There is now a prominentR wave in lead V2 and tall right precordial T waves which could be indicativeof posterior myocardial infarction.TRACING #3 Poor qualitytracing. There is no significant aortic valve stenosis. ST segment elevations in leads II, III, aVF and V4-V6 withST segment depressions in leads VI-V2 consistent with an acuteinfero-posterolateral myocardial infarction. Leftward axis. No previous tracing available forcomparison.TRACING #1 Clinical correlation is suggested. Increased mi-precordial leadvoltage. | 7 | [
{
"category": "Echo",
"chartdate": "2107-04-22 00:00:00.000",
"description": "Report",
"row_id": 68989,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain.\n? Acute myocardial infarction.\nHeight: (in) 71\nWeight (lb): 170\nBSA (m2): 1.97 m2\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSubcostal views are limited.\nLEFT ATRIUM: The left atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction.\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. There is no significant aortic valve stenosis. No\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. There is systolic motion of the mitral chordae (normal\nvariant), but no resting outflow tract gradient. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. There is no\npulmonic valve stenosis.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The patient is bradycardic (HR<60bpm).\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. There is mild regional left ventricular systolic dysfunction with\nhypokinesis of the posterior wall and basal inferior wall. The right ventricle\nis not well seen.The aortic leaflets (3) appear structurally normal with good\nleaflet excursion. The mitral leaflets are structurally normal. There is no\nmitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-04-25 00:00:00.000",
"description": "Report",
"row_id": 155257,
"text": "Sinus rhythm. Since the previous tracing of T wave abnormalities are\nless marked.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2107-04-24 00:00:00.000",
"description": "Report",
"row_id": 155258,
"text": "Sinus rhythm. Since the previous tracing of ST-T wave changes in\nevolution persist.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2107-04-23 00:00:00.000",
"description": "Report",
"row_id": 155259,
"text": "Sinus rhythm. T wave inversions in leads III, aVF and V5-V6 consistent with\nevolution of the infero-posterolateral myocardial infarction. Compared to the\nprevious tracing of T wave inversions are new. There is now a prominent\nR wave in lead V2 and tall right precordial T waves which could be indicative\nof posterior myocardial infarction.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2107-04-22 00:00:00.000",
"description": "Report",
"row_id": 155260,
"text": "Sinus rhythm. Compared to the previous tracing of ST segment\nelevations, consistent with acute infero-posterolateral myocardial infarction,\nhave resolved. Lateral ST-T wave flattening persists.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2107-04-22 00:00:00.000",
"description": "Report",
"row_id": 155261,
"text": "Sinus rhythm. ST segment elevations in leads II, III, aVF and V4-V6 with\nST segment depressions in leads VI-V2 consistent with an acute\ninfero-posterolateral myocardial infarction. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2107-04-22 00:00:00.000",
"description": "Report",
"row_id": 155262,
"text": "Sinus rhythm with a single late cycle ventricular premature beat. Poor quality\ntracing. Low limb lead voltage. Leftward axis. Increased mi-precordial lead\nvoltage. Clinical correlation is suggested.\n\n"
}
] |
76,658 | 123,009 | This is a 77 year old female with past medical history significant for hypertension presenting in complete heart block s/p temporary pacemaker placement and kidney failure (acute vs. CKD). # Complete Heart Block - Etiology a recent MI given elevated trop to 8 with inferior q-waves on EKG leading to complete heart block. Dual chamber permanent pacer placed and set to 80 bpm. PA/LAT CXR showed appropriate positioning. Pt received 4 doses of prophylactic IV Vancomycin. No abx on discharge. Completed physical therapy that suggested home with PT. EP interrogated the pacer on discharge and was OK with discharge. . # Completed Inferior MI - Given q waves and lack of ST changes and elevated troponins, pt had MI in the near past, reports chest discomfort a week or so ago. ECHO showed EF 45%. We started medical management with , 325, Atorva 80, Metop XL 25, Echo showed inferior posterior wall hypokinesis, and EF 45%. Pt was without chest pain during her admission. . # Acute Kidney Injury with possible CKD - Cr 4.7 on admission. Cr 1.6 on Discharge. We treated her with gentle IVF, renally dosing meds, avoiding nephrotoxins, and fixing her conduction system allowing appropriate forward flow. The etiology is unclear given unknown baseline Cr, mostly like it is ATN to poor forward flow. On discharge we restarted . . # HTN - We initially held all home BP meds (Dilt, HCTZ, telmasartan) during the admission given her low BPs. Patient was instructed to restart telmasartan, and she was started on metoprolol. . ### Transitions of care: - BP has been low during hospital stay, consider starting ACEi for remodeling benefit as outpatient. | RV function depressed.PERICARDIUM: No pericardial effusion.Conclusions:The right ventricular cavity is dilated with depressed free wallcontractility. The right ventricular cavity is dilated with depressed free wallcontractility. The right ventricular free wall thickness isnormal. Abnormal septal motion/position consistent with RV pressure/volumeoverload.AORTA: Normal aortic diameter at the sinus level. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo;RIGHT VENTRICLE: Normal RV free wall thickness. Normal main PA. No Doppler evidence for PDAPERICARDIUM: Small pericardial effusion.Conclusions:A pacemaker wire is seen in the right atrium and right ventricle. FINDINGS: There is slight tortuosity and calcification along the thoracic aorta. The left ventricular cavity size isnormal. Moderate [2+] tricuspid regurgitation isseen. There is mild pulmonary artery systolichypertension. Mildlydepressed LVEF. Focal calcifications inascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Normal ascending aorta diameter. PATIENT/TEST INFORMATION:Indication: Pericardial effusionHeight: (in) 60Weight (lb): 175BSA (m2): 1.77 m2BP (mm Hg): 89/49HR (bpm): 70Status: InpatientDate/Time: at 12:54Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT VENTRICLE: Dilated RV cavity. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. There is no sign of cardiactamponade.Compared with the findings of the prior study (images reviewed) of , the following findings are new:(1) pacemaker wire now seen in RA/RV, entering and probably perforating RVfree wall(2) small pericardial effusion now seen subtending area where pacemaker wiretip seen (no sign of cardiac tamponade)(3) pacemaker-induced LV dyssynchrony is now present(4) inferior posterior wall hypokinesis now present(5) RV is now dilated and hypocontractilediscussed with Dr HblockHeight: (in) 60Weight (lb): 175BSA (m2): 1.77 m2BP (mm Hg): 105/68HR (bpm): 79Status: InpatientDate/Time: at 10:23Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. An eccentric, posteriorly directed jet of moderate (2+) mitralregurgitation is seen. Moderate (2+) MR. tothe eccentric MR jet, its severity may be underestimated (Coanda effect).TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. FINDINGS: Single frontal view of the chest was obtained. Cannot excludeold inferior and anterior myocardial infarctions. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Sinus bradycardia with occasional atrial premature beats and high grade,probably complete, A-V block with ventricular escape rhythm. There is abnormal septal motion/position consistent with rightventricular pressure/volume overload. Compared to the prior study the fluid status is slightly worse. [Due to acoustic shadowing, the severity of tricuspid regurgitation maybe significantly UNDERestimated.] There has been interval removal of a transvenous pacer. There is mild pulmonary vascular redistribution. Patchy retrocardiac opacity, probably in the left lower lobe, is most suggestive of minor atelectasis. [Due to acousticshadowing, the severity of tricuspid regurgitation may be significantlyUNDERestimated.] IMPRESSION: Status post removal of transvenous pacer. The right atrium is moderately dilated. There is vague patchy hilar opacification on each side, which may suggest slight congestion. There is volume loss at both bases and an early infiltrate cannot be excluded in either lower lobe. IMPRESSION: Suspicion for slight congestion, otherwise unremarkable. Focal calcifications inaortic root. FINDINGS: Left-sided battery pack with pacemaker lead wires terminating in the right atrium and right ventricle without change in position. The heart is probably at the upper limits of normal size. There is a small pericardial effusion subtending the epicardialsurface where the pacemaker wire tip emerges. Opacification at the right base could represent atelectasis and small effusion. FINDINGS: There is a right IJ pacer wire that extends to the region of the apex of the right ventricle, in similar location compared to prior. Overall left ventricular systolic function is mildly depressed (LVEF =45%) secondary to hypokinesis of the inferior and posterior walls, and topacemaker-induced dyssynchrony. Moderate [2+] TR. Mild pulmonary edema from is mostly resolved. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of , a pacemaker wire is no longer seen; no pericardial effusionseen. Normal tricuspidvalve supporting structures. Interval insertion of pacer has been made through the right internal jugular approach with its tip projecting at the expected location of right ventricle. Normal LV cavity size. RV functiondepressed. There is volume loss in both lower lungs and bilateral pleural effusions. No acute cardiopulmonary process. Cardiomediastinal silhouette is stable. No PS.Physiologic PR. FINDINGS: In comparison with study of earlier in this date, there has been placement of a right IJ pacer that extends to the region of the apex of the right ventricle. Due to the eccentric nature of the regurgitant jet, itsseverity may be significantly underestimated (Coanda effect). The cardiomediastinal silhouette is stable. Normal mitralvalve supporting structures. The tip ofthe pacemaker wire appears to penetrate the right ventricular free wall andmay protrude beyon the epicardial surface of the right ventricular free wall(through-and-through perforation).The left atrium is dilated. COMPARISONS: Multiple prior chest radiographs, most recently of . Portable AP radiograph of the chest was reviewed in comparison to , . Leftventricular wall thicknesses are normal. TECHNIQUE: Chest, portable AP upright. Bilateral pleural effusions are present. Compared to the study from the prior day, the appearance to the lower lungs is worse. Patient currently desaturating. A catheter or pacingwire is seen in the RA and extending into the RV.LEFT VENTRICLE: Normal LV wall thickness. PATIENT/TEST INFORMATION:Indication: Myocardial infarction. TECHNIQUE: AP and lateral views of the chest. 6:19 PM CHEST (PORTABLE AP) Clip # Reason: eval for cardiopulm process MEDICAL CONDITION: History: 78F with malaise, bradycardia REASON FOR THIS EXAMINATION: eval for cardiopulm process FINAL REPORT CHEST RADIOGRAPH HISTORY: Malaise and bradycardia. | 10 | [
{
"category": "Echo",
"chartdate": "2103-10-19 00:00:00.000",
"description": "Report",
"row_id": 64161,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion\nHeight: (in) 60\nWeight (lb): 175\nBSA (m2): 1.77 m2\nBP (mm Hg): 89/49\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 12:54\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT VENTRICLE: Dilated RV cavity. RV function depressed.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe right ventricular cavity is dilated with depressed free wall\ncontractility. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , a pacemaker wire is no longer seen; no pericardial effusion\nseen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2103-10-19 00:00:00.000",
"description": "Report",
"row_id": 64107,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Hblock\nHeight: (in) 60\nWeight (lb): 175\nBSA (m2): 1.77 m2\nBP (mm Hg): 105/68\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:23\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mildly\ndepressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo;\n\nRIGHT VENTRICLE: Normal RV free wall thickness. Dilated RV cavity. RV function\ndepressed. Abnormal septal motion/position consistent with RV pressure/volume\noverload.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral\nvalve supporting structures. No MS. Eccentric MR jet. Moderate (2+) MR. to\nthe eccentric MR jet, its severity may be underestimated (Coanda effect).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. [Due to acoustic\nshadowing, the severity of tricuspid regurgitation may be significantly\nUNDERestimated.] Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nA pacemaker wire is seen in the right atrium and right ventricle. The tip of\nthe pacemaker wire appears to penetrate the right ventricular free wall and\nmay protrude beyon the epicardial surface of the right ventricular free wall\n(through-and-through perforation).\n\nThe left atrium is dilated. The right atrium is moderately dilated. Left\nventricular wall thicknesses are normal. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is mildly depressed (LVEF =\n45%) secondary to hypokinesis of the inferior and posterior walls, and to\npacemaker-induced dyssynchrony. The right ventricular free wall thickness is\nnormal. The right ventricular cavity is dilated with depressed free wall\ncontractility. There is abnormal septal motion/position consistent with right\nventricular pressure/volume overload. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral\nregurgitation is seen. Due to the eccentric nature of the regurgitant jet, its\nseverity may be significantly underestimated (Coanda effect). The tricuspid\nvalve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is\nseen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may\nbe significantly UNDERestimated.] There is mild pulmonary artery systolic\nhypertension. There is a small pericardial effusion subtending the epicardial\nsurface where the pacemaker wire tip emerges. There is no sign of cardiac\ntamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the following findings are new:\n\n(1) pacemaker wire now seen in RA/RV, entering and probably perforating RV\nfree wall\n\n(2) small pericardial effusion now seen subtending area where pacemaker wire\ntip seen (no sign of cardiac tamponade)\n\n(3) pacemaker-induced LV dyssynchrony is now present\n\n(4) inferior posterior wall hypokinesis now present\n\n(5) RV is now dilated and hypocontractile\n\ndiscussed with Dr \n\n\n"
},
{
"category": "ECG",
"chartdate": "2103-10-18 00:00:00.000",
"description": "Report",
"row_id": 125942,
"text": "Sinus bradycardia with occasional atrial premature beats and high grade,\nprobably complete, A-V block with ventricular escape rhythm. Cannot exclude\nold inferior and anterior myocardial infarctions. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254231,
"text": " 8:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ptx, line placement\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 78F with with cordis and pacer\n REASON FOR THIS EXAMINATION:\n eval for ptx, line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Line placement.\n\n Portable AP radiograph of the chest was reviewed in comparison to , .\n\n Interval insertion of pacer has been made through the right internal jugular\n approach with its tip projecting at the expected location of right ventricle.\n Cardiomediastinal silhouette is stable. No evidence of pneumothorax is\n present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254221,
"text": " 6:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 78F with malaise, bradycardia\n REASON FOR THIS EXAMINATION:\n eval for cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Malaise and bradycardia.\n\n COMPARISONS: None.\n\n TECHNIQUE: Chest, portable AP upright.\n\n FINDINGS: There is slight tortuosity and calcification along the thoracic\n aorta. The heart is probably at the upper limits of normal size. There is\n vague patchy hilar opacification on each side, which may suggest slight\n congestion. Patchy retrocardiac opacity, probably in the left lower lobe, is\n most suggestive of minor atelectasis.\n\n IMPRESSION: Suspicion for slight congestion, otherwise unremarkable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254328,
"text": " 3:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluation of location of new temp pacer wire\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with HTN presented with recent MI c/b complete heart block\n now a new pacer wire\n REASON FOR THIS EXAMINATION:\n evaluation of location of new temp pacer wire\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pacer placement.\n\n FINDINGS: In comparison with study of earlier in this date, there has been\n placement of a right IJ pacer that extends to the region of the apex of the\n right ventricle. No evidence of pneumothorax. Opacification at the right\n base could represent atelectasis and small effusion. Somewhat similar but\n less prominent appearance is seen on the left. In the appropriate clinical\n setting, supervening pneumonia would have to be considered.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254298,
"text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for any pulmonary process\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with HTN presented with recent MI c/b complete heart block\n now with pacer wire removed, pacer wire found to have gone through RV, now\n desatting\n REASON FOR THIS EXAMINATION:\n Evaluate for any pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with recent MI complicated by complete heart\n block, now with pacer wire removed. Patient currently desaturating. Evaluate\n for pulmonary process.\n\n COMPARISONS: Multiple prior chest radiographs, most recently of .\n\n FINDINGS: Single frontal view of the chest was obtained. There has been\n interval removal of a transvenous pacer. The cardiomediastinal silhouette is\n stable. No pneumothorax, focal consolidation, or pleural effusion.\n\n IMPRESSION: Status post removal of transvenous pacer. No acute\n cardiopulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254477,
"text": " 7:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Check position of temp pacing wire\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with complete heart block s/p temporary pacemaker placement\n and kidney failure\n REASON FOR THIS EXAMINATION:\n Check position of temp pacing wire\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Complete heart block with temporary pacer.\n\n FINDINGS: There is a right IJ pacer wire that extends to the region of the\n apex of the right ventricle, in similar location compared to prior. There is\n volume loss at both bases and an early infiltrate cannot be excluded in either\n lower lobe. Compared to the study from the prior day, the appearance to the\n lower lungs is worse.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1254505,
"text": " 1:57 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check pacer wire placement\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman p/w CHB s/p permanent pace maker placement.\n REASON FOR THIS EXAMINATION:\n check pacer wire placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Pacemaker.\n\n FINDINGS: There is a new dual-lead pacemaker with leads projecting over the\n expected locations. There is volume loss in both lower lungs and bilateral\n pleural effusions. There is mild pulmonary vascular redistribution. An\n underlying infectious infiltrate in the lower lobes cannot be excluded.\n Compared to the prior study the fluid status is slightly worse.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-10-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1254603,
"text": " 2:37 PM\n CHEST (PA & LAT) Clip # \n Reason: pacemaker placement, please do the PA/Lat instead of portabl\n Admitting Diagnosis: COMPLETE HEART BLOCK; ACS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with new AV pacer for heart block\n REASON FOR THIS EXAMINATION:\n pacemaker placement, please do the PA/Lat instead of portable\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old man with a new dual-lead pacer for heart rate.\n\n COMPARISON: .\n\n TECHNIQUE: AP and lateral views of the chest.\n\n FINDINGS: Left-sided battery pack with pacemaker lead wires terminating in\n the right atrium and right ventricle without change in position. Bilateral\n pleural effusions are present. Mild pulmonary edema from \n is mostly resolved.\n\n"
}
] |